In Brief August 2011 • Volume 6 • Issue 1 Substance Use Disorders in People With Physical and Sensory Disabilities Approximately 23 million people in the United with physical and sensory disabilities—hearing States, including people with disabilities, need loss, deafness, blindness, and low vision—to better treatment for substance use disorders (SUDs), a major understand SUDs and assist their clients in finding behavioral health disorder.1 In addition, more than accessible SUD treatment services. 24 million adults in the United States experienced serious psychological distress in 2006.2 People with What is an SUD? and without disabilities may face many of the same Substance use disorder is a broad term that encompasses barriers to substance abuse treatment, such as lacking abuse of and dependence on drugs or alcohol insurance or sufficient funds for treatment services, or (Exhibit 1). It includes using illegal substances, such feeling they do not need treatment. as heroin, marijuana, or methamphetamines, and using In addition, people with disabilities may face other legal substances, such as prescription or over-the-counter barriers to SUD treatment, particularly finding medications, in ways not prescribed or recommended. treatment facilities that are fully accessible. Vocational SUDs Harm People With rehabilitation (VR) counselors, vocational education providers, and others who work with people with Disabilities disabilities report that their clients with SUDs have It is difficult to estimate the number of people with less successful vocational outcomes than clients physical disabilities who have SUDs. Some studies without SUDs.3 suggest that people with disabilities have higher rates To improve outcomes, it is important that clients of legal and illegal substance use than the general with disabilities and SUDs receive services for both population, whereas other studies show lower rates.5 conditions and that the disabilities do not prevent Although debate exists among researchers about the clients from receiving treatment for SUDs. This In prevalence of SUDs among people with disabilities, Brief is intended to help people who work with people there is agreement that active SUDs can seriously Exhibit 1. Defining Substance Abuse and Dependence Both substance abuse and substance dependence refer to maladaptive patterns of substance use. Substance abuse usually refers to using any substance in a way that leads to a failure to fulfill major responsibilities at work, school, or home, or to substance- related legal or interpersonal problems. It also includes using substances in situations that put one’s physical safety at risk. Substance dependence usually manifests as continued use of a substance despite negative physical or psychological effects, inability to cut down or control the use of the substance, tolerance (using more of the substance to get the same effect), and withdrawal symptoms when the substance is no longer consumed. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)4 provides fuller definitions of substance abuse and substance dependence. Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover IInn BBrriieeff harm the health and quality of life of individuals with before sustaining a disability will likely continue to use disabilities. An active SUD can: substances afterward. Other people may have developed ■ Interfere with successful engagement in rehabilitation SUDs after using substances such as pain medications or services.3 alcohol to cope with aspects of their disability or to cope ■ Interact with prescribed medications; alcohol, for with social isolation or depression. Exhibit 2 lists SUD example, can interfere with antiseizure medications. risk factors for people with disabilities. ■ Impede coordination and muscle control. ■ Impair cognition. Exhibit 2. SUD Risk Factors for People ■ Reduce the ability to follow self-care regimens. With Disabilities ■ Contribute to social isolation, poor communication, ■ Pain and domestic strife. ■ Contribute to poor health, secondary disabling ■ Access to prescription pain medications conditions, or the hastening of disabling diseases ■ Chronic medical problems (e.g., cirrhosis, depression, bladder infections). ■ Depression ■ Inhibit educational advancement. ■ Social isolation ■ Lead to job loss, underemployment, and housing ■ Enabling by caregivers instability. ■ Unemployment ■ Limited education Women With Disabilities and SUDs ■ Low socioeconomic level Across all age groups, more women than men