Licence Appeal Tribunal File Number: 16255/MED

An appeal under subsection 50(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8, from a decision of the Registrar of Motor Vehicles to suspend a licence pursuant to Section 47(1) of the Act.

Between:

Gregory Lees

Appellant

and

Registrar of Motor Vehicles

Respondent

DECISION

ADJUDICATOR: Dr. Isla McPherson, Member

APPEARANCES:

For the Appellant: Gregory Lees, Appellant

For the Respondent: Ian Sookram, Agent

Held by teleconference: October 15, 2024

OVERVIEW

1Gregory Lees (the “appellant”) appeals from the decision of the Registrar of Motor Vehicles (“Registrar”) to suspend his Class G licence under s. 47(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8 (the “Act”) after the Registrar received an unsolicited medical condition report stating that the appellant suffers from a medical condition that may affect his ability to drive safely.

2The Registrar has the authority under s. 47(1)(g) of the Act to suspend or cancel a driver’s licence for any sufficient reason. Section 14(1)(a) of O. Reg. 340/94 under the Act (the “Regulation”) states that a holder of a driver’s licence must not suffer from any mental, emotional, nervous or physical condition or disability likely to significantly interfere with their ability to safely drive a motor vehicle of the applicable class safely. Under s. 14(2)(b) of the Regulation, the Minister of Transportation may require a driver to provide satisfactory evidence that they are able to drive safely.

3The Registrar takes the position that the appellant suffers from two medical conditions, namely alcohol use disorder and a mental health condition, that are likely to significantly interfere with his ability to drive safely and that this provides sufficient reason to suspend his licence under s. 47(1)(g) of the Act.

4The appellant appeals the suspension under s. 50(1) of the Act. He denies that he suffers from alcohol use disorder and a mental health condition and denies that he suffers from a medical condition which interferes with his ability to drive safely.

5Pursuant to section 50(2) of the Act, after a hearing the Tribunal may confirm, modify, or set aside the decision or order of the Registrar.

ISSUES

6The issue in this appeal is whether the appellant suffers from a medical condition that is likely to significantly interfere with his ability to drive a motor vehicle safely.

7To resolve that issue, I will address the following questions:

i. Does the appellant suffer from a medical condition?

a. Does the appellant suffer from alcohol use disorder?

b. Does the appellant suffer from a mental health condition?

ii. If so, are either of these medical conditions likely to significantly interfere with his ability to drive a motor vehicle safely?

8The Registrar bears the burden of proving on a balance of probabilities that the answer to each of the above questions is “yes.”

RESULT

9Having considered all the evidence and submissions and for the reasons that follow, I find that the Registrar has satisfied its burden to establish that the appellant suffers from both alcohol use disorder and a mental health condition and that they are both likely to significantly interfere with his ability to drive a motor vehicle safely and I confirm the Registrar’s decision to suspend the appellant’s driver’s licence.

ANALYSIS

Does the appellant suffer from alcohol use disorder?

10The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely alcohol use disorder.

11The Registrar’s position is supported by:

i. An unsolicited Medical Condition Report (MCR) from Dr. B.;

ii. A progress note completed by Dr. R-N.;

iii. A prior Licence Appeal Tribunal Hearing Decision;

iv. A progress note completed by Dr. G.;

v. A letter and laboratory investigations completed by Dr. G.;

vi. A Substance Abuse Assessment form completed by Dr. M.;

vii. A Medical Report Form completed by Dr. M.

12Dr. B submitted an unsolicited MCR dated January 20, 2010. Dr. B. has identified themselves as a hospitalist and reported that the appellant suffers from alcohol dependence. Dr. B. indicated he had known the appellant for two months and provided the narrative comments that although the appellant was not currently taking alcohol, he had seriously impaired judgment from prior use. He indicated the appellant was improving with support from external social supports, but there were prior reports of erratic driving and the appellant demonstrated questionable ability to maintain sobriety.

13Following the submission of the MCR, the Registrar suspended the appellant’s driver’s licence effective February 2, 2011, and requested the completion of a Substance Abuse Assessment Form.

