dvla guidance selective, misleading, and bits missing.

#1
Dvla are being selective and misleading in their guide, and are failing to point out that 3 of the criteria need to be present together.

Dvla guide to definition of misuse:-
There is no single definition to embrace all the variables within alcohol misuse – but the DVLA offers the following:
“A state that causes, because of consumption of alcohol, disturbance of behaviour, related disease or other consequences likely to cause the patient, their family or society present or future harm and that may or may not be associated with dependence.”
The World Health Organization’s classification (ICD-10) code F10.1 is relevant.

Definition of controlled drinking
Drinking within government recommended health guidelines (currently 14 units per week).
Guide to definition of dependence
There is no single definition to embrace all the variables within alcohol dependence – but the DVLA offers the following:
“A cluster of behavioural, cognitive and physiological phenomena that develop after repeated alcohol use, including:
■ a strong desire to take alcohol
■ difficulties in controlling its use
■ persistent use in spite of harmful consequences
■ and with evidence of increased tolerance and sometimes a physical withdrawal state.”
Indicators may include any history of withdrawal symptoms, tolerance, detoxification or alcohol-related seizures.
The World Health Organization’s classification (ICD-10) code F10.2 is relevant.

Compare this to the full text from WHO bluebook, https://www.who.int/classifications/icd/en/bluebook.pdf

F1x.1 Harmful use
A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self-administration of injected drugs) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol).

Diagnostic guidelines
The diagnosis requires that actual damage should have been caused to the mental or physical health of the user.
Harmful patterns of use are often criticized by others and frequently associated with adverse social consequences of various kinds. The fact that a pattern of use or a particular substance is disapproved of by another person or by the culture, or may have led to socially negative consequences such as arrest or marital arguments is not in itself evidence of harmful use.
Acute intoxication (see F1x.0), or "hangover" is not in itself sufficient evidence of the damage to health required for coding harmful use.

Harmful use should not be diagnosed if dependence syndrome (F1x.2), a psychotic disorder (F1x.5), or another specific form of drug- or alcohol-related disorder is present.
F1x.2 Dependence syndrome
A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco.
There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals.
Diagnostic guidelines
A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

(a) a strong desire or sense of compulsion to take the substance;
(b) difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use;
(c) a physiological withdrawal state (see F1x.3 and F1x.4) when substance use has ceased or been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms;
(d )evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill nontolerant users);
(e) progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects;
(f) persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm.
Narrowing of the personal repertoire of patterns of psychoactive substance use has also been described as a characteristic feature (e.g. a tendency to drink alcoholic drinks in the same way on weekdays and weekends, regardless of social constraints that determine appropriate drinking behaviour).
It is an essential characteristic of the dependence syndrome that either psychoactive substance taking or a desire to take a particular substance should be present; the subjective awareness of compulsion to use drugs is most commonly seen during attempts to stop or control substance use. This diagnostic requirement would exclude, for instance, surgical patients given opioid drugs for the relief of pain, who may show signs of an opioid withdrawal state when drugs are not given but who have no desire to continue taking drugs.
The dependence syndrome may be present for a specific substance (e.g. tobacco or diazepam), for a class of substances (e.g. opioid drugs), or for a wider range of different substances (as for those individuals who feel a sense of compulsion regularly to use whatever drugs are available and who show distress, agitation, and/or physical signs of a withdrawal state upon abstinence).
 

TipsyNurse

Well-known member
#2
The DVLA do not decide whether you have alcohol dependence, they rely on either your GP, their private medical, or rarely their own medical panel.

The issue they have is that the NHS officially uses ICD but most doctors use DSM. So there is little point publishing their own definition because it will only lead to arguments when a doctor could be using a totally different scheme. They, correctly, are saying that the decision should be made against reliable diagnostic criteria, not just gut instinct.

That is why the handbook for healthcare professionals has no definitions at all - there is no need as dependence and misuse are terms with specific clinical meanings, not rough ideas
 

DonkeyKong

Well-known member
#3
This is something I am very interested in, although I’ve got another year to think about it... Can I put I have never misused alcohol, despite the fact I stated on the one occasion I was caught with excess alcohol I had drunk because of anxiety? Can anyone who was caught Drink-driving actually state that they never misused alcohol? I mean, surely, Disturbance of Behaviour must apply to every DD?

