Screening for undetected substance abuse among vocational rehabilitation clients.

Alcohol and other drug disorders (commonly refered to as substance abuse or chemical dependency) are problems frequently encountered in the field of vocational rehabilitation (VR). Nationwide, in fiscal year 1990, 215,924 clients of state VR agencies were successfully rehabilitated. Of these, 23,903, or 11.1 percent, had a primary disability of substance abuse or dependence, and 8,031, or 3.7 percent, had a secondary disability of substance abuse or dependence. In fiscal year 1990, the Texas Rehabilitation Commission (TRC), Texas' primary VR agency, rehabilitated 17,110 people. Of these, 2,641, or 15.4 percent, had a primary or secondary disability or both identified as substance abuse or dependence. While the remaining 84.6 percent did not have a primary or a secondary disability of substance abuse or dependence, little is known about whether there are undetected alcohol and drug problems among these clients which might hamper successful VR outcomes.(1)

Substance abuse or dependence may go undetected among clients for at least two reasons. The first is denial of these problems by substance abusers and their loved ones, a topic addressed in virtually every textbook on substance abuse. The personal experiences of VR professionals may also affect their perceptions of these problems. The second reason for undetected substance abuse is that like other helping professionals, VR counselors have been described as lacking adequate knowledge of substance abuse and as having inadequate preparation to work with this clientele (Dickman & Phillips, 1983; Greer, 1989). They may also give low preference to substance abuse clients (Marson, 1978; Allen, Peterson, & Keating, 1982; Goodyear, 1983). Although recent evidence indicates that knowledge and attitudes of professionals about chemical dependency may be changing in a positive direction (Taricone & Janikowski, 1990), failure to detect substance abuse may account for some clients being labeled rehabilitation failures rather than successes. The question of whether there is inadequate identification of alcohol and drug problems among VR clients concerned TRC and the Texas Commission on Alcohol and Drug Abuse enough to prompt the agencies to jointly sponsor research to investigate this issue. The study was conducted by faculty of The University of Texas at Austin, School of Social Work.(2)

Study Methodology

More specifically, the study described in this article was designed to address four questions:

* Is there undetected substance abuse among TRC clients?

* What types of instruments are most useful in screening for substance abuse among VR clients?

* Are clients with particular disabilities more likely to be undetected substance abusers?

* Does undetected substance abuse affect case closure status? In order to answer these questions, a field study design with quantitative and qualitative components was selected. Undetected substance abuse was defined as an alcohol or drug problem that was not identified by TRC as a primary or secondary disability of the client.

The researchers asked VR counselors in one district in central Texas to refer to them active clients, age 18 and older, who had been accepted for TRC services. Cost factors made statewide sampling impractical. Clients younger than 18 were excluded because additional consent from parents or guardians would have been required. Counselors were asked to refer clients whether or not they had a substance abuse or dependence disability, and clients with all types of disabilities were included. Research team members were generally not informed in advance of the client's disability. In some cases, the disability was obvious because the client was interviewed at a halfway house or sheltered workshop. Inclusion of clients with substance abuse disabilities allowed the researchers to determine if the instruments selected to detect substance abuse were accurately identifying those already known to have problems with alcohol or other drugs. Interested clients met with a research team member who described the study in greater detail, including confidentiality procedures. The researcher emphasized that the client's decision whether or not to participate would not affect his/her relationship with TRC.

To determine what type of instrument might be most useful in identifying substance abusers, the researchers considered a number of possibilities. Two different types of instruments, the Addiction Severity Index (ASI) and the Substance Abuse Subtle Screening Inventory (SASSI), were selected. ASI is a structured interview and SASSI is a brief, self-administered, screening device (these instruments are discussed in greater detail below). The research team members who administered the instruments were qualified clinicians and received special training for the study.