are disabled.6 ■ Little exposure to SUD prevention education Women with co-occurring disabilities and SUDs are at high ■ History of physical or sexual abuse risk for experiencing physical abuse and domestic violence. One study of people with disabilities and SUDs found that 47 percent of women reported histories of physical, Numerous signs may suggest the presence of an active sexual, or domestic violence, compared with 20 percent SUD. These include, but are not limited to: of men with disabilities reporting abuse experiences. In ■ Dilated or constricted pupils. the same study, 37 percent of women reported sexual abuse, ■ Slurred speech. compared with 7 percent of men.7 ■ Inability to focus, visually or cognitively. Another study found that 56 percent of women with ■ Unsteady gait. disabilities reported abuse, with 89 percent of these ■ Blackouts. reporting multiple abusive incidents.8 What is more, being a ■ Insomnia. victim of physical or sexual abuse is a risk factor for SUD. ■ Irritability or agitation. ■ Depression, anxiety, low self-esteem, resentment. ■ Odor of alcohol on breath. SUD Risk Factors and Warning ■ Excessive use of aftershave or mouthwash (to mask Signs the odor of alcohol). For some people, drug or alcohol abuse is a direct or ■ Mild tremor. indirect cause of their disability, for example, by their ■ Nasal irritation (suggestive of cocaine insufflation). becoming intoxicated and then falling or causing a car ■ Eye irritation (suggestive of exposure to marijuana crash. Without SUD treatment, people who had SUDs smoke). 2 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover Substance Use Disorders in People With Physical and Sensory Disabilities August 2011, Volume 6, Issue 1 ■ Odor of marijuana on clothing. Other common screening tools are: ■ Abuse of drugs or alcohol by family members. ■ Alcohol Use Disorders Identification Test, available ■ Many missed appointments with VR, job interviews, at http://www.projectcork.org/clinical_tools/html/ and the like. AUDIT.html ■ Difficulty learning new tasks. ■ Michigan Alcoholism Screening Test, available at ■ Attention deficits. http://www.projectcork.org/clinical_tools/html/ ■ Lack of initiative. MAST.html ■ Drug Abuse Screening Test (including prescription Some manifestations of certain disabilities may be difficult drugs), available at http://www.projectcork.org/ to distinguish from the signs of SUDs mentioned above. clinical_tools/html/DAST.html For example, people with multiple sclerosis may have an ■ National Institute on Drug Abuse (NIDA)-modified unsteady gait, slurred speech, and memory impairment. Alcohol, Smoking, and Substance Involvement Other signs, such as depression or anxiety, may indicate a Screening Test, which includes prescription drugs, different, distinct behavioral health condition. available at http://www.drugabuse.gov/nidamed/ Screening for SUDs screening/ Screening is not the same as diagnosing; it simply indicates whether further evaluation by an SUD professional Screening is not the same as is indicated. The National Institute on Alcohol Abuse diagnosing; it simply indicates and Alcoholism (NIAAA) developed a single-question whether further evaluation screening tool for alcohol use disorder (Exhibit 3). Clients should also be screened for illicit drug use and prescription by an SUD professional is medication abuse. VR professionals, physical therapists, indicated. and others may benefit from training on how to administer screening and assessment tools. No screening tools have been validated in Deaf popula- Exhibit 3. Single-Question Screening Test tions.9 Ask men: “ How many times in the past year have If possible, clients who exhibit warning signs or symptoms you had 5 or more drinks in a day?” should be screened for SUDs. If screening is not possible or Ask women: “How many times in the past year have if the screening is positive, the client should be referred to you had 4 or more drinks in a day?” an SUD treatment provider for further assessment. A response of more than 1 day is considered positive. Some clients may benefit from a brief intervention (a discussion of 5 minutes or less) to prevent their substance use from becoming an SUD. Information on brief interventions for alcohol use disorders is available from The Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Substance Abuse Treatment Family Centered Substance Abuse Treatment Grants for Adolescents and their Families (Assertive Adolescent and Family Treatment) was designed to provide substance abuse services to adolescents (including those with disabilities and those from military families) and their families or primary caregivers in geographic areas where services are needed. Grantees implement evidenced-based practices that are family centered and context specific and focus on the interaction between youth and their environments. 