Linda Murangira v. Registrar of Motor Vehicles, 2024 CanLII 33182

Licence Appeal Tribunal File Number: 15709/MED

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

Between:

Linda Murangira

Appellant

and

Registrar of Motor Vehicles

Respondent

DECISION

ADJUDICATOR: Dr. Erica Weinberg

APPEARANCES:

For the Appellant: Linda Murangira, Self-represented

For the Respondent: Ian Sookram, Representative

HEARD by teleconference: April 4, 2024

OVERVIEW

1Linda Murangira (the “appellant”) appeals from the decision of the Registrar of Motor Vehicles (the “Registrar” or the “respondent”) to suspend their 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 a report from a treating health care provider that the appellant suffers from a medical condition that may affect their 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 a vehicle of the applicable class safely.

3The Registrar takes the position that the appellant suffers from two medical conditions, namely seizure due to alcohol withdrawal and alcohol use disorder (“AUD”), that are likely to significantly interfere with their ability to drive a vehicle of the appropriate class safely and that this provides sufficient reason to suspend their licence under s. 47(1)(g) of the Act.

4The appellant appeals the suspension under s. 50(1) of the Act. They deny they suffer from either seizure due to alcohol withdrawal or AUD and deny they suffer from a medical condition which interferes with their 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 their ability to drive a motor vehicle of the applicable class safely.

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

i. Does the appellant suffer from a medical condition, namely seizure due to alcohol withdrawal and/or AUD?

ii. If so, are either or both likely to significantly interfere with their ability to drive a motor vehicle of the applicable class 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 their ability to drive a motor vehicle of the applicable class safely and I confirm the Registrar’s decision to suspend the appellant’s driver’s licence.

ANALYSIS

Does the appellant suffer from a medical condition?

(a) Does the appellant suffer from seizure due to alcohol withdrawal?

10The evidence presented at the hearing does not establish, on a balance of probabilities, that the appellant suffers from seizure due to alcohol withdrawal.

11The Registrar’s position is supported by the medical condition report (“MCR”) submitted by Dr. Bun.

12In the MCR dated August 19, 2023, Dr. Bun reported that the appellant suffers from sudden incapacitation due to seizure from alcohol/drug withdrawal.

13However, the appellant testified that they have never had a seizure, nor have they ever had loss of consciousness or syncope.

14Dr. Bun’s report contrasts with the October 18, 2023 completed Substance Use Assessment form by Dr. Brown-Shreves, who reported that the appellant had not experienced a seizure in the past 12 months. In the Comments Section, Dr. Brown-Shreves wrote, “This client has no history of documented seizures and reports never having had one.”

15I prefer the medical opinion of Dr. Brown-Shreves over the medical opinion of Dr. Bun and find on a balance of probabilities, that the appellant does not suffer from seizure due to alcohol withdrawal. The appellant testified they attended many weekly appointments with Dr. Brown-Shreves but only one appointment with Dr. Bun, that being the day Dr. Bun filled in for Dr. Brown-Shreves and completed the MCR. I assign less weight to Dr. Bun’s medical opinion regarding the condition of seizure due to alcohol withdrawal. I find, on a balance of probabilities, that Dr. Bun did not know the appellant’s ongoing issues as well as Dr. Brown-Shreves.

16I find that the Registrar has not established on a balance of probabilities that the appellant suffers from seizure due to alcohol withdrawal.

(b) Does the appellant suffer from AUD?

17The evidence presented at the hearing establishes, on a balance of probabilities, that the appellant suffers from a medical condition, namely AUD.

18The Registrar’s position is supported by medical reports completed by both Drs. Bun and Brown-Shreves, plus letters from healthcare professionals at the Royal Ottawa Mental Health Centre (the “Royal”).

19In the MCR, Dr. Bun reported that the appellant suffers from Substance Use Disorder to alcohol (AUD). In the October 2023 Substance Use Assessment form, Dr. Brown-Shreves reported that the appellant suffers from severe substance use disorder to alcohol (AUD) and has recently completed a supervised treatment program as a result of this reported condition. In the Comments Section, Dr. Brown-Shreves wrote that the appellant: is known for severe AUD; began naltrexone one week ago; and is tapering down their alcohol consumption with the aid of the medication. A March 8, 2024 letter, co-authored by social worker Mr. Pasha and Dr. Awadia (Addiction Medicine) at the Royal, confirms the appellant’s admission to the Royal’s Assessment and Stabilization Unit (“ASU”) from February 21, 2024 to March 1, 2024 and subsequent transfer to the Royal’s Concurrent Disorders Unit (“CDU”) on March 1, 2024. In a March 5, 2024 letter, social worker Ms. Gazel at the Royal stated that the appellant was admitted to the CDU for a 6-week long program, the purpose of which was to teach individuals skills to help manage their concurrent mental health and substance use disorder. A March 6, 2024 letter from pharmacist Ms. Kozyra at the Royal confirms that the appellant was prescribed naltrexone. As a licenced and duly qualified physician in the province of Ontario, I know that naltrexone is an anti-craving medication used to treat AUD. I take notice of this fact pursuant to s. 16(b) of the Statutory Powers Procedure Act, R.S.O. 1990, c. S.22 (the “SPPA”).

