Annals of Emergency Medicine
Volume 55, Issue 2 , Pages 211-214, February 2010

Commentary: Women and Alcohol: Increasingly Willing to Drive While Impaired?

Department of Emergency Medicine, Center for Injury Prevention and Control, The George Washington University Medical Center, Washington, DC

Article Outline

 

[McKay MP. Commentary: Women and alcohol: increasingly willing to drive while impaired? Ann Emerg Med. 2010;55:211-214.]

As I began to write this, I got to thinking about women and alcohol and driving and started to recall the voices of patients I've cared for over the years:

“But the crash wasn't my fault. HE ran a red light and hit ME. It was his fault, so it shouldn't matter whether or not I had a few drinks.” Mildly injured woman in her 30s with a BAC more than 300 g/dL.

“You're not going to tell the police, are you?” Injured 22-year-old female driver with a BAC of 180 g/dL.

“Where's my purse? Where's my purse? Where's my purse?” Brain-injured female pedestrian struck by an uninjured but intoxicated female driver, BAC 210 g/dL.

“But I was too drunk to walk … so I drove home.” Miraculously uninjured driver, single-vehicle crash into a bridge embankment, BAC 475 g/dL. When I asked the investigating police officer whether he was going to arrest the patient, he said, “No.” The patient was never seen by anyone at the scene inside the car (self-extricated) and so could not be successfully prosecuted as the driver.

Then I thought about recent news stories about drunk-driving moms. I thought about Diane Schuler, a mom who got on the Taconic Parkway in Westchester, NY, going the wrong way in July 2009. After nearly 2 miles she struck a sports utility vehicle head on. All 3 occupants of the sports utility vehicle, Diane, and 4 of 5 children riding in her car were killed. She is reported to have had a BAC of 190 g/dL.1 On October 11, 2009, another mom, Carmen Huertas, was driving 6 school-aged kids when she lost control and flipped her van into a tree after spending the evening imbibing at a birthday party. Three kids were ejected and injured; an 11-year-old died.2 I'm sure a bunch of emergency physicians were involved in caring for the injured in both these crashes, and 9 times in these 2 crashes, a physician had to notify family of a loved one's death.

In the emergency department (ED), we see many patients with alcohol use disorders, more men than women, overall. But women are a special group. Although women metabolize alcohol slightly faster on average than men, if both sexes imbibe the same amount of ethanol, the women's initial BAC will average higher than the men's because of differences in average body weight and total body water. In addition, women are more likely to develop complex health problems from chronic alcohol use: women develop serious liver, heart, and brain effects after consuming much lower average and lifetime doses of alcohol than men.3, 4, 5 Women who drink even moderately while pregnant risk birth defects and lifelong behavioral effects for the child.6

The findings in today's Traffic Safety Facts Research Note from the NHTSA7 identify some even more hair-raising issues about women and alcohol. The first is the trigger for the Note: this report was triggered by a 2007 report on crimes from the Federal Bureau of Investigation showing a 28.8% increase in the number of DUI arrests (not convictions) of women in the preceding 10 years. The 2008 Crime in the United States report is now out and shows an even greater difference: a 35% increase in DUI arrests of women since 1999. Women still accounted for only 21% of national adult DUI arrests in 2008 (N=181,391), but the absolute number is 47,112 additional women arrested for being over the legal limit of 0.08 BAC in 2008 compared with 1999. In the same period, total DUI arrests were essentially flat and the number of arrests for men decreased 6.6%, 47,440 fewer men arrested. As comparison, total crime arrests in the same period for men decreased 3.1% and increased 11.6% for women.8

These persistent findings could be the result of targeted enforcement against female drivers by law enforcement across the country, but I think that's a pretty big stretch (and very unlikely). On the other hand, it may be that police officers have become less likely to let women off with a warning instead of an arrest. Another possibility is that during the decade, women increased the number of total miles they drove a year and equivalently increased their miles of driving while intoxicated, and thus were more likely to be arrested. The most frightening possibility, however, is the idea that although fewer men were willing to drive after drinking significantly, the social culture is changing in the opposite direction for women. Although I'm a believer in equal rights for women, I'm hoping that women are not becoming more “like men” in their willingness to drive after drinking.

