Substance use among applicants for vocational rehabilitation services.

Recent clinical and research findings have clearly demonstrated that the presence of a physical, mental, or psychological disability can place an individual at greater risk for problems associated with substance abuse (Buss & Cramer, 1989; de Miranda & Cherry, 1989; Moore & Siegal, 1989; Moore, 1991). Despite the fact that persons with disabilities experience disability-specific and more common risks for substance abuse, little has been known of the patterns of alcohol and drag use among people with disabilities and the associated risk factors.

There is little doubt that substance abuse by consumers of rehabilitation services interferes with their success in these systems. It has been postulated that untreated substance abuse as a co-existing disability eventually will lead to medical problems or other barriers to a fully functional life. "In their collective wisdom, rehabilitation counselors have recognized that a significant portion of the persons whom they serve have two or more disabilities. The first disability, the mason they were referred, was often recognized as a physical or mental disability. It is usually easily diagnosed with common functional limitations. The second disability, substance abuse, is rarely mentioned and often recognized late in the rehabilitation process." (Corthell and Brown, 1991, p. ix.)

Substance abuse can either precede or follow the onset of another disability (Glass, 1980/81), but often it leads to the acquisition of other disabilities. For example, subacute head injuries may be a common by-product of a lifestyle that includes drug abuse (Alterman and Tarter, 1985). When substance abuse is present there are more likely to be additional risk factors as well. The risks include limited social resources, low socioeconomic conditions, and multiple disability status, all of which reduce the likelihood of successful vocational rehabilitation (Heinemann, McGraw, Brandt, Roth, & Dell'Oliver, 1990; Ford & Moore, 1992; Renwick & Krywonis, 1992). Nevertheless, there have been few previous studies addressing substance abuse problems in rehabilitation settings, and consequently little is known of rehabilitation procedures with individuals who experience both chemical dependency and a concomitant disability.

In 1990, the SARDI (Substance Abuse Resource and Disability Issues) project was funded by the Center for Substance Abuse Prevention (CSAP) to address issues of substance abuse and disability among a variety of professionals, including those working in rehabilitation settings. This five state regional pilot was conducted in Illinois, Indiana, Kentucky, Michigan, and Ohio. During the two-year period of primary study, 30 agencies and organizations such as university disability offices, vocational and medical rehabilitation programs, community mental health agencies, and other specialized disability services contributed to an extensive evaluation data base.

The purpose of this article is to illustrate the findings from the survey of alcohol, other drug, and medication use conducted within Michigan Rehabilitation Services (MRS), one of the SARDI service and research sites. More specifically, prevalence and distributions of substance use among rehabilitation applicants, as well as their disability conditions, attitudes toward substance use among people with disabilities, and demographic background are described. In addition, primary relationships among the variables of interest are examined.

Method

Subjects

The respondents in this study were individuals with disabilities who were seeking vocational rehabilitation services at a number of field offices for Michigan Rehabilitation Service (MRS). A total of 246 respondents within the MRS system completed the survey questionnaires. The 19 respondents who claimed to have chemical dependency as a primary disability (7.7%) were excluded from data analysis in order to focus exclusively on substance use among people with other disabilities.

Of these 227 respondents, 62.4 % were male. The median age was 35 years. Caucasians comprised 76.0 %, while 19.5 % were African American. Respondents self-reported the following "primary disabilities": 16.7 % - mental illness, 14.5 % - learning disability, 6.6 % - hearing impairment, and 13.7 % - spinal cord injury. Slightly over 30 % of the respondents had congenital disabilities. For those with acquired disabilities, half experienced disability onset before 25 years of age. Approximately 26 % of the respondents self-identified as "multi-disabled", and 39.2 % reported on-going problems with chronic pain. A total of 52.3 % of the sample took prescribed medication when the survey was conducted, and over 40 % were using prescribed medication from two or more different doctors at the time when the survey was conducted. Educational level was not obtained from respondents due to the primary goal for the survey and limited time and resources.

Research Questions and Measures

Several research questions were generated based on previous studies by the authors and reviews of the literature. These include: 1) How does alcohol and other drug (AOD) use of applicants compare with the general population? 2) Are there demographic differences in AOD use rates among applicants? 3) Do individual attitudes toward disability correlate with rates of AOD use?