3 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover IInn BBrriieeff NIAAA at http://pubs.niaaa.nih.gov/publications/AA66/ ■ Residential programs—short- and long-term AA66.htm. Clients whose signs suggest a mental health structured living to help people re-enter their issue should be referred to a professional for further community. assessment. In addition, people in recovery often attend mutual-help groups, such as Alcoholics Anonymous (AA), Narcotics Types of SUD Services Anonymous (NA), and SMART (Self Management and Recovery Training) Recovery to share experiences and SUD services include: support one another’s recovery efforts. Many meetings of ■ Prevention education—information in various AA and NA that are wheelchair accessible are identified formats that helps people understand the risks of in meeting lists. Online meetings are an option for those substance use. who are Deaf and hard of hearing, people with visual ■ Indepth assessment—an evaluation by a treatment disabilities, or people who live in locations without provider to determine whether an SUD is present accessible meetings. Some AA groups will pay for a and, if so, what level of care is needed and what sign language interpreter or make use of sign language treatment options are available. interpreters who are in recovery themselves. ■ Outpatient or inpatient detoxification—medically supervised withdrawal from alcohol or drugs. Accessible SUD Treatment ■ Outpatient treatment—psychosocial interventions Facilities and individual and group counseling on substance use. Despite requirements of the Americans with ■ Medication-assisted treatment and counseling— Disabilities Act (ADA), studies suggest that many methadone, buprenorphine, and other medications treatment facilities are not fully accessible to people for opioid dependence or acamprosate, disulfiram, with disabilities.10, 11, 12, 13, 14 Examples of physical barriers and naltrexone for alcohol use disorders; medication- include doors and hallways too narrow for wheelchairs, assisted treatment works best if combined with uneven flooring, nonfunctioning elevators, and a reliance psychosocial counseling interventions. Barriers to Treatment for People Who Are Blind or Visually Impaired A survey of VR counselors and SUD treatment providers found that barriers to SUD treatment for people who are blind or visually impaired are formidable. Frequently identified barriers are presented below: ■ Negative attitudes and prejudices about people with SUDs. Some VR professionals regarded people with SUDs and disabilities as “not worthy” of SUD treatment, particularly if outcomes are perceived as poor for people with these two co-occurring conditions. ■ Lack of staff training. SUD counselors reported a need to learn about working with people who are blind, and VR counselors report a need to learn about SUDs in their clients. ■ Inaccessible methods and materials. Many facilities that provide SUD services reported that they are “handicapped accessible” if they provide ramps for clients. But people who are visually impaired require Braille signs and other navigational features and alternatives to sight-based counseling treatment activities like films and booklets to have genuine accessibility to treatment services. Survey respondents noted it is important to identify which agency will coordinate comprehensive client care. Respondents also commonly mentioned that, because there are no formal mechanisms for shared communication and case management, SUD and VR services providers may not know how to manage cases and work together across fields to provide services for their clients.15 4 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover Substance Use Disorders in People With Physical and Sensory Disabilities August 2011, Volume 6, Issue 1 Treatment Innovations for People Who Are Deaf or Hard of Hearing Few fully accessible SUD treatment services exist for people who are Deaf. Specialty treatment facilities for people who are Deaf exist, but the number has declined in the last decade. In 2009, only five providers in the United States offered inpatient SUD services especially for people who are Deaf, and four provided