Comparing fatal traffic crashes, women accounted for 15% of drunken drivers in fatal crashes (>0.08 BAC) in 2007, up from 13.5% in 1998. In absolute numbers, this is 38 more women and 1,266 fewer legally intoxicated men involved in fatal crashes in 2007.9 Again, we are clearly going in the wrong direction. Particularly among young female drivers, the trend for increasing alcohol involvement in fatal crashes appears to be mimicking that of young male drivers.10

Today's Note identified changes between 2007 and 2008 (although the overall results from 2008 crashes were not available when I wrote this commentary). The report covers changes in specific states, and there are some notable standouts. In Kansas, the total number of drivers involved in fatal crashes decreased (15% fewer men and 35% fewer women), but the number of intoxicated male drivers in fatal crashes increased by 26% and the number of intoxicated female drivers increased by a whopping 77%. Of course, year-to-year trends are less reliable than trends during longer periods.

When it comes to alcohol-impaired female drivers in fatal crashes, I think the scariest finding is that these female drivers were 3 times as likely as male drivers to have children younger than 14 years in the vehicle at the fatal crash. And although 62% of the time the impaired drivers killed themselves, 18% of the time the fatality was a passenger in their vehicle. (In case you're wondering, for the purposes of this commentary, I'm willing to assign the “fault” to the impaired driver.) Only 20% of the time when an alcohol-impaired driver was involved did the fatality occur in another vehicle or to a nonoccupant (pedestrian, bicyclist, etc). Thus, impaired women are putting the children in their vehicle (most of whom are likely their own children) at significant risk.

In fact, alcohol is involved in about a quarter of crashes that fatally injure children younger than 15 years each year. More than 60% of the time, the dead child is an occupant in the vehicle with the impaired driver.11 In addition, fatally injured children riding in a vehicle with an impaired driver are less likely to have been properly restrained compared with those involved in fatal crashes but riding with an unimpaired driver.

What should our role as emergency physicians be in combating this frightening trend for women? I think there are several things we can and should do. The first, on an everyday basis, is to include a discussion of safer drinking with our patients who drink. Likely, the best way to go about this is to screen patients for alcohol use and then discuss safe(r) strategies with those who do drink. Screening and brief intervention in the ED works—at least to some measurable degree—and may work better for women than for men, particularly among nondependent drinkers.12 I routinely (OK, I'll admit, time allowing) have focused my brief interventions on the patient's beliefs about alcohol and the benefits and risks of its use to the individual. Armed with the information from today's Traffic Safety Facts, I will begin to add a plea that my patients contract to never drive with children in the vehicle after even 1 drink. Focusing on women and safety is another piece of the puzzle that may help, but perhaps a message about being too smart to get sucked into dumb behavior more often demonstrated by men would reinforce the message. I can't tell you that will work, but I am going to try it.

Maintained behavior change is a complex and often difficult process, as any of us who have begun a new diet or exercise regimen can attest. Although a single message in the ED appears to provide some benefit, hearing the same message from multiple sources is also key to success. This means that the safety message needs to get out there from non-ED sources as well.

Much of the focus on alcohol-impaired drivers is on young men, the highest-risk group. They are the primary target of the message in the NHTSA's state-based effort “You Drink & Drive. You Lose.” This campaign began in 1999 and has recently changed its name to “Drunk Driving. Over the Limit. Under Arrest.” The media campaigns include public safety announcements and paid advertising in print, online, on the radio, and on television. The campaign also includes a focused enforcement component (the enforcement component doesn't profile drivers by sex). This year, the timeline for the campaign was during the summer and culminated on Labor Day weekend. Along with other projects, this effort seems to be working: Fewer men are impaired drivers in fatal crashes and fewer men are being arrested for drunk driving.

However, the campaign's focus on the most common offender may make it less effective for other groups. Men and women may respond differently to marketing campaigns, particularly those aimed at health behaviors.13 The NHTSA's current campaign focuses on the risk of arrest and judicial consequences. It may be the case that health marketing campaigns highlighting the risk to passengers and others may be more effective for women or at least decrease the risk of the impaired woman being willing to transport children in the vehicle with her. I believe this should be an area for further research.

Finally, in our effort to combat drinking and driving, I'm constantly frustrated by the fact that the police will often ignore intoxicated drivers who present to the ED for injury care. I know this frustrates many of us and many of our trauma surgical colleagues. When I've asked why, several police officers (and a couple of judges) have told me that officers cannot perform any alcohol testing without a suggestive result on a field sobriety test (being involved in a crash is not sufficient cause). Even for patients who are not critically injured, being in a cervical collar, tied down to a backboard, having extremity injuries, or being given narcotic pain medications by us make field sobriety testing impossible. Thus, injured, intoxicated drivers often avoid the judicial effects of their drunk driving. Although many of the details of DUI adjudication are state specific, this problem is universal.