14The Registrar’s position is further supported by a progress note from Dr. R-N dated March 9, 2011, submitted to the Registrar by the appellant. This note reports that the appellant has a longstanding pattern of alcohol abuse and has been diagnosed with alcohol abuse, alcohol dependence and probable alcohol induced psychosis leading to hospitalization. Dr. R-N noted that the appellant had not operated a vehicle while intoxicated per collateral history from his family. Dr. R-N’s progress note acknowledges the appellant had been abstinent for a period of months but was currently admitted to hospital due to an episode of drinking alcohol on March 1, 2011, and the appellant showed an interest in attending substance abuse treatment programs. Dr. R-N acknowledged the appellant had his licence suspended due to alcohol dependence but gave no recommendation regarding the appellant’s suspended licence or support for reinstatement.

15The Registrar responded to this submission from the appellant with a letter dated March 15, 2011, requesting a completed Substance Abuse Assessment Form.

16The appellant subsequently appealed his case to the Licence Appeal Tribunal and a hearing took place August 11, 2011. The appellant was unsuccessful in his appeal and the decision concludes that “the Applicant has a serious problem with alcohol”.

17The appellant submitted a progress note to the Registrar completed by psychiatrist Dr. G dated October 14, 2011. Dr. G acknowledged the note was requested by the appellant to further his goal of reacquiring his driver’s licence. Dr. G commented that the appellant had remained sober since November 2010 with the exception of a relapse in March 2011. He commented that the appellant had been attending AA meetings and completed three weeks at a facility and was motivated to pursue community treatment programs. At the time of the clinical encounter the appellant was admitted to hospital for depression and suicidal ideation.

18The Registrar responded with a request for confirmation of further abstinence from alcohol without relapse and bio-chemical laboratory markers.

19The appellant subsequently submitted a second letter from Dr. G dated January 13, 2012. The letter indicated the appellant had been drinking alcohol recently and this recent consumption of alcohol was apparent in the appellant’s lab markers. Submitted lab values demonstrated elevated liver enzymes and evidence of alcohol and THC in the blood. The letter indicated the appellant planned to participate in a rehabilitation program in February 2012. No recommendation was provided regarding the appellant’s driver’s licence.

20The Registrar responded with a letter dated March 9, 2012, requesting confirmation of a one-year period of abstinence, urine toxicology and bio-chemical markers.

21Four years later the appellant submitted a letter from psychiatrist Dr. M dated August 11, 2016, and a completed Substance Abuse Assessment Form. Dr. M indicated the appellant had been abstinent from alcohol for a period nine months and completed a six-week rehabilitation program. Dr. M indicated he was advocating for reinstatement of the appellant’s licence. The completed Substance Abuse Assessment Form indicated the appellant had used alcohol regularly since age 16, had a pattern of binge and regular use of alcohol and generally consumed 12 drinks on each occasion, had a diagnoses of alcohol abuse and the recommendation of the physician was to abstain from alcohol. The form reported in addition to alcohol the appellant used amphetamines, cocaine and cannabinoids and answered affirmatively to the questions that the appellant had difficulty with friends, family and work as a result of using substances. Dr. M. also answered affirmatively that the appellant had been arrested for possession of drugs, experienced withdrawal symptoms and gotten into fights when under the influence.

22The Registrar responded with a request for confirmation of continued abstinence from non-prescribed psycho active substances and the results of a urine toxicology screen.

23Results of urine toxicology provided October 26, 2016, were positive for benzodiazepines and cannabinoids, and the Registrar responded with a request for confirmation of abstinence from alcohol and non-prescribed psychoactive substances for a period of one year and submission of a completed Substance Use Assessment Form.

24Seven years later a Medical Report form was submitted from Dr. M dated August 17, 2023. Dr. M provided affirmative response to question of whether the appellant suffered from addiction and provided a narrative that the appellant had a history of alcohol use disorder, and his latest relapse was 4 months earlier in April 2023.

25The appellant’s position is that he no longer suffers from alcohol use disorder as he has been sober for over a year and has met the Ministry’s requirements. He reports that he can use alcohol in moderation but has chosen to remain abstinent.