Maybe needs a different thread, but, if you go to the GP and say that anxiety is killing me, and you go on to tell him that you have drunk to cope with it... does this mean he will say you have gone to him with an alcohol problem, despite having actually gone to him for the anxiety?
 
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TipsyNurse

Well-known member
#4
The best thing to do - and I say this as a clinician - is not mention anything you don't want recorded on your health records if you later plan to allow people - in this case the DVLA - access to it.

Clinicians tend to record everything to say because, to us, your health record is a confidential narrative between us and you. As a nurse I might see alcohol mentioned once and think "who gives a ****".

The DVLA essentially say, "We have permission to see these records. Now condense that complex narrative into ten yes or no questions."

That puts the doctor into an impossible situation. I got rat arsed drunk at the work Christmas party. No doubt if some miserable DVLA drone was there I'd have got a big tick in the misuse box. It doesn't mean isolated incidents are representative of the last three years.
 

DonkeyKong

Well-known member
#6
Tipsy... this is too late for me. 6 months Before my offence I showed up to my Docs and said the anxiety was crippling me. I was in a bad state, despondent. I told her I needed to try antidepressants again, despite trying and stopping both certraline and citralopram over the prior 2 years. because they made me feel worse. I mentioned that at that point I had recently been drinking a lot of vodka as a last resort. She was horrible. Showed me a list of ADs and said choose one quickly, as she wanted to go home and was doing me a favour. She prescribed Fluoroxotine. I didn’t take it. She absolutely did tell me my drinking was too high, and I should cut down and stop.
Six months later, my offence happened.
So, will she report that to the DVLA next year when I do my test? When I take my test it will be over 2.5 years since that happened, and 2 years since the offence. I want to say I haven’t been to the Docs for alcohol problems... but don’t know if this is true, or whether she would cooberate that. My CDT will be clear, but I don’t know whether I should just say NO on all the questions?

Oh by the way, you are right. It’s hard to tell st the moment what replies are to what comments, but... if I could rewind... I would never have said a word about anything to my DR. It’s all just evidence to be used against you if you ever do anything wrong.
 
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#7
Hi Tipsynurse,
my view on the dvla guide was that it is deliberately vague so that they can push the decision on to gp’s, (which they are general are pretty pissed off about) and by not spelling it out clearly can then claim “only acting on information received”, thus isolating themselves from legal challenge, leaving gp’s to carry the can, (not that I have any sympathy). Maybe I’m too cynical, but having dealt with dvla……..

The main reason I posted it was for general info, and in case anyone wanted to challenge their gp’s opinion of dependence, which too often seems to be an arrogant “because I am a doctor and I say so”, without reference to any standards, or any attempt to assess dependence properly.

In my case, it was pretty unnerving to find out (too late) that support for my entire argument was contained in ICD 10 and NICE guidance that the gp should have known about, and which if they had done their job properly in the first place would then have been ammunition for them to tear me a new one in rebuttals. Instead, only vague reference to the dvla version (not ICD) and a lot of mud from the notes was used. When I made a complaint, I expected a cast iron defence from a professional that knew precisely what they were talking about; that simply wasn’t the case.

Long story short, not all gp’s are equal, most are judgemental, which means it is even more important to have very clear standards and take the time to make an objective assessment. As it stands, a brief glance at the dvla version would only confirm a subjective opinion that’s already been made; it should at least point out that 3 of these criteria need to be present at the same time, not just the one that fits.

Totally agree about being careful what is said in case it goes in the record. It was just my bad luck to get a drippy wet gp that took a very dim view of alcohol (teetotal?) and only wrote down anything that confirmed that view. If only I had gotten the sensible one…..
 

TipsyNurse

Well-known member
#8
It's not vague though. Alcohol misuse and dependence are clinical terms with a specific meaning, no different to asking if someone had a broken arm.

The problem is the DVLA don't care about context. If you ask a doctor if someone has had a broken arm in the last year they can give you a yes/no answer. However that doesn't tell you if they had a hairline fracture three years ago which only required paracetamol for a couple of days, you came out of a sling last week, or their arm went septic and was amputated.

Personally my view is they should just use the £90 to fit an alcohol test ignition to your car. Make it automatic jail time if you DD in someone else's car or get someone else to blow for you. That way you are not trying to second guess whether someone will repeat offend.
 
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