Licence Appeal Tribunal File Number: 15576/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:

Matthew Mitchell

Appellant

and

Registrar of Motor Vehicles

Respondent

DECISION

ADJUDICATOR: Dr. Isla McPherson, Member

APPEARANCES:

For the Appellant: Matthew Mitchell, Appellant

For the Respondent: Ian Sookram, Agent

Held by teleconference: February 20, 2024

OVERVIEW

1Matthew Mitchell (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 from a treating physician stating that the appellant suffers from a medical condition that may affect his ability to drive a motor vehicle 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 a medical condition, namely seizure due to alcohol withdrawal, that is 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 seizure due to alcohol withdrawal 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 seizure due to alcohol withdrawal?

ii. If so, is this 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 a medical condition that is 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 substance use disorder?

10The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely seizure due to alcohol withdrawal.

11The Registrar’s position is supported by:

i. a Medical Condition Report dated February 12, 2023, completed by Dr. O.;

ii. a discharge summary dated February 12, 2023, completed by Dr. O.; and

iii. a narrative letter dated February 2, 2024, written by Dr. W.

12The Medical Condition Report (MCR) submitted by Dr. O. supports the respondent’s position that the appellant suffers from seizure due to alcohol withdrawal. Dr. O. admitted the appellant to hospital following a presentation to the Emergency Department via ambulance on February 11, 2023, and submitted an unsolicited MCR dated February 12, 2023, identifying two medical conditions. Dr. O. reported that she suspected the appellant suffered from a seizure due to alcohol/drug withdrawal and checked the box on the form indicating that this disorder has a moderate or high risk of sudden incapacitation or has resulted in sudden incapacitation, and that it has a moderate or high risk of recurrence. In addition, Dr. O. checked a second box on the MCR indicating that the appellant has a diagnosis of an uncontrolled substance use disorder with alcohol and is non-compliant with treatment recommendations.

13Following the submission of the MCR, the Registrar suspended the appellant’s driver’s licence effective February 23, 2023, and requested the completion of a Substance Use Assessment Form.

14The appellant submitted a Substance Use Assessment Form completed by Dr. A., dated September 28, 2023, which supports his position that he does not suffer from seizure due to alcohol withdrawal or alcohol use disorder. The form indicates the appellant does not suffer from a substance use disorder, that he continues to consume alcohol without a period of abstinence, that he did not complete a supervised treatment program, and that he did not suffer from a seizure in the past 12 months. Dr. A. identified themselves as an addiction medicine physician and provided a narrative comment indicating that based on an assessment on September 28, 2023, the events of February 11, 2023, were not in keeping with a withdrawal seizure.

15In response to the submission of the Substance Use Assessment Form, the Registrar continued the appellant’s driver’s licence suspension and requested from the appellant the discharge summary from the February 11, 2023 admission to hospital. The respondent testified that the Registrar was looking for clarification given the conflicting medical information received.

16The discharge summary dated February 12, 2023, supports the Registrar’s position. In this submission, Dr. O. recorded a discharge diagnosis of alcohol withdrawal seizure. She acknowledged that the seizure event was unwitnessed but described the medical reasoning to arrive at the diagnosis, including the context of heavy alcohol use with suspected decrease in the previous 24 hours, the appellant’s state of confusion, and an elevated lactate level. Dr. O. recorded under the past medical history, “alcohol use disorder, previously 12 years”. Regarding treatment, Dr. O. noted that, during the current admission, the appellant required detoxification from alcohol but left the hospital before completing the recommended treatment. Dr. O. reported the appellant’s girlfriend disagreed with his discharge from hospital when she stated, “[the appellant’s girlfriend] would have preferred him to stay in hospital for detox.“ Dr. O. further documented that, as the appellant “intends to continue with the same level of drinking,” she therefore recommended a community-based addiction program and that, should the appellant wish to stop drinking, she advised he not stop abruptly but receive assistance from his family doctor or a detox program. She explicitly stated that she advised the appellant not to drive.

17In response to the submission of this discharge summary, the Registrar continued the appellant’s driver’s licence suspension due to the medical condition of seizure due to alcohol withdrawal and advised the appellant he would be eligible for reinstatement once he provided confirmation that he remained seizure free and abstinent from alcohol for a period of one year. However, this period could be reduced to six months if a healthcare provider confirms he successfully completed an alcohol treatment program and is supportive of driving privileges.

18In advance of the hearing, the appellant submitted a letter from M. Pleau, a community withdrawal management counsellor, stating the appellant has been receiving community withdrawal management services since January 12, 2024, and is eligible for three months of services. The note further states that they are working with the appellant to maintain relapse prevention from alcohol.

19In response to the submission of this letter, the Registrar confirmed the suspension due to seizure due to alcohol withdrawal and now required prior to reinstatement that the appellant remained seizure free and abstinent from alcohol for a period of six months and has support from a healthcare practitioner for driving privileges.