26Under cross examination the appellant testified it has been approximately six years since his last treatment program for alcohol use. The appellant was questioned about alcohol withdrawal symptoms and testified that he was admitted to hospital to manage withdrawal symptoms approximately three years ago. The appellant was questioned about ongoing supports and responded that he has attended AA “on and off” and has a sponsor and is determined to remain abstinent. The appellant has been prescribed several medications in the past to support his recovery and is currently taking naltrexone for the past 2 years.

27The appellant was questioned as to why he had not submitted more updated medical information given that the last medical submission was completed 14 months prior. The appellant reported that he terminated the relationship he had with his psychiatrist Dr. M, whom had been his physician for 10 years after a disagreement. The appellant has a family physician Dr. B and has seen him three times in the past six to eight months. The appellant testified that Dr. B is the physician who has continued to prescribe his naltrexone, but the appellant did not ask Dr. B for any updated medical documentation confirming his abstinence from alcohol.

28The Registrar has submitted seven documents from four physicians along with biochemical lab markers spanning the last 13 years that all consistently document a diagnosis of alcohol use disorder. The latest report from August 17, 2023, describes a period abstinence of only four months, checks affirmatively to the question of whether the appellant suffers from an addiction disorder and the narrative comments confirm a history of alcohol use disorder. The appellant does not dispute his lengthy history of alcohol use but submits he has been abstinent from alcohol for over a year. I have considered the appellant’s submission that he no longer has an alcohol use disorder, but in light of the longstanding history of repeatedly relapsing alcohol use disorder despite treatment programs, I do not give this testimony weight in the absence of supportive medical documentation. I further find it unusual that the appellant has seen his family physician three times in past 6-8 months, has testified this physician is his prescriber of naltrexone, and yet did not ask this physician for any updated medical information to confirm a period abstinence or recovery from alcohol use disorder. From the appellant’s testimony, it seems that he has had the opportunity to ask a knowledgeable healthcare provider to document updated information, and no information has been submitted.

29The Registrar’s extensive medical evidence is weighed against the appellant’s testimony that he no longer has alcohol use disorder as he has recovered. In this situation I find the medical evidence clear, consistent, and persuasive. I appreciate the appellant’s position that they have been sober for over a year, however in the absence of medical evidence that confirms that they no longer suffer from alcohol use disorder, I find the Registrar has proven on a balance of probabilities that the appellant has alcohol use disorder.

Does the appellant suffer from a mental health disorder?

30The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely a mental health disorder.

31The Registrar’s position is supported by:

i. A progress note from psychiatrist Dr. R-N;

ii. A progress note from psychiatrist Dr. G;

iii. A Substance Abuse Assessment Form by psychiatrist Dr. M;

iv. A Medical Report Form from psychiatrist Dr. M.

32In a progress note from Dr. R-N dated March 9, 2011, the psychiatrist indicates that the appellant has been diagnosed with “probable alcohol induced psychosis” and this diagnosis led to an admission to hospital in 2010. Dr. R-N also reports that the appellant’s mood is moderately depressed but not psychotic and suggests the appellant will attend an inpatient program at Penetanguishene Mental Health Centre which assess and assists individuals with dependence issues and mental health issues. The note ends documenting the appellant is adherent to psychiatric medications Cipralex and Lithium and participating in mental health care.

33In the progress note from Dr. G dated October 14, 2011, he reports that the appellant had been sober for a period of months, however at the time of the letter required admission to hospital for depression with suicidal ideation. The letter also reports the appellant has been experiencing ongoing paranoia and hallucinations requiring anti-psychotic medications Seroquel and Invega.

34In the Substance Abuse Assessment form from Dr. M dated August 11, 2016, he has checked affirmatively the box indicating the appellant has a psychiatric disorder and then written in the narrative comments that the appellant suffers from anxiety disorders and has a history of psychosis.

35In the Medical Report Form from psychiatrist Dr. M dated August 17, 2023, the physician has answered affirmatively to the question of whether the appellant has a psychiatric disorder.

36The appellant testified that he no longer has a psychiatric disorder as he is no longer consuming alcohol. He attributes all of his psychiatric illnesses to the consumption of alcohol. He reports that when he was drinking alcohol he would suffer from auditory hallucinations.