The primary research instrument of this study was a self-report questionnaire, which consisted of 119 variables. Questions regarding substance use and their consequences were chosen to parallel information from existing national and drug use epidemiology studies (e.g., National Household Survey on Drug Abuse, NIDA, 1990). The major dependent variables in this study were use of psychoactive substances, including cigarette smoking, alcohol, and illicit drug use. Current use of alcohol and marijuana were measured by two separate questions, with seven response categories ranging from "Never" to "More than one time per day". Variables on smoking and lifetime cocaine and crack use were also measured by single items. These questions mimicked items on the National High School Senior Drug Use Survey (Johnston, O'Malley & Bachman, 1985).

Independent variables included attitude toward AOD use among people with disabilities; disability conditions, including nature and onset of disability as well as presence of chronic pain; and demographic background in terms of gender, age, and race. Face validity of these questions were based on expert opinion. Favorable attitude toward AOD use among people with disabilities was obtained by the statement: "Because I have a disability, I sometimes get the feeling that I have less to lose and more to gain from using alcohol or other drugs than people who are not disabled." The individuals responded on a seven point likert-type scale ranging from "1" - " strongly disagree" to "7" - "strongly agree."

Procedure

At least one staff member in each of the 34 field offices located throughout the state was designated as being responsible for data collection. New applicants to the MRS system were asked in serial order if they would be willing to participate in a confidential survey of medication and other drug use. Those volunteering for the survey were provided with a check for $5 for their completed survey. No attempt to randomize respondents was made, but field office staff members were directed to attempt recruitment of all applicants until their supply of surveys was depleted. Persons who could not complete a paper/pencil form, such as in cases of low reading ability, or visual limitations, could place a collect phone call to the researchers and complete the survey. To assure confidentiality, respondents were provided two number-coded envelopes in which to mail the informed consent and the competed questionnaire. All completed surveys were mailed directly to the principle investigator by respondents, thereby maintaining confidentiality.

Results

Current Substance Use

Figure 1 presents smoking distribution among MRS consumers who responded to the survey. A total of 20 % of the disability sample reported smoking more than one pack of cigarettes per day, and 21.3 % reported half to a whole pack a day. Another 9.8% reported daily use in quantities smaller than a half pack per day. Among the MRS consumers more than a half of the sample (51.1%) were identified as current smokers, while approximately 27 % of general population reported smoking cigarettes during the last month (NIDA, 1991). The incidence of cigarette smoking among the MRS consumers was nearly twice as high as the general population, and it constitutes a significant health risk not withstanding any other complications arising from health problems or medication demands.

The alcohol use patterns are illustrated in Figure 2. Similar to the general population, 51.4% of MRS applicants report some current alcohol consumption (50.9% for general population; NIDA, 1991). Atproximately 5 % of the MRS applicants drink alcohol daily or more than once a day, and 6.3 % drink at least twice a week. According to the National Household Survey on Drug Abuse in 1988 and 1990, slightly over 5% of respondents in the general population used 5 or more drinks on 5 or more days in the past 30 days (NIDA, 1992).

Illicit drug use appears more prevalent among MRS consumers than the general population. A total of 10.4 % of the MRS respondents reported current use of marijuana, compared to 4.8 % for the general population (NIDA, 1991). Lifetime cocaine and crack cocaine use among MRS consumers was 28.8 %: meaning that this percentage of respondents had tried cocaine in their life time. The percentage is much higher than the 11.7% prevalence for the general population from a similarly matched age and geographic distribution group (NIDA, 1991). More outstanding, 17.7% of the MRS consumers had used crack cocaine, while the percentage of lifetime crack use for the general population was 1.9% (NIDA, 1991). Inspection of crack use distribution among MRS applicants indicated that consumers from all over the state reported use, not just those from large urban areas such as Detroit.

Percentage distributions of current substance use by gender, age, and race are demonstrated in Table 1. Male respondents report more frequent substance use than females across the three categories of smoking, alcohol use, and marijuana or pot use. The differences are statistically significant for alcohol and marijuana use. Among the four age groups (29 or younger, 30-39, 40-49, and 50 or older), people in their 30's have the highest percentages of cigarette smoking and marijuana use than others. The group with the highest percentage of current alcohol use is associated with those 40 to 49 years of age. No significant differences in use between African Americans and caucasians were found for either alcohol or marijuana, although caucasians reported somewhat lower marijuana use than others.