outpatient treatment.16 A national survey in 2008 by SAMHSA found that 27 percent of opioid treatment facilities offered interpretation services for people who are Deaf or hard of hearing.17 However, there are numerous barriers to providing fully accessible mainstream SUD treatment to people who are Deaf, including cultural and linguistic barriers, lack of local SUD treatment providers trained to work with people who are Deaf, lack of American Sign Language interpreters, inability of people who are Deaf to participate in group counseling (a mainstay of SUD treatment), increased costs associated with making treatment accessible to people who are Deaf, and more.18 One way to fill the treatment gap is to advocate telehealth SUD treatment services for people who are Deaf. Telehealth technology, such as electronic mailing lists and video conferencing, can connect people who are Deaf to appropriate SUD specialists across the country, and it can be adapted for an array of SUD services, from recovery support after treatment to mutual-help groups. Telehealth could also be used to train more people who are Deaf to be SUD counselors. One promising model piloted by Wright State University is Deaf off Drugs and Alcohol (DODA), a program for Ohio residents that supplements local SUD treatment with Internet- and video-based case management, group therapy, individual therapy, and followup. DODA also manages mutual-help/12-Step meetings available 7 days a week, which are conducted via video conferences and open to anyone in the country.18 More information on innovative SUD services for people who are Deaf is available at http://www.med. wright.edu/citar/sardi/doda.html. on signage to provide directions, which leaves people with Ways to Help Clients With SUDs low or no vision without a means to find their way through VR counselors, physical therapists, and others who work facilities. with people with disabilities are in a good position to Many other types of barriers exist. Some SUD treatment understand the importance of identifying and treating administrators believe that their facilities are more behavioral health conditions, such as SUDs, and to accessible than they actually are.14 Of various types of advocate for their clients’ right to accessible SUD healthcare providers, outpatient SUD treatment providers treatment services. To help clients with SUDs: are among the least likely to report that their services are 1. Learn about behavioral health issues, such as SUDs, accessible to people with disabilities or that they have had and promote prevention. A wealth of information about training on mobility impairments.10 drug and alcohol use, abuse, and dependence and their Comparatively little information is available on how many consequences can be found online. people with disabilities have been denied SUD treatment because of physical barriers in the treatment facility itself. ■ Free ADA-compliant publications on SUDs can be One survey of 174 SUD treatment providers in Virginia downloaded from SAMHSA’s Publication Ordering found that 87 percent of people with multiple sclerosis, Web page, at http://www.store.samhsa.gov/home 75 percent of people with muscular dystrophy, and ■ Information about drugs of abuse is on NIDA’s Web 67 percent of people with spinal cord injuries who sought site, at http://www.nida.nih.gov services were denied SUD treatment services because of ■ Information about alcohol use disorders is located on physical barriers at the treatment facility.13 NIAAA’s Web site, at http://www.niaaa.nih.gov 5 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover IInn BBrriieeff ■ An overview on SUDs for VR counselors, Substance and Cognitive Disabilities, was written to help SUD Use Disorders and Vocational Rehabilitation: VR treatment providers work with people with cognitive and Counselor’s Desk Reference, and other information on physical disabilities. Appendix D, in particular, is useful substance use and people with disabilities is available for advocating accessibility in treatment facilities. The from Wright State University, at http://www.med. TIP is available online at http://www.ncbi.nlm.nih.gov/ wright.edu/citar/sardi/products.html bookshelf/br.fcgi?book=hssamhsatip&part=A52487. A Quick Guide based on TIP 29 was created to help SUD 2. Don’t ignore signs of a possible SUD in clients with treatment administrators comply with ADA requirements disabilities. When there is doubt that disability alone and better serve people with disabilities. The Quick