37Under cross-examination the appellant reports that he continues to take anti-anxiety and anti-depressant medications and reports being on Wellbutrin, Latuda and clonazepam. Pursuant to s. 16(b) of the Statutory Powers Procedure Act, I as a duly licenced medical doctor, take notice that Latuda is an anti-psychotic medication. He reports he is taking these medications as a precaution. In response to questioning, he reports that in the past he has taken Seroquel and Lithium but these were discontinued as they were not effective.

38While the appellant disagrees with a diagnosis of a mental health condition while he is not consuming alcohol, there is no medical evidence to suggest that the appellant’s psychiatric history is entirely due to alcohol, nor that his psychiatric conditions have resolved. The medical evidence suggests that after maintaining sobriety for several months the appellant has continued to experience paranoia and psychosis requiring medications. In addition to the history of psychosis, the appellant has suffered from depression with suicidal ideation and anxiety disorders. The latest Medical Report Form completed by Dr. M continues to document the presence of psychiatric disease while also commenting that the appellant has been sober for several months.

39I find the medical evidence in this case relevant and persuasive. Based on the information available, I find that the Registrar has established on a balance of probabilities that the appellant suffers from a mental health condition.

Is the appellant’s medical condition of alcohol use disorder likely to significantly interfere with his ability to drive a motor vehicle safely?

40I find that the Registrar has proven on a balance of probabilities that the appellant’s medical condition is likely to significantly interfere with his ability to drive a motor vehicle safely.

41The Registrar argues that the appellant’s alcohol use disorder interferes with his ability to drive safely and relies on the Canadian Council of Motor Transport Administrators Medical Standards for Drivers [February 2021] (the “CCMTA Standards”). Chapter 15 describes substance use disorders in general and the concerns with driving safely with respect to those conditions. Specifically Standard 15.6.3 states that drivers who are under the influence of alcohol would be eligible for a licence if they:

i. Meet the criteria for remission and/or has abstained from the substance for 12 months.

ii. Earlier re-licensing may be considered upon favourable recommendation from an addictions specialist and/or treating physician recognized by the licensing authority, and the successful completion of a drug rehabilitation program.

iii. The functional abilities necessary for driving are not impaired.

iv. Where required a road test or other functional assessment shows that the functional abilities for driving are not impaired.

42The CCMTA Standards further outline the effects of alcohol on the functions necessary for driving including: reduced reaction times, blurred or double vision, altered depth perception, reduced judgement and insight, blunted alertness and reduced motor co-ordination. The use of alcohol impairs a driver’s judgment and behaviour towards others, including determining whether they are fit to drive or not. Although a person may, when not under the influence of alcohol, determine never to drive when intoxicated, their assessment of their ability to drive will likely be affected by having consumed alcohol.

43The Registrar’s position is further supported by the appellant’s history of having a criminal conviction for impaired driving, the narrative report in the MCR that the appellant has seriously impaired judgment from prior alcohol use and a history of erratic driving behaviour, that the appellant’s licence was initially suspended due to an incident while driving that involved the police, and there are no medical submissions within the past year documenting his abstinence from alcohol or supporting reinstatement of his licence.

44The appellant’s position is that he does not have a medical condition that will interfere with his ability to drive. The appellant testified that he was not under the influence of alcohol when his licence was initially suspended in 2011. He testified that the incident that led to his suspension was that someone stole his parking spot, which resulted in him yelling at the other driver. Following this response, the police became involved, and this resulted in the appellant going to the hospital where a MCR was completed.

45The appellant testified he has been abstinent from alcohol for over a year and “passed the bloodwork markers”. He testified he has done what the Registrar is asking, and he needs his licence to help his aging mother and to attend a place of employment. He testified he knows others who have crashed their vehicles while intoxicated and had their licences reinstated earlier than his. He testified he has learned from his prior impaired driving charge and would never put himself in that position again. The appellant did not submit the bloodwork markers referenced in his testimony.

