Policy Issues in VR Related to Consumers with Substance Use Disorders

1. Policy Issues in VR Related to Consumers with Substance Use Disorders Substance Abuse & Vocational Rehabilitation - the Elephant in the Room: Research, Policies, and Exemplary Practices Tuesday, Oct 16, 2007 Key Bridge Marriott Arlington, VA Dennis Moore, Ed.D. Professor, Department of Community Health Boonshoft School of Medicine Wright State University

2. Policy Issues in VR Related to Consumers with Substance Use Disorders Substance Abuse & Vocational Rehabilitation - the Elephant in the Room: Research, Policies, and Exemplary Practices Tuesday, Oct 16, 2007 Key Bridge Marriott Arlington, VA Dennis Moore, Ed.D. Professor, Department of Community Health Boonshoft School of Medicine Wright State University

6. Source: SAMHSA OAS, 2007

7. Employment rates at VR intake Persons with a diagnosis of SUD, TBI, or SMI have an average “work outside home” employment rate of 14.5% at the time of application to state VR programs, whereas all other disability categories have an average rate of 24.6% at this same period in time (Moore & Weber, 2003).

8. VR Consumer Profile Persons with SUD Consumers with SUD will have a 50% chance or more of experiencing each of the following: relationship problems due to their use, trouble at work or school because of use, victim of violence related to use, and likely to have been hospitalized because of use (RRTC, 2002: 6 state epidemiological study)

9. Significant Zero-order Correlation Coefficients of Drug Use: Six state epidemiological study VR Age (Exact age) -.069** Gender (Male=1) .065** Income (10 point scale) -.064** Family Use (Family substance abuse=1) .131*** Friend Use (Friend drug use=1) .417*** Attitude of Entitlement (13 point scale) .212*** Self-esteem (21 point scale) -.138*** Hostility (21 point scale) .126*** Risk-taking (21 point scale) .194*** ** p<0.01; *** p<0.001; “drug use” = ‘1’ (Moore & Li, 1998)

10. Recent finding – SUD prevalence • Substance Abuse in VR-Screener (SAVR-S) was validated using DIS & trained research interviewers with 1,000 consumers of VR in OH & IL • Active SUD diagnosis (DSM IV r Criteria) in 22.1% of sample (IL & OH) at time of application to VR • Finding is consistent with previous research (33% - 23%) (DiNitto & Schwab, 1993; Moore & Li, 1998) Heinemann, Lazowski, Moore, Miller, & McAweeney. (in press). Rehabilitation Psychology

12. RRTC findings - rural western state 2000(N=243: 27% response rate) • Overall 22.3% self-reported that they were an alcoholic, drug addict, or both an alcoholic and drug addict in recovery, while Chemical Dependency (CD) was designated by the Disability Services Division as the primary and/or secondary disability for only 2.5% of the sample.

13. VR agency policy response to RRTC findings • Show an ability to remain drug/alcohol free for a period of time (3-6 months), with verification • Be involved in abstinence support, with verification • Adhere to professional recommendations regarding recovery • Adhere to law enforcement requirements • Participate in periodic reviews with VR counselor • Responsibility to provide timely verification for the above contract to be signed by consumer and counselor

14. RRTC R3: State level policy analyses and the provision of rehabilitation services to consumers with substance abuse problems Why conduct this study? • Active SUD in VR likely 25% • Wide variability in prevalence of SUD in VR • Policies and practices impact SUD identification • Screening models for SUD not developed • Screening as a tool or weapon?

15. RRTC R3: State level policy analyses and the provision of rehabilitation services to consumers with substance abuse problems • Phase I – policy document review • Phase II –surveys of VR and SUD • Phase III – case studies of 6 VR programs

16. Factors identified via focus groups, interviews, expert opinion • Order of selection (OOS) • Functional impairment ratings of SUD • Confusion over eligibility (ADA, Rehab Act, SSA) • Sobriety waiting periods • Proof of sobriety • Availability of SUD treatment • Specialized vs. general caseloads and services • Perceived success rates for addressing SUD in VR • Counselor competency

17. VR Director Responses44 states

18. Does your VR policy manual address consumer substance abuse? N = 78 VR admin

19. From a practical perspective, please choose the order of selection description that best describes your agency?N = 78 administrators, 44 states

20. If your staff refer someone to substance abuse treatment, in what percent of the cases is VR likely to pay for that treatment based on your experience? SUD treatment paid by VR • Mean = 12.2% • range = 0-100%: SD = 28.8%