20The appellant submitted a letter from Dr. W., Clinical Director of the Substance Use and Concurrent Disorders Program, dated February 2, 2024 which supports the Registrar’s position. The letter states the appellant has sought out treatment at the Rapid Access Addiction Medicine Clinic in the Substance Use and Concurrent Disorders Program and has a diagnosis of an alcohol use disorder. Dr. W. further states that the appellant reported he stopped drinking as of December 11, 2023, and his bloodwork has not yet returned to normal but has improved, suggesting he is abstaining. She indicates his bloodwork will be repeated, and he has been referred to counselling services and is currently taking an anti-craving medication for the alcohol use disorder.

21The appellant denies that he suffers from alcohol use disorder or seizure due to alcohol withdrawal. The appellant takes the position that the seizure due to alcohol withdrawal diagnosis was based on extrapolation. The appellant testified that he has never had a seizure of any kind. The appellant relies on the Substance Use Assessment Form from Dr. A. that documents he does not have a substance use disorder nor had an alcohol withdrawal seizure.

22Under cross examination, the appellant testified that the night of February 11, 2023, he was “drinking heavily” and “wasn’t really responsive” so his girlfriend had phoned an ambulance. He testified he began drinking consistently over ten years ago but his alcohol consumption did not have an impact on his work or relationships. He testified that, over the past year or two he had been drinking 8-9 beers daily and maintains he does not have alcohol use disorder. He testified he abstained from alcohol for two months.

23The appellant testified that when he decided to stop drinking alcohol, the Substance Use and Concurrent Disorder Clinic he was a patient with required daily visits for seven days for assessment and to receive a tapering dose of Valium, an alcohol withdrawal medication. During this period of time, he reports he experienced symptoms of feeling “shaky”.

24During the hearing it was discussed that both the appellant and the respondent had submitted a completed Substance Use Assessment Form (SUAF) signed by Dr. A. and dated September 28, 2023. While the substantive content of the form was the same between them, the two copies of this form had clearly different handwriting documenting the demographic information as well as the date beside the signature. Both the appellant and the respondent submitted that they had not altered the form that each party submitted, nor did they have an explanation for why the form completed on the same day by the same doctor would have different handwriting. As the medical content of the SUAF was unchanged between the two copies, the form was accepted as evidence with consideration given to these unexplained differences in handwriting in the form from the respondent vs the appellant.

25The SUAF from Dr. A. indicates that the appellant does not have alcohol use disorder and is in direct contradiction to a more recent report dated February 2, 2024, from Dr. W., indicating that the appellant, “has a diagnosis of alcohol use disorder” and is currently receiving treatment. The appellant explained the differences in assessment and diagnosis between Dr. A. and Dr. W. as individual differences in each doctor’s practices. Under cross examination the appellant reported that he has seen Dr. W. more frequently than Dr. A.

26There is medical evidence before the Tribunal in the form of two submissions completed by Dr. O. documenting the diagnosis of seizure due to alcohol withdrawal at the time of admission to hospital in February 2023. The medical evidence from Dr. O. also indicates that there was a concurrent diagnosis of alcohol use disorder. The submission from Dr. W. confirms in a letter dated less than 3 weeks from the hearing that the appellant has a diagnosis of alcohol use disorder. These medical submissions are weighed against the appellant’s testimony that he does not have seizure due to alcohol withdrawal or alcohol use disorder and the medical evidence from Dr. A. in the SUAF indicating there is no alcohol use disorder and the event in February 2023 was not in keeping with a seizure.

27In considering evidence from these parties, I find the medical evidence submitted by Dr. O. to be persuasive and carry more weight than the medical evidence of Dr. A. regarding the medical event of February 11, 2023, necessitating admission to hospital. Dr. O.’s medical documentation was completed contemporaneously with the opportunity to consider not only the medical history, but the physical examination, relevant investigations and consult with the emergency department physician. While I considered the evidence of Dr. A. favouring the appellant, I recognize that her assessment was made after a significant amount of time elapsed as it was completed 7 months following the incident, and she would not have had access to the same assessment tools to arrive at a diagnosis as Dr. O., such as the physician examination, investigations or opportunity to collaborate with colleagues. Furthermore, Dr. A. has not provided an alternative explanation for the event that transpired on February 11, 2023 which was significant enough to require admission to hospital and substantial diagnostic investigations and monitoring.

28Dr. A.’s confirmation that the appellant does not have an alcohol use disorder is also disputed by the medical evidence in both Dr. O’s and Dr. W.’s submissions. Both Dr. O. and Dr. W. have documented that the appellant does have a diagnosis of alcohol use disorder, and Dr. W.’s submission is the most current information provided at less than three weeks prior to the hearing date. Dr. W. is also a specialist in addiction medicine and, by the appellant’s testimony, the physician he has seen most frequently regarding his alcohol use.

29Lastly, despite the medical content being the same on the two copies of the same-dated SUAF from Dr. A., the different handwriting between the two cause me to question the authenticity of both copies. In the absence of a satisfactory explanation for the handwriting discrepancy and for all of the above reasons, I decline to assign any weight to the evidence from Dr. A.