46Insight is an important consideration when considering safety to drive. Insight means that a driver is aware of their medical condition, understands how the condition may impair their functional ability to drive and has the judgment and willingness to comply with a suggested treatment regime. From the submissions and the appellant’s testimony it is evident that he has struggled with alcohol use disorder for well over a decade. This medical condition has been primarily managed under psychiatric care and this is evident from the documentation received from three different psychiatrists on the appellant’s file, including the latest one being involved in his care for 10 years, and as such it is very concerning that the appellant has terminated his relationship with his long-standing psychiatrist and has not secured a new psychiatrist, nor has he demonstrated why this may present a risk of relapse for his medical condition. Insight into having a chronic disease means that that you understand that the disease may fluctuate over time and therefore monitoring for those periods where the disease state may be incompatible with driving is necessary, and the appellant did not demonstrate an understanding of this in his testimony.

47The evidence before the Tribunal is that the appellant has suffered a long history of relapsing alcohol use disorder. I note that the appellant has been enrolled in several inpatient and outpatient rehabilitation programs. While I applaud his efforts towards sobriety, I find it concerning that he has continued to relapse after each treatment program, bringing into question the appellant’s ability to follow treatment recommendations and have insight into the risks associated with repeatedly consuming alcohol and its impact on the ability to safely operate a motor vehicle. The appellant testified that the last program was six years ago and since that time he has resumed alcohol consumption to an extent that he has been admitted to hospital for alcohol withdrawal symptoms. Furthermore, I note that the appellant has had his licence suspended for 13 years and has submitted medical information from three different physicians but has not demonstrated that he has maintained abstinence from alcohol for one year before relapsing during this time. While Dr. M did support the appellant’s reinstatement in 2016 after abstinence for several months, the appellant relapsed with alcohol use since that time and Dr. M did not provide a recommendation for reinstatement of the appellant’s driver’s licence in his most recent letter of August 17, 2023.

48Section 14(2)(a) of the Regulation allows the Registrar to consider the CCMTA Standards when determining whether the requirements of s. 14(1) are met. The Tribunal may take the CCMTA Standards into consideration but are not bound by them.

49Although not bound by the CCMTA Standards, they are considered when making the decision because these Standards are the result of a lengthy and intensive process to provide medical standards based on the best evidence available and with a focus on functional ability to drive rather than exclusively on medical diagnoses.

50I find the CCMTA standards relevant and am persuaded to apply them given the circumstances of this case. My review of the evidence shows that the conditions recommended for relicensing outlined in the CCMTA Standards have not been met.

51As such, for the reasons cited, I am satisfied on a balance of probabilities that the appellant’s medical condition of alcohol use disorder is likely to significantly interfere with his ability to drive safely.

Is the appellant’s medical condition of a mental health condition likely to significantly interfere with his ability to drive a motor vehicle safely?

52The Registrar relies on the CCMTA Standards Chapter 14. Chapter 14 of the Standards documents that psychiatric disorders can result in either a persistent or episodic impairment of the functions necessary for driving and highlights that a driver’s level of insight is a critical consideration when assessing the risk of an episodic impairment of functional ability due to a psychiatric disorder.

53The Registrar relies on Standard 14.6.1. This Standard indicates a driver is eligible for a licence if the condition is stable, the driver has sufficient insight to stop driving if the condition becomes acute, the functional abilities necessary for driving are not impaired, and a treating physician supports a return to driving.

54Section 14(2)(a) of the Regulation allows the Registrar to consider the CCMTA Standards when determining whether the requirements of s. 14(1) are met. The Tribunal may take the CCMTA Standards into consideration but are not bound by them.

55The appellant argues that his licence should be reinstated for the following reasons: his medical condition is resolved as he has been abstaining from alcohol, he takes the medication prescribed, and Dr. M has written on the Medical Report Form dated August 17, 2023, that he is stable and there are no significant psychiatric concerns.

56Under cross-examination the appellant testified that he has been admitted to hospital approximately 6 times for his mental health concerns. Although he states that he has not experienced an episode of psychosis for approximately two years, he at times feels depressed over his loss of driver’s licence.

