Substance Abuse and Vocational Rehabilitation –
The Elephant in the Room: Research, Policies, and Exemplary Practices
Dennis Moore Transcript
1. Title: Policy Issues in VR Related to Consumers with Substance Use Disorders
Dennis Moore, Ed.D.
Professor, Department of Community Health
Boonshoft School of Medicine
Wright State University
Dennis Moore: What I’m going to be talking about today is policy issues related to Voc Rehab and
particular consumers who have a substance use disorder and I’m going to touch on some things related to
some basic statistics about the general population and then the Voc Rehab population and then get into
some policy issues and some of the things that we’ve discovered in some recent research that we’ve done.
By the way, when I refer to SUD or “SUD,” that stands for “substance use disorder” and it’s probably the
most common convention for addressing that now and that’s what I’m going to be using throughout the
3. National SUD Baseline: Binge Alcohol Use
Let’s start by taking a look at some of the more recent statistics that are available on the general
population. The chart that’s in front of you now is a map of the United States and I know that you can’t
read the numbers below because they’re probably too small, but the red zones of the country (where all of
the Swedes live), starting from Wisconsin going to North Dakota, have the most frequent alcohol binge
drinking that occurs in the United States. And the states that would be traditionally Southern Baptist and
then Utah are notable in being the states with the least amount of binge drinking. The red states, the most
amount of drinking, indicates that 25-31% of the population 12 years of age or older binge drank within
the last month and binge drinking is five drinks or more on one occasion.
4. National SUD Baseline: Alcohol Dependence
The next chart is alcohol dependence or abuse in the last year, which would be an active SUD diagnosis
within the DSM, and it’s not quite the same states. And if we look at the number of people who have an
SUD for alcohol dependence or abuse, we’re talking about a red state where the range is from 9-10½%
down to a white state where it’s only about 6-7% and again the states aren’t exactly aligned and that’s
because policy and culture both impact the difference between heavy drinking and the consequences. It’s
possible to be heavy drinkers, such as the French, and have relatively lower rates of substance
dependence, and it’s an interesting thing. Policy is one of the things that impacts that and it could be
policy from everything that got talked about last session such as drunk driving laws, to the location of
facilities where you can buy alcohol. All of those things can make a difference in the rates of abuse and
dependence in a population.
5. National SUD Baseline: Illicit Drug Dependence
This chart is illicit drug dependence or abuse in the past year and illicit drugs, of course, are the things
that are the least covered under the ADA and the Rehab Act if somebody is actively using. The states that
have the highest abuse rates are not the same states that showed up in the alcohol chart. The red states
have a rate of 3-4% and that’s again the annual average for dependence or abuse of illicit drugs, and
actually the states in some respects reflect where methamphetamine problems are the most high. They
also represent for the most part rural states. Isn’t that interesting? And that goes back to a comment that
Jeff made in a previous session where he was talking about down state Illinois versus Chicago.
6. SAMHSA: Use & Abuse by Employment Status
The next chart also is produced by SAMHSA and it is