20The appellant argues that they do not suffer from AUD, they do not have a problem with alcohol/their alcohol consumption and they are not dependent on alcohol. They testified that in the past they could go long periods without consuming alcohol and are very disciplined with respect to their diet and alcohol consumption. However, over the past year or so when their mother became palliative and was admitted to hospital, and particularly when the appellant began sleeping overnight at the hospital to assist with their mother’s care, the appellant began using alcohol as a ‘sleep aid’ at home, consuming approximately 1.5 L of red wine over two-and-one-half days.

21When questioned, the appellant acknowledged that sometime around September 2023 they were also an in-patient at the Royal ASU, that they were prescribed and took naltrexone during this hospital stay, and then continued naltrexone for a short while afterwards.

22I prefer the medical information from the multiple healthcare professionals mentioned above over the appellant’s testimony and find, on a balance of probabilities that the appellant suffers from AUD. The named doctors are all qualified to make such a diagnosis and determine whether the appellant suffers from that condition, the appellant has attended the Royal as an in-patient on two separate occasions for management of AUD and the appellant has been prescribed and has taken naltrexone for AUD on two separate occasions.

23I assign less weight to the appellant’s testimony that they do not suffer from AUD and that using alcohol as a sleep aid does not mean they suffer from AUD. I know that consuming 1.5 L of red wine over two-and-one-half days approximates to at least four standard drinks of alcohol per day, depending on the percent alcohol in the wine. I prefer the healthcare professionals’ objective, medically supported assessments over the appellant’s subjective self-assessment.

24I find that the Registrar has established on a balance of probabilities that the appellant suffers from AUD. Accordingly, the Registrar has established that the appellant suffers from one of the two medical conditions alleged.

Is the appellant’s medical condition likely to significantly interfere with their ability to drive a motor vehicle of the applicable class safely?

25I find that the Registrar has proven on a balance of probabilities that the appellant’s medical condition of AUD is likely to significantly interfere with their ability to drive a motor vehicle of the applicable class safely.

26The Registrar’s representative argues that AUD can significantly interfere with a driver’s ability to drive safely and presents a safety risk to other road users. They further argue that in order to consider reinstatement of the appellant’s driver’s licence they require confirmation that the appellant has remained abstinent from alcohol for a period of one year and that this period may be reduced to six months if a healthcare practitioner confirms that the appellant has successfully completed an alcohol treatment program and is supportive of the appellant’s driving privilege.

27Section 14(2)(a) of the Regulation allows the Registrar to consider the Canadian Council of Motor Transport Administrators Medical Standards for Drivers [February 2021] (the “CCMTA Standards”), when determining whether the requirements of s. 14(1) are met. The Tribunal may take the CCMTA Standards into consideration, although they are not binding on the Tribunal.

28The Registrar relies on the CCMTA Standards, in particular Chapter 15.6.3 (Substance Use Disorder) plus internal policies at the Ministry of Transportation. Chapter 15.6.3 provides that all drivers suffering from Substance 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 re-licencing may be considered upon favourable recommendation from an addiction specialist and/or treating physician recognized by the licensing authority, and the successful completion of a drug rehabilitation program.

29Furthermore, the respondent’s representative stated that the effects of alcohol on the functions necessary for driving may include: reduced reaction times; blurred or double vision; altered depth perception; reduced judgment and insight; blunted alertness; and reduce motor co-ordination.

30The appellant argues that they do not suffer from a medical condition that significantly interferes with their ability to drive a motor vehicle safely.

31The appellant testified that they: have been abstinent from alcohol since September 26, 2023, now over six months; have never driven a motor vehicle after drinking alcohol; and do not currently have any alcohol in their home.

32When questioned about their drinking/driving habits during the time when they were going back and forth to care for their mother at a hospital Mondays to Fridays from 11 p.m. to 7 a.m. and prior to their driver’s licence suspension, the appellant testified: they never drank alcohol prior to 6 p.m.; they may have consumed ‘a glass of wine’ to get 3-4 hours sleep prior to returning to the hospital; and perhaps they drove to the hospital following this.

33When questioned why they returned to the Royal for treatment starting February 21, 2024, the appellant testified that they had been unable to get doctors to assist them in getting their driver’s licence back and thought that being monitored/supervised on a more long-term basis at the Royal would be helpful.