30Based on the evidence that I accepted, I find that the Registrar has established on a balance of probabilities that the appellant suffers from seizure due to alcohol withdrawal.

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

31I 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.

32The Registrar relies on the CCMTA Standards, in particular Chapters 17.6.3 (Alcohol Withdrawal Seizures) and 15.6.3 (Substance Use Disorder) along with internal policies at the Ministry of Transportation. Chapter 17.6.3 provides that all drivers are eligible for a licence if:

i. The treating physician has confirmed that the cause of the seizure was alcohol withdrawal (i.e., the driver is not epileptic)

ii. They have undergone addiction treatment and have received a favourable report from an addiction counsellor;

iii. And the criteria for licence reinstatement are met in accordance with the Substance Use Disorder Standard (see 15.6.3).

33Chapter 15.6.3 provides that all drivers suffering from alcohol use disorder may be eligible for a licence if they meet the criteria for remission and/or have abstained for twelve months. It also states that earlier relicensing may be considered upon favourable recommendation from an addiction specialist and/or treatment physician recognized by the licensing authority, and the successful completion of a drug rehabilitation program. The respondent indicated that the Ministry is requiring a minimum of six months of abstinence.

34Section 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.

35The CCMTA Standards indicate that seizures, such as the type of seizure the appellant is reported to have suffered, cause an episodic impairment of the functions necessary for driving and a driver cannot compensate. Thus, experiencing a seizure would significantly interfere with a driver’s ability to drive safely and present a safety risk to the driver themselves and other road users.

36The CCMTA Standards also indicate that seizures must be controlled as a prerequisite to driving and the purpose of a seizure free period for a provoked seizure is to establish that the likelihood that the provoking factor has been successfully treated or stabilized. As alcohol use is the provoking factor in this scenario, I am concerned that the latest medical report from a physician (Dr. W.), dated less than three weeks before the hearing, states that the appellant has an active diagnosis of alcohol use disorder, continues to demonstrate abnormal laboratory results and requires treatment with both counselling and prescription medication. In addition, the narrative letter from M. Pleau notes that the appellant is one month into a three month period of eligible services. These latest submissions do not suggest that the provoking factor of alcohol use has been treated and thus supports the Registrar’s position.

37The appellant argues that he does not suffer from a medical condition that significantly affects his ability to drive safely and he does not pose a risk to other drivers on the road. He testified that driving is essential to his life and his licence suspension has been a huge impediment. He testified that despite not having a diagnosis of alcohol use disorder or alcohol withdrawal seizure, he has taken additional steps “in good faith” and attended addiction services to address his alcohol use.

38I acknowledge the appellant’s position that he does not have a medical condition that will affect his ability to drive and the steps to address his alcohol use are considered, and that he has demonstrated a period of abstinence for two months. However, this falls short of the six month time frame advanced by the Registrar. Despite the steps taken by the appellant, the most recent medical submission, which was completed by Dr. W., does not suggest that the appellant has recovered or completed treatment for alcohol use disorder, nor does she give any support to the reinstatement of driving privileges.

39The only medical submission that refers to the appellant’s driving is the discharge summary from Dr. O. which states that she specifically advised the appellant not to drive.

40Based on the evidence and submissions, I disagree with the appellant’s position that he does not have alcohol use disorder or a seizure due to alcohol withdrawal. I find the narrative letter from Dr. W. to be current, clear, and written from a position of authority with her qualifications in addiction medicine and acting director of a substance disorder clinic. I accept her diagnosis that the appellant has alcohol use disorder. I also note that the appellant’s description of feeling “shaky” when he stopped alcohol and requiring a daily assessment and tapering dose of valium demonstrates further evidence of withdrawal symptoms requiring medical intervention. I find the appellant’s position that he does not have alcohol use disorder demonstrates limited insight into his alcohol use and its associated risks.

41Although not bound by the CCMTA Standards, the Tribunal may consider them 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. While each appeal including this one must be judged on its own merits, I am persuaded to apply the CCMTA Standards here. My review of the evidence shows that none of the conditions recommended for relicensing outlined in the CCMTA Standards have been met.

42I acknowledge the burden that the lack of a driver’s licence has on the appellant; however, driving is a privilege and not a right. Further, the relatively short period of abstinence from alcohol, diagnosis of alcohol use disorder and ongoing recommendations for counselling, bloodwork monitoring and prescription medication suggest that the provoking factor for the seizure has not yet stabilized. Given the complete incapacitation experienced when having a seizure and the inability to compensate while driving, I accept and apply the CCMTA guidance that having a period of stability of the provoking factor of a seizure is reasonable, and at only a third of the recommended period of abstinence passing, I find this relatively short period of time and the absence of support of a current treating physician to be insufficient to set aside the suspension.

43As 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

44I find that the Registrar has discharged the onus of establishing on a balance of probabilities that the appellant suffers from a medical condition, namely seizure due to alcohol withdrawal, and that condition is likely to significantly interfere with his ability to drive a motor vehicle safely.

ORDER

45For 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.