One solution may be legislation that enables ED caregivers to suggest “probable cause” to investigating police officers, ie, that specific drivers may have been impaired. (We have specific experience and expertise in identifying patients who are impaired by drugs or alcohol and have access to medical BAC testing.) If that suggestion were legally sufficient to enable officers to perform breathalyzer or official BAC testing, more injured, intoxicated drivers would enter the judicial system. Of course, for our protection, such legislation would need to include a clause protecting the physician from liability resulting from the suggestion and the interaction should not be mandatory (some physicians may believe that it would interfere with the patient-physician relationship). Naturally, the legislation would have to protect us from an allegation of HIPAA violation, just as we are protected in reporting child and elder abuse. Finally, we'd need to perform some research to document any benefit of such a change.

After reading this report, I'm going to focus on the women with alcohol use disorders just a little bit more. I will find the time to perform the screening and brief intervention more frequently and I'm going to point out the risk to women with young children; I think their children may motivate behavior change far better than me alone. The time to stop this disturbing trend is right now.

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References 

  1. Molloy J. Diane Schuler's murderous act happened well before she caused the Taconic tragedy. New York Daily News. http://www.nydailynews.com/news/2009/08/05/2009-08-05_diane_schuler_committed_murder.htmlAccessed December 15, 2009
  2. Akam S, Moynihan C. Bronx woman is charged in crash that killed girl, 11. New York Times. http://www.nytimes.com/2009/10/12/nyregion/12crash.html?_r=2Accessed December 15, 2009
  3. Urbano-Márquez A, Estruch R, Fernández-Solá J, et al. The greater risk of alcoholic cardiomyopathy and myopathy in women compared with men. JAMA. 1995;274:149–154
  4. Sohrabji F. Neurodegeneration in women. Alcohol Res Health. 2003;26:316–319Available at: http://pubs.niaaa.nih.gov/publications/arh26-4/316-318.htm. Accessed December 15, 2009
  5. Becker U, Deis A, Sørensen TI, et al. Prediction of risk of liver disease by alcohol intake, sex, and age: a prospective population study. Hepatology. 1996;23:1025–1029
  6. Jacobson JL, Jacobson SW. Effects of prenatal alcohol exposure on child development. Alcohol Res Health. 2003;26:282–286Available at: http://pubs.niaaa.nih.gov/publications/arh26-4/282-286.htm. Accessed December 15, 2009
  7. National Highway Traffic Safety Administration. Alcohol Impaired Drivers Involved in Fatal Crashes, by Gender and State, 2007-2008. Washington, DC: National Highway Traffic Safety Administration; 2009;Traffic Safety Facts Research Note. DOT HS 811 195
  8. US Department of Justice, Federal Bureau of Investigation. 2008 Crime in the United States. Table 33. Ten year arrest trends. http://www.fbi.gov/ucr/cius2008/data/table_33.htmlDecember 15, 2009
  9. US Department of Transportation, National Highway Traffic Safety Administration. Traffic safety facts 2007. Table 16. Drivers in fatal crashes by blood alcohol concentration and sex. 1982-2007. http://www-nrd.nhtsa.dot.gov/Pubs/TSF2007FE.PDFDecember 15, 2009
  10. Tsai VW, Anderson CL, Vaca FE. Young female drivers in fatal crashes: recent trends, 1995-2004. Traffic Inj Prev. 2008;9:65–69
  11. Quinlan KP, Brewer RD, Sleet DA, et al. Characteristics of child passenger deaths and injuries involving drinking drivers. JAMA. 2000;283:2249–2250
  12. Academic ED SBIRT Research Collaborative. The impact of screening, brief intervention, and referral for treatment on emergency department patients' alcohol use. Ann Emerg Med. 2007;50:699–710710.e1-6
  13. Judah G, Aunger R, Schmidt WP, et al. Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health. 2009;99(suppl 2):S405–S411

 Section editors: Mary Pat McKay, MD, MPH; Todd Thoma, MD; Chris Kahn, MD, MPH; Catherine S. Gotschall, ScD

PII: S0196-0644(09)01807-1

doi:10.1016/j.annemergmed.2009.12.007

Annals of Emergency Medicine
Volume 55, Issue 2 , Pages 211-214, February 2010

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