For the most part, the team members were able to alternate the use of the instruments so as not to introduce bias according to which clients took the SASSI and which took the ASI. In a few cases, the SASSI was used because the client did not have enough time to complete the ASI. Only the SASSI was used with deaf clients. A skilled sign language interpreter assisted. Deaf clients were not asked to complete the ASI, because signing the interview and translating clients' responses would have taken more time than other clients were asked to contribute and more time than clients might have been able to devote. The researchers could not identify any substance abuse screening instrument that had been validated with deaf people.

Instruments were administered over a 6-month period from November 1990 to May 1991. The TRC automated client data base was also used as a source of information. Clients also agreed to allow the researchers to review their case files. This allowed the researchers to determine if the client may have had a third disability of substance abuse or dependence (third disabilities are not entered on the automated data base) or if the counselor's notes indicated an alcohol or drug problem.

Instruments

The Addiction Severity Index was "developed to fill the need for a reliable, valid, and standardized diagnostic and evaluative instrument in the field of alcohol and drug abuse" (McLellan, Luborsky, Woody & O'Brien, 1980, p. 26). It has been widely used in substance abuse treatment and research and can be administered by helping professionals from virtually all disciplines with appropriate training (Grissom & Bragg, 1991). Administration generally takes a minimum of 30 minutes; but, with people who have communications disabilities or those who have significant problem histories, administration can take longer.

The ASI covers seven areas of the client's life: medical, employment and economic support, alcohol use, other drug use, legal, family and social, and psychological or psychiatric (McLellan et al., 1980). A score indicating the severity of the client's current problems can be computed for each of the seven areas (McGahan, Griffith, Parente, & McLellan, 1990). The ASI has been shown to be reliable and valid among substance abusers applying for treatment (for details see McLellan et al., 1980; McLellan, Luborsky, Cacciola, Griffith, Evans, Barr, & O'Brien, 1985; Fureman, Parikh, Bragg, & McLellan, 1990). It has been used in criminal justice settings and with mentally ill and homeless people, but reliability and validity with these populations has not currently been established. We are not aware of previously published work in which the instrument has been used with VR clients.

Although the ASI has no classification system (i.e., no normative scores or clinical cutting points) for distinguishing those who have alcohol or other drug abuse or dependence problems from those who do not, it provides substantial information about the individual that can be used to make an assessment. In this study, a panel of three of the research team members (all MSW's certified by the state of Texas, two of whom also have certification in the chemical dependency field) reviewed each client's responses to identify alcohol or drug problems. While there was a concern that this procedure might overestimate substance abuse problems, the researchers focused on the following responses:

* Number of years of problem use of alcohol, heroin, methadone, opiates or analgesics, barbiturates, other sedatives, hypnotics or tranquilizers, cocaine, amphetamines, cannabis, hallucinogens, and inhalants. The ASI criterion for problem use is three or more times a week for 6 months or more, or regular and severe abuse of alcohol or drugs in 2-day binges (Fureman, Parikh, Bragg, & McLellan, 1990, p. 19).

* The presence of alcohol or other drug-related consequences, such as drug overdose, delirium tremens, episodes of inpatient drug or alcohol treatment, evidence of medical concerns about addiction, and DWI or other alcohol- or drug-related arrests.

* Current attendance in outpatient counseling for drug or alcohol rehabilitation or current attendance at Alcoholics Anonymous or Narcotics Anonymous groups.

Examples of cases that the researchers classified as having alcohol or drug abuse problems were clients who had used illegal drugs for a period of years, had drug overdoses or suicide attempts using drugs, were experiencing problems related to long-term use of pain medications, had been in alcohol or drug detoxification or other drug treatment, expressed worries about their use of alcohol or other drugs, or had other alcohol- or drug-related problems. In an effort to provide a conservative estimate of the number of clients with alcohol or drug problems, certain types of cases were omitted, such as clients with a period of alcohol abuse in high school or college that seemed to be resolved in adulthood. Also excluded were clients with extensive use of prescription medication when it was indicated that use was closely monitored by a physician.