21. Do you have an MOU or working agreement with other (VR/AOD) agency, and does this involve a transfer of funds(VR = 44 states: AOD = 34 states)

22. Do you have a “sobriety waiting period”, either “formal” or “informal” in VR?

23. VR Counselors IL & OH

24. Do you screen for SUD?(N = 213 VR counselors in 2 states)

25. Do you feel that rehabilitation of persons with a history of a substance abuse disorder is more or less likely to result in a successful closure than consumers with other disabilities? N = 214 counselors, 2 states

26. How do you screen for SUD?N = 213 VR counselors in 2 states

27. If a reliable and valid, low-cost, short screening instrument for substance abuse were available specifically for the VR setting, would you use it? N = 214 counselors in 2 states

28. Please rate how effective you feel you are in working with a consumer who has a substance abuse problem

29. State Alcohol/Drug agency directors 34 states

30. How would you best classify the actual job description of your staff member who is in charge of compliance with the ADA for clients and services to persons with disabilities?N = 37 AOD admin

31. Is there a need for more vocational rehabilitation services for AOD clients in your state?N = AOD Dir

32. AOD Dept MIS includes disability-specific client variables required of providers (e.g., deaf, blind, traumatic brain injury)N = 37 AOD Directors 48.6% - yes 45.9% - no 5.4% - no response • Range 1 – 13 categories • Mean categories = 6.3

33. Disability Reported At Intake SUD Programs NY OASAS 1999 (N = 146,782) Persons entering tx = 12.3% have another disability Persons entering tx = 17.7% have two or more other disabilities Total 30.0% SUD + One other disability = 28.3% have MI as this disability SUD + Two or more disabilities = 91.7% have MI as one of them Moore & Weber, 2000

34. Additional policy-related issues identified through surveys and SUD screening • Should SUD screening be mandatory for VR applicants • Are SUD screening results available for record requests (e.g., SSA disability determination) • Client choice versus counselor judgment – is refusing SUD tx or support permissible? • Due diligence requirement for informing potential employer about relapse-workplace safety issues • When and how does consumer with SUD request accommodations from employer? • What additional confidentiality requirements exist with SUD records beyond HIPAA (e.g., 42 CFR)?

35. National Responses

36. A Conceptualization of consumer SUD within VR and AOD systems • (rehabilitation) Individual attempting or in recovery interested in “re-building” life, including work • (habilitation) Individual with “trifecta” of MI, SUD, and chronic medical conditions, where one or more of conditions is unaddressed in systems of care (Thompson, 2007) Evidence suggests 90% of resources needed for 10% of consumers

37. Federal Level: External Workgroup on Disability Policy Recommendations to CSAT/SAMHSA 2007 1: Train SAMHSA staff in disability and ADA 2: Data collection on disabilities in TEDS and the National Household Survey on Drug Use and Health 3: Enforce ADA-compliance Matrix for State Block Grants and discretionary programs 4: Identify cadre of national trainers skilled in disability-related interventions 5: Develop ADA Compliance Curriculum for states and treatment organizations 6: Develop SAMHSA website for persons with disabilities 7: Issue grants for treatment of youths and adults with physical and cognitive disabilities

38. Possible federal/national responses in VR (e.g., RSA, CSAVR) • Form workgroup comparable to SAMHSA disability workgroup to review findings and make recommendations • Support increased training in SUD for VR field, and inculcate in rehab training programs • Strengthen national and federal partnerships for data collection, identifying effective practices, and shared funding • Promote SUD detection and appropriate rehabilitation planning within VR systems • Disseminate information on best practices and policies Policies must be sensitive to Primary Diagnosis of SUD, as well as one of ‘hidden’ conditions

39. RRTC - NIDRR can assist with national plans • Facilitate national workgroup (e.g., via ICDR) • Publish and disseminate VR-SUD training materials • Publish research findings • myvrtraining.com website • Toolkits for VR professionals • Publish policies and related documents • Assist with education about need for disability-related variables in national datasets

40. Policy change increasingly falls to state, rather than federal government

41. Evidence to date suggests that solutions should include: • Data collection related to persons with disabilities in multiple settings, including SUD treatment • VR policies and practice guidelines relative to active SUD and rehabilitation responses • Coordinated inter-agency responses are required (i.e., VR, MH, and AOD agencies must work together) • Greater focus on training in SUD for VR and Disability Issues for other agencies

42. Q & A