Guide explains a sign or behavior, screen the client for an SUD or is available at http://www.store.samhsa.gov/product/ refer the client to a behavioral health specialist for further QGCT29. evaluation. SUD is a preventable and treatable condition. A nonjudgmental approach to giving feedback to clients Other resources include: about the potential consequences of their substance use ■ Baylor College of Medicine Center for Research on can enhance their motivation to seek further evaluation and Women with Disabilities treatment. http://www.bcm.edu/crowd Click on “Secondary conditions.” From the resulting 3. Build a directory of local treatment providers and page, click on “Substance abuse.” facilities that work with or would be willing to learn to work with people with disabilities. SAMHSAʼs online ■ Minnesota Chemical Dependency Program for Deaf Substance Abuse Treatment Facility Locator includes and Hard of Hearing Individuals more than 11,000 U.S. treatment facilities. State-specific http://www.mncddeaf.org information is available at http://dasis3.samhsa.gov. ■ Wright State University Substance Abuse Resources Online recovery meetings are available in a variety of and Disability Issues (SARDI) Program formats, including text-based chats and discussion forums, http://www.med.wright.edu/citar/sardi audio and telephonic meetings, and video meetings. Many links are available from the SARDI home page. Information about online meetings is available at: The “Materials” link offers access to several print resources available free or for a small fee. These ■ Alcoholics Anonymous Online Intergroup include Substance Use Disorders and Vocational http://aa-intergroup.org/index.php Rehabilitation: VR Counselorʼs Desk Reference; ■ Narcotics Anonymous Chat and Online Meetings for Substance Abuse, Disability & Vocational Drug Addicts Rehabilitation; and Blindness, Visual Impairment, and http://www.12stepforums.net/na Substance Abuse. ■ SMART Recovery Online 5. Once a client enters treatment and is ready for VR, http://www.smartrecovery.org/meetings/olschedule.htm work with the client’s primary care physician, SUD case manager, and other treatment professionals to 4. Where possible, help SUD treatment administrators best serve the client. TIP 29 (Chapter 4) presents ideas on understand how they can make their facilities establishing linkages for case management. The chapter accessible to people with disabilities. SAMHSA’s can be viewed at http://www.ncbi.nlm.nih.gov/bookshelf/ Treatment Improvement Protocol (TIP) 29: Substance br.fcgi?book=hssamhsatip&part=A52886. Use Disorder Treatment for People With Physical 6 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover Substance Use Disorders in People With Physical and Sensory Disabilities August 2011, Volume 6, Issue 1 Resources 4 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author. TIP 29: Substance Use Disorder Treatment For People With Physical and Cognitive Disabilities, offers treatment 5 Yu, J., Huang, T., Newman, L., & SRI International. (2008). providers guidelines on caring for people with either Substance use among young adults with disabilities: Facts physical or cognitive disabilities, as well as drug abuse from National Longitudinal Transition Study 2. Washington, or alcohol abuse problems. The TIP discusses screening, DC: Department of Education Institute of Education Science. treatment planning, and counseling, and links to other 6 Centers for Disease Control and Prevention. (2009). Prevalence service providers (http://www.ncbi.nlm.nih.gov/books/ and most common causes of disability among adults— NBK14408/). United States, 2005. MMWR, 58(16), 421–426. 7 Wolf-Branigin, M. (2007). Disability and abuse in relation to Products based on TIP 29: substance abuse: A descriptive analysis. Journal of Social KAP Keys for Clinicians Based on TIP 29: Substance Work in Disability & Rehabilitation, 6(3), 65–74. Use Disorder Treatment for People With Physical and 8 Milberger, S., Israel, N., Le Roy, B., Martin, A., Potter, L., & Cognitive Disabilities Patchak-Schuster, P. (2003). Violence against women with http://www.kap.samhsa.gov/products/tools/keys/pdfs/ physical disabilities. Violence and Victims, 18(5), 581–591. KK_29.pdf 9 Alexander, T. D., & Tidblom, I. (2005). Screening for alcohol Quick Guide for Clinicians Based on TIP 29: Substance and other drug use problems among the Deaf. Alcoholism Use Disorder Treatment for People With Physical and Treatment Quarterly, 23(1), 63–78. Cognitive Disabilities 10 