57Under cross-examination the appellant was questioned why he had not submitted more updated medical information regarding his mental health, as the latest medical document was from 14 months earlier. The appellant testified that he had ended the relationship with Dr. M over a disagreement about the side effect of a drug. He also testified it was hard for him to travel to Dr. M’s office as it was out of town, and he did not have a vehicle. The appellant was questioned as to where he is getting his psychiatric medications since leaving Dr. M. The appellant responded that he initially had difficulty with his family physician Dr. B not feeling comfortable prescribing his psychiatric medications, so he was travelling to a clinic in another city to obtain the prescriptions. He has also attended a second larger clinic even further away from his home to obtain the prescriptions. Without a consistent psychiatrist, the appellant was asked if he has appointments regarding his mental health with Dr. B, but the appellant has indicated he does not talk to his family physician about his mental health. When questioned about his efforts to secure a new psychiatrist he indicated he has done some research but did not want to pay for a psychiatrist. When asked if he had talked to his family physician about a referral to a psychiatrist, he indicated he had not. I find this situation perplexing as psychiatric care in Ontario is covered under the Ontario Health Insurance Plan (OHIP) and therefore does not require a patient to pay for services, and a referral from a family physician is perhaps the most common and intuitive way to be connected with psychiatric care.

58I appreciate that the appellant testifies he has not experienced psychosis in two years. However, I do take note that psychosis may be the most urgent psychiatric situation regarding fitness to drive and an acute psychotic episode is incompatible with safe driving. I take this issue into consideration of the appellant’s insight into his mental health diagnoses. As mentioned, insight is an important consideration when considering safety to drive. I am concerned about the level of insight and understanding the appellant has into his mental health conditions, especially as they appear to be chronic and relapsing having resulted in at least six hospital admissions. The appellant’s level of insight appeared poor when he testified that his mental health concerns are only as a result of alcohol consumption. Although I recognize alcohol consumption would have triggered his alcohol induced psychosis, I also note the medical submissions comment on ongoing paranoia and hallucinations requiring anti-psychotic medication use after months of abstinence. I also question the level of insight the appellant has into the importance of receiving mental health care and following treatment recommendations when he ended the relationship he had with a psychiatrist for 10 years over a disagreement about a side effect. Furthermore, the appellant also cited travel as a concern with seeing his former psychiatrist, but now has to travel further than previously to obtain prescription renewals from various different providers. This lack of stability in his care, with no specific oversight of these chronic illnesses, creates a real risk of the appellant running out of his prescription psychiatric medications as well as offers him no consistent healthcare provider to reach out to should his symptoms escalate, which in turn creates a very vulnerable situation for a relapse.

59While I appreciate the appellant’s position that his latest letter from Dr. M states that his psychiatric conditions are stable, I do note that Dr. M has provided no recommendation regarding reinstatement of the appellant’s driver’s licence and given the chronic and relapsing nature of his mental health conditions, I find this medical information to be too dated to assign much weight. What the CCMTA Standards highlight prior to considering reinstatement is a period of stability. I find the medical evidence of the appellant dated at this point as it is over a year old. The appellant’s position is weighed against the medical evidence on file which is that the appellant has suffered from mental health conditions, for many years, including psychosis, requiring multiple hospitalizations, and the scientific research that psychosis can have a direct effect upon fitness to drive.

60I appreciate the hardships that the appellant is undergoing with the loss of his driver’s licence but given the medical evidence and the individual merits of this case, I believe that medical documentation within the past year is reasonable and prudent for road safety given the risks associated with driving during a psychotic episode.

61Although this Tribunal is not bound by the CCMTA Standards, they can be considered when making the decision for the reason that these Standards are the result of a lengthy and intensive process to provide medical standards based on the best evidence available and with a focus on functional ability to drive rather than exclusively on medical diagnoses.

62As such, for the reasons cited, I am satisfied on a balance of probabilities that the appellant’s medical condition is likely to significantly interfere with his ability to drive safely.

Conclusion

63I find that the Registrar has discharged the onus of establishing on a balance of probabilities that the appellant suffers from both medical conditions, namely alcohol use disorder and a mental health condition, and that these conditions are likely to significantly interfere with his ability to drive a motor vehicle safely.

ORDER

64For the reasons set out above, pursuant to subsection 50(2) of the Act, I confirm the Registrar’s decision to suspend the appellant’s driver’s licence.

Released: November 7, 2024

__________________________

Dr. Isla McPherson, Member