Table 2 presents results of substance use by disability. One significant relationship appears. Those respondents who have congenital disabilities (occurring either before or at birth) are more likely to use marijuana than those who report acquired disabilities. This finding is in direct contrast to previous studies of substance use by people with congenital v.s. trauma-originated disabilities (Moore & Siegal, 1989). Moreover, it is found that the respondents with chronic or steady pain and with multiple disabilities are more likely to use marijuana than those who don't experience chronic pain and multiple disabilities. Overall, however, self-reported multiple disabilities and chronic pain appear to not make statistically significant differences in substance use.

Attitude Toward Use in Light of Disability

Zero-order correlation coefficients were estimated for current alcohol use, drug use, and the respondents' attitudes of AOD use as a person with a disability. This was measured by the self-rating of agreement to the statement "Because I have a disability, I sometimes get the feeling that I have less to lose and more to gain from using alcohol or other drugs than people who are not disabled". The variable was coded as a seven-point scale, as were the variables of alcohol and drug use. As shown in Table 3, both current alcohol and drug use were significantly associated with a favorable attitude toward AOD use among people with disabilities. The more favorable the attitude toward AOD use among people with disabilities, the more likely the respondents use alcohol (r=.26) and marijuana (r=.18). Also, a statistically significant relationship is found between alcohol use and drug use, suggesting that those heavy alcoholic drinkers are likely to be heavy drug users as well.

Table 1

Percentage Distributions of Current Substance Use Among MRS Consumers by
Demographic Characteristics (N=224)

                Smokers          Alcohol users     Marijuana/pot users
             Yes        No       Yes        No       Yes         No

Gender

Male         55.4       44.6     58.0       42.0     13.8       86.2
Female       44.7       55.3     41.0       59.0      4.9       95.1

             Chi-Square=2.41     Chi-Square=6.00     Chi-Square=4.34
             Prob=0.12           Prob=0.01(*)        Prob=0.04(*)

Age

29/younger   44.8       55.2     53.7       46.3     11.9       88.1
30-39        57.7       42.3     50.7       49.3     14.5       85.5
40-49        50.0       50.0     57.9       42.1      5.3       94.7
50/older     50.0       50.0     35.3       64.7      5.9       94.1

             Chi-Square=2.47     Chi-Square=2.83     Chi-Square=3.44
             Prob=0.48           Prob=0.42           Prob=0.33

Race

White        47.0       53.0     51.5       48.5      9.1       90.9
Nonwhite     64.2       35.8     54.9       45.1     16.0       84.0

             Chi-Square=4.74     Chi-Square=0.18     Chi-Square=1.92
             Prob=0.03(*)        Prob=0.67           Prob=0.17

* p [is less than] .05

Discussion

Due to the context and purposes of this study, there are several limitations relating to the sample size, respondent selection, and the nature of self-report information. The sampling was not random, but involved serial recruitment of applicants to MRS field offices by counselors working at each of the 34 participating sites. Because the survey was completed by applicants to the MRS system, rather than active clients, there is some chance that these individuals would not qualify for services. A discussion of this possibility with MRS officials indicated that most applicants to their system eventually are accepted for services due to the nature and expertise of referral sources. The study was terminated after a pre-determined time period rather than after a set number of respondents had been recruited due to the responsibilities for respondent recruitment placed on agency counselors. Self-report drug use information can be considered suspect, although the incidence and prevalence figures obtained in this study do not imply a strong trend toward under-reporting use. In spite of the limitations, there are several findings worthy of consideration.

The results of this study support previous findings indicating that individuals with disabilities who are seeking vocational rehabilitation services use alcohol, tobacco, and other drugs as much as, or more than, the general population. The overall patterns of use, indicate that when considered as a group, people with disabilities have access to and use licit and illicit drugs on a regular basis: they also appear to experience greater risks for substance abuse than the general population.

Several categories of drug use appear to be especially high for the VR sample, not the least of which is tobacco use. The respondents in this study used tobacco at rates approximately twice as high as the general population, in spite of already experiencing health, medical, and likely fitness problems in excess of the general population. Such high rates of smoking are very likely to have an adverse impact on the overall success of vocational rehabilitation agencies in placing and maintaining clients in job settings. A strong case can be made for including smoking cessation treatment within the Individualized Work Rehabilitation Plan and including tobacco risk assessments as a routine part of vocational assessment.

The very high rates of lifetime use of cocaine and crack cocaine by the VR applicants is a matter of great concern. Reasons for these rates can only be speculated until more detailed study is possible. It may be that two distinct cohorts of individuals contribute to the high rates, those whose pre-morbid substance abuse patterns contributed to the acquisition of another disability and those with an early onset disability who have never been successfully confronted about their abuse even though it is of such proportion that it impairs the ability to hold meaningful employment. Typically, it is the vocationally-oriented group of high school students who report the most varied and frequent drug use in the national high school drug use surveys (Johnston, O'Malley & Bachman, 1985). Adults coming from such an educational background may constitute a substantial sub-group of those who seek VR services.

Table 2

Percentage Distributions of Current Substance Use Among MRS Consumers by
Nature of Disability (N=224)

                 Smokers        Alcohol users     Marijuana/pot users
               Yes     No        Yes      No       Yes       No

Congenital

Yes            52.2   47.8       54.4     45.6     17.6     82.4
No             50.6   49.4       50.0     50.0      7.0     92.8

               Chi-Square=0.04   Chi-Square=0.37   Chi-Square=5.52
               Prob=0.83         Prob=0.54         Prob=0.02(*)

Multiple

Yes            54.2   45.8       47.5     52.5      12.1    87.9
NO             50.0   50.0       52.8     47.2       9.8    90.2

               Chi-Square=0.31   Chi-Square=0.49    Chi-Square=0.23
               Prob=0.58         Prob=0.48          Prob=0.63

Chronic pain

Yes            52.9   47.1       57.0     43.0      12.1    87.9
No             49.6   50.4       48.8     51.2       9.0    91.0

               Chi-Square=0.22   Chi-Square=1.37    Chi-Square=0.51
               Prob=0.64         Prob=0.24          Prob=0.47

* p [is less than] .05
Table 3

Zero-order Correlation Among Current Alcohol and Drug Use, and Favorable
Attitude Toward AOD Use by MRS Consumers (244)

Variable                     1              2                3

1. Alcohol use               1.00
2. Drug use                   .18(**)       1.00
3. Favorable Attitude         .17(*)         .26(***)        1.00

* p [is less than] .05
** p [is less than] .01
*** P [is less than] .001

Regardless of the causes for such apparent rates for illicit drug use, there are immediate implications for vocational rehabilitation. It is very likely that a substantial sub-population of applicants to these systems have the most difficulty with vocational preparedness due to their drug use patterns, not any co-existing disabilities. It is imperative that VR counselors obtain accurate assessments of substance abuse involvement on all applicants to their systems, irrespective of the primary disability category. Attitudes that their "disability" in some way justified their consumption positively correlated with the heaviest users in the current study, and this may be an important clue during VR assessments for locating abusers.

In particular, VR counselors need to be aware that the "primary disability" may be the focus of everyone's attention, and therefore substance use problems are either ignored or forgiven by family members, friends and rehabilitation professionals. Accommodations to substance abuse issues within vocational rehabilitation must also address increased cooperation with other agencies. The rehabilitation process is made more complex when substance abuse is present, and it requires even more of an interdisciplinary approach for effective remediation.

Rehabilitation programs may lack expertise or resources for addressing substance abuse, and, therefore, these programs cannot meet the needs or recognize the recovery issues of a consumer with a substance abuse problem. At the same time, chemical dependency treatment programs do not typically include professionals with knowledge of severe physical disability. Therefore it is very difficult for such programs to adequately meet the needs of the substance abuse client with a physical disability. Limited financial and professional resources are most wisely utilized if substance abuse problems are addressed in combination with other physical and vocational rehabilitation issues within a multi-disciplinary context.

The models for creating interdisciplinary cooperation require further refinement and definition. Professionals in either drug treatment or rehabilitation lack proven methods for addressing co-existing substance abuse and disability issues. This is especially critical since untreated drug problems make physical and vocational rehabilitation unsuccessful. Also, untreated physical and mental vocational rehabilitation problems attenuate the effectiveness of chemical dependency treatment.

Although chemical dependency treatment and vocational rehabilitation can go hand in hand, VR counselors must be able to make determinations about when needed rehabilitation services are inappropriate because a substance abuse condition will render that service meaningless. This implies that some services or eligibility must be contingency-based, with demonstrated abstinence or sobriety as prerequisites to some VR services. This approach frequently is required of individuals whose primary disability is chemical dependency, but it is under-utilized with those with other primary conditions.

Author Notes

We gratefully acknowledge the assistance and support of Dr. Peter Griswald, Director, and Paul Wright from Michigan Rehabilitation Services.

Dr. Harvey Siegal, Director of the Substance Abuse Intervention Programs, School of Medicine, Wright State University has provided invaluable administrative and research assistance with this work.

This study was financially supported by a grant from the Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration.

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