Bachman, S. S., Vedrani, M., Drainoni, M. L., Tobias, C., & http://www.kap.samhsa.gov/products/tools/cl-guides/pdfs/ Andrew, J. (2007). Variations in provider capacity to offer QGC_29.pdf accessible health care for people with disabilities. Journal of Social Work in Disability & Rehabilitation, 6(3), 47–63. Quick Guide for Administrators Based on TIP 29: Substance Use Disorder Treatment for People With 11 Thapar, N., Warner, G., Drainoni, M. L., Williams, S. R., Ditchfield, H., Wierbicky, J., & Nesathurai, S. (2004). A Physical and Cognitive Disabilities pilot study of functional access to public buildings and http://www.kap.samhsa.gov/products/tools/ad-guides/pdfs/ facilities for persons with impairments. Disability and QGA_29.pdf Rehabilitation, 26(5), 280–289. Notes 12 West, S. L. (2007). The accessibility of substance abuse treatment facilities in the United States for persons with 1 Substance Abuse and Mental Health Services Administration. disabilities. Journal of Substance Abuse Treatment, 33(1), (2010). Results from the 2009 National Survey on Drug Use 1–5. and Health: National findings. NSDUH Series H-38A, HHS 13 West, S. L., Graham, C. W., & Cifu, D. X. (2009). Rates Publication No. (SMA) 10-4856. Rockville, MD: Author. of alcohol/other drug treatment denials to persons with 2 Substance Abuse and Mental Health Services Administration. physical disabilities: Accessibility concerns. Alcoholism (2007). Results from the 2006 National Survey on Drug Use Treatment Quarterly, 27, 305–316. and Health: National findings. NSDUH Series H-32, HHS 14 Voss, C. P., Cesar, K. W., Tymus, T., & Fiedler, I. G. (2002). Publication No. (SMA) 07-4293. Rockville, MD: Author. Perceived versus actual physical accessibility of substance 3 Davis, S. J., Koch, D. S., McKee, M. F., & Nelipovich, M. abuse treatment facilities. Topics in Spinal Cord Injury (2009). AODA training experiences of blindness and visual Rehabilitation, 7(3), 47–55. impairment professionals. Journal of Teaching in the Addictions, 8(1), 42–50. 7 Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover Behavioral Health Is Essential To Health • Prevention Works • Treatment Is Effective • People Recover 15 Koch, D. S., Shearer, B., & Nelpovich, M. (2004). Service 17 Substance Abuse and Mental Health Services Administration. delivery for persons with blindness or visual impairment (2010). Overview of Opioid Treatment Programs Within the and addiction as coexisting disabilities: Implications for United States. Rockville, MD: Author. Retrieved June 3, addiction science education. Journal of Teaching in the 2011, from http://www.oas.samhsa.gov/2k10/222/ Addictions, 3(1), 21–48. 222USOTP2k10.htm 16 Titus, J. C., & Guthmann, D. (2010). Addressing the black hole 18 Moore, D., Guthmann, D., Rogers, N., Fraker, S., & Embree, in substance abuse treatment for Deaf and hard of hearing J. (2009). E-therapy as a means for addressing barriers to individuals: Technology to the rescue. Journal of the substance use disorder treatment for persons who are Deaf. American Deafness and Rehabilitation Association, 43(2), Journal of Sociology & Social Welfare, 36(4), 75–92. 92–100. In Brief This In Brief was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by the Knowledge Application Program (KAP), a Joint Venture of The CDM Group, Inc., and JBS International, Inc., under contract number 270-09-0307, with SAMHSA, U.S. Department of Health and Human Services (HHS). Christina Currier served as the Government Project Officer. Disclaimer: The views, opinions, and content expressed herein do not necessarily reflect the views or policies of SAMHSA or HHS. No official support of or endorsement by SAMHSA or HHS for these opinions or for particular instruments, software, or resources is intended or should be inferred. Public Domain Notice: All materials appearing in this document except those taken from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication: This publication may be ordered from SAMHSA’s Publications Ordering Web page at http://www.store.samhsa.gov/home. Or, please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727). The document can be downloaded from the KAP Web site at http://www.kap.samhsa.gov. Recommended Citation: Substance Abuse and Mental Health Services Administration. (2011). Substance Use Disorders in People With Physical and Sensory Disabilities. In Brief, Volume 6, Issue 1. In Brief HHS Publication No. (SMA) 11-4648 Substance Use Disorders in People With Physical Printed 2011 and Sensory Disabilities