34In addition, the appellant testified that their plan going forward is to: complete the CDU program (completion date of April 14, 2024); remain abstinent from alcohol; potentially volunteer in one of the group programs at the Royal; and regain employment.

35I acknowledge that: 2023 was a very difficult year for the appellant; the appellant’s Extended Driver Record Search For Criminal Code Convictions shows no entries for alcohol-related offences; the appellant plans on abstinence as a lifestyle; and they are a very disciplined and capable person.

36However, I note inconsistencies in the appellant’s unwavering testimony that they have been abstinent from alcohol since September 26, 2023 and some of the medical information before me.

37Dr. Brown-Shreves’ October 18, 2023 completed Substance Use Assessment form states that: the appellant has not yet abstained from alcohol, began naltrexone one week ago; is tapering down their alcohol consumption; and currently reports an alcohol consumption of roughly three drinks per week.

38Moreover, I find on a balance of probabilities, that the laboratory data the appellant submitted from their recent stay at the ASU is inconsistent with a person who has been abstinent from alcohol for a prolonged period of time (e.g., six months) prior to admission to hospital on February 21, 2024. I note that the appellant’s liver function/enzyme tests (i.e., Aspartate Transaminase [“AST”], Alanine Transaminase [“ALT”] and Gamma-Glutamyl Transferase [“GGT”]) were all measured to be well above the normal range on February 22, 2024, yet these values decreased significantly when re-measured on February 28, 2024. Although these enzyme tests may be affected by other diseases of the liver or other organs and by medications, I know that such a drastic reduction of these liver enzyme values in six days, i.e., AST from 208 to 61 (normal <31); ALT from 110 to 49 (normal <36) and in particular GGT from 807 to 332 (normal <36) is, on a balance of probabilities, consistent with a recent rather than a prolonged abstinence from alcohol. In addition, I also note that the appellant’s red blood cells’ Mean Corpuscular Volume (“MCV”) was elevated on admission at 103 (normal 76-98). Although I know that a MCV can be elevated for other reasons, a high MCV is a common marker of alcohol overuse affecting red blood cell composition. I know red blood cells have a lifespan of about 90 days in the blood, so if the appellant had been abstinent from alcohol for 90 days or longer prior to admission to the Royal, I would have expected the MCV to have normalized. I take notice of this information as a licenced and duly qualified physician in the province of Ontario, under s. 16(b) of the SPPA.

39When questioned about what their hospital doctor(s) told them regarding their abnormal laboratory findings, the appellant testified that their doctor(s) stated it had to do with their ‘high consumption history’ and that in due time the laboratory values should or would decrease.

40While the CCMTA Standards are well-reasoned and provide assistance, every case must be considered on its own facts.

41Although I am not bound by the CCMTA Standards, I find them reasonable.

42Given the evidence and submissions, I am persuaded to apply the CCMTA Standards in the circumstances of this case.

43The use of alcohol affects the functions necessary for driving including reaction times, visual acuity, judgement and insight, alertness and motor co-ordination. The use of alcohol impairs a driver’s judgment and behaviour towards others, including in 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.

44I acknowledge that, when considering earlier re-licencing of a driver’s licence for AUD, Chapter 15.6.3 of the CCMTA Standards does not state a specific time period required for abstinence. In addition, I acknowledge the appellant’s testimony that they have been abstinent from alcohol since September 26, 2023, now over six months. However, despite the optimism, when taking into consideration the inconsistencies in the appellant’s testimony and the medical information before me, and the fact that the appellant still denies or cannot accept they suffer from AUD, I find on a balance of probabilities that the appellant currently lacks sufficient insight into their condition of AUD. 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 their treatment regime and any conditions of licensing. Insight is an important consideration when determining fitness to drive.

45Furthermore, based on the circumstances of this case, I find that it is too early for earlier reinstatement of the appellant’s driver’s licence. The appellant is still completing the CDU program. Although the appellant testified that their physician at the Royal may provide a narrative letter following completion of the CDU program on April 14, 2024, as of the date of the hearing, the appellant has no favourable recommendation from any treating healthcare professional for earlier re-instatement of their driver’s licence. The appellant testified that they are not following-up with Dr. Brown-Shreves at this time. I accept that the respondent’s submission that further time and medical information should be submitted is reasonable keeping in mind public road safety.

46I am satisfied on a balance of probabilities that the appellant’s medical condition is likely to significantly interfere with their ability to drive safely.

Conclusion

47I find that the Registrar has discharged the onus of establishing on a balance of probabilities that the appellant suffers from AUD, that is likely to significantly interfere with their ability to drive a motor vehicle of the applicable class safely.

ORDER

48For 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.