Hank George, FALU, CLU, FLMI
"The World Health Organization has estimated that, by 2020, motor vehicle accidents (MVAs) will be second only to ischemic heart disease as a cause of years of life lost and third as a cause of disability after ischemic heart disease and depression."
Richard A. Mayo, BM, BCh
Psychiatric Clinics of North America
"Although alcohol-related fatal crashes were substantially reduced between 1982 and 1995, there has been little change over the last 10 years."
James D. Fell, et al
Pacific Institute for Research and Evaluation
Annals of Advances in Automotive Medicine
Traffic crashes are the leading cause of death at ages 2 to 33 in the USA and many other western countries. [Hingson]
How common is driving under the influence?
- In a 2011 survey, 1.8% of American adults admitted to driving drunk at least once in the prior year. This equates to roughly 4 million people. [MMWR, 2011]
- Epidemiologic calculations suggest that there were 112 million drunken driving events in 2010, which is down 31% from the prior year's estimate. [MMWR, 2011]
- In the USA, 1.4 million motorists are arrested (and in most cases, convicted) for driving while intoxicated (DWI). [Furr-Holden]
- The odds of a person with a BAC (blood alcohol content) of 0.10 being arrested for DWI on a given driving episode is estimated at no more than 1 in 200. [Beitel]
- Roughly 1/3rd of all US motor vehicle crash fatalities involved drivers with a blood alcohol content of at least 0.08, consistent with unequivocal intoxication. [MMWR, 2011]
- In a new study of 16,942 fatal crashes, 40% of fatally injured drivers had a BAC of 0.08 or higher. [Romano]
- In another new study, this one with 20,150 fatal car accidents, 40% of drivers killed in these accidents were intoxicated. [Brady]
- In Canada, 28% of fatally injured drivers at ages 26-35 had BAC concentrations at or above the same threshold. [Maskalyk]
- 20% of serious auto accidents in urban China are attributed to alcohol excess and this number is thought to be an understatement due to imperfect record keeping. [Li, Rao]
- In Ireland, 30% of drivers in fatal crashes were intoxicated. [Bedford]
- In Australia, it was 29% [Drummer]
- Only 14% of drunken drivers in American fatal crashes have an existing diagnosis of alcohol dependency; therefore, the vast majority will not have a clinical history of an alcohol use disorder. [Furr-Holden]
What about intoxicated use of a motorcycle?
"…drinking and riding a motorcycle is a stubborn problem in which total alcohol-related crashes are increasing…the number of fatal motorcycle crashes began to climb in 1998 and have risen each year since."
The incidence of positive BAC tests is 24% greater in motorcycle vs. car fatalities. [Fell]
In a 2004 investigation [MMWR, 2004]:
- 48% of fatally injured motorcyclists were intoxicated.
- Peak death rate in this setting shifted from ages 20-24 to ages 40-44.
- Over age 34, the % of drunken motorcyclists was higher than the % of drunk automobile drivers.
In a recent investigation, 49% of moped operators injured in accidents had a positive blood alcohol level, 45% had a prior DWI and 72% of those were repeat offenders.
In addition, 38% had a revoked license at the time of injury and half of these individuals had multiple revocations. [Brintzenhoff]
What are the YELLOW and RED FLAGS for an increased risk of being an intoxicated driver?
Overall, the risk is higher in males and in persons smoking > 1 pack of cigarettes per day.
Major risk factors include:
- History of substance abuse, including prescription drugs
- Binge drinking is the #1 predictor; defined as taking 5 or more drinks at one sitting
- Habitually not wearing seat belt
- Single vehicle accidents and/or striking fixed vs. moving objects
- Car crashes occurring between midnight and sunrise
- Prior convictions for reckless driving, driving too fast for conditions, weaving in and out of traffic, and failure to keep in the proper lane
- Any criminal history
- Antisocial personality disorder
- Borderline personality disorder
- Multiple current psychiatric disorders, especially mood-related (depression, bipolar disorder, etc.)
- Frequent/sustained use of benzodiazepines for sleep-related purposes
- Prior driver's license suspension/revocation
- "Open container" violations (driving with an open bottle of an alcoholic beverage)
- Frequently engaging in risk-taking behaviors such as extensive gambling, poor health practices, etc.
- Delay in reinstatement of suspended/revoked driver's license
- Elevated MCV on a complete blood count
[Birdsall, Blencowe, Fell, Freeman, Gjerde, Hingson, Pavanello, Romano, Sansone, Schermer, Voss, Wang]
Do many DWI/DUI convicts meet the criteria for an alcohol use disorder?
Yes, consistently in study after study:
- Miller (1986): 73%
- Parks (1996): 68%
- Brinkmann (2002): 48%
- Furr-Holden (2011): 50%
Is it likely that the % of DWI/DUI convicts diagnosed with an alcohol-related disorder will increase in the future?
Yes, because the criteria for this diagnosis have been liberalized substantially in the new edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-5).
DSM-5 sets the criteria for psychiatric diagnoses in the United States and is widely used in other countries as well.
This said, there has been great controversy over many of the changes embraced in this latest DSM edition and its overall impact remains clouded at this writing.
Which US States have the highest % of drivers involved in fatal crashes with a blood alcohol of 0.08 or higher?
In this order [Fell]:
- North Dakota
- South Carolina
- Rhode Island
What do we know about DWI/DUI recidivism?
Recidivism refers to incurring 2nd and subsequent DWI/DUI convictions.
"For most individuals, being convicted of a DWI is a life-changing experience most do not want to repeat.
Conversely, individuals with at least two DWI's are at substantial risk of continued episodes of impaired driving either due to substance abuse problems or a denial that he engages in an activity that is harmful to himself or others."
Danny Perkins, JD, FALU
On the Risk
"Repeat offenders represent a group that is distinct not only from the general population but also…from the majority of first-time DUI offenders."
Howard J. Shaffer, et al
Journal of Consulting and Clinical Psychology
- The recidivism rate after a first conviction is roughly 10% [Chaudhary]
- The risk of a 2nd conviction is 10-fold greater than a first conviction; given 2 convictions, the odds of a third are 14-fold higher vs. having just one, and the likelihood continues to rise with additional convictions. [Rauch]
- The average interval from 1st to 2nd DWI/DUI is 6 years, which raises questions about the value of temporary flat extra premiums in this setting…more on this later. [Cavaiola]
- The risk of alcohol dependence (alcoholism) is higher in those with more than one DWI conviction whereas the odds of alcohol abuse only (without addiction) actually declines in persons with multiple convictions. [Couture, Shaffer]
- Recidivists have a high prevalence of other criminality. [Hubicka]
- Elevations of both GGT and CDT in first-time offenders are associated with a higher risk of recidivism. [Portman]
- Repeat offenders have a 50% probability of comorbid drug use disorders, over 30% have major depression and at least 15% will be diagnosed with posttraumatic stress disorder. [Albanese, Lapham, Peller]
- Conduct disorder in childhood and a history of problem gambling at any time are associated with a greater risk of a 2nd DWI/DUI. [LaPlante, Shaffer]
- Prior traumatic brain injury is significantly more common in recidivists. [Ouimet]
And most comorbid psychiatric diagnoses in DWI/DUI offenders go unrecognized clinically! [McMillan]
Is there any clue to identifying the "hard core" drunken driver?
Yes – a blood alcohol of 0.15 mg/dL at any time. [Baker, Fell and Tippetts]
These are clearly RED FLAG cases.
Is there significant excess mortality in DWI/DUI?
In a Scandinavian study, mortality was 3.8 times expected after full adjustment for risk factors. [Karlsson]
Mann found that mortality in DWI recidivists was 2.5-fold higher at ages 15-34, 2-fold greater at ages 35-54 and 1.3 times expected at older ages.
For additional mortality information, see the superb MVR study by RGA actuaries Tim Rozar and Scott Rushing.
Drunken driving is also substantially implicated in increased odds of hospitalization for a wide range of reasons, including suicide attempts (7.7-fold), drug abuse (16.7-fold) and an alcohol user disorder (16.5-fold). [Karlsson]
What are the ideal underwriting resources when assessing applicants with a history of DWI/DUI?
Obviously, American underwriters will want a MVR (motor vehicle report) and pharmacy profile (to check for drugs associated with alcoholism and comorbid psychiatric disorders).
All applicants should routinely be asked about their driving records on teleinterviews, especially at face amounts where MVRs are not routinely ordered…and in all countries where motor vehicle records cannot be obtained for underwriting purposes!
Elevations of the following tests raise a RED FLAG in this setting:
- Isolated GGT
- AST:ALT ratio ≥ 2.0
- Markedly elevated HDL-C
- Elevated mean corpuscular volume (MCV) in medical records
In our opinion, all applicants with a history of DWI/DUI within at least 5 – ideally more – years should be required to have a CDT test and if CDT is positive, they should be postponed pending further clinical assessment.
We also believe that court records should be routinely checked in these cases given the increased prevalence of criminality.
Does the use of temporary flat extra premiums for DWI/DUI make sense?
In our view, no, because the driver (no pun) of the mortality risk is whether or not the individual has an alcohol use disorder and we use table ratings, not temporary flat extras, for these disorders.
One might argue for a temporary flat extra in 1st offense cases provided they are devoid of any other significant clues to possible alcohol abuse. However, the latency interval of 6 years between 1st and 2nd DWI/DUI convictions argues against this approach.
In all other cases, a permanent rating – potentially subject to reconsideration after an extended interval free of further issues – makes more sense to us.
We hope you found this paper useful.
It is presented in the same format as our narrative type Continuing Education Program courses.
For more information about these courses, please visit www.hankgeorgeinc.com or contact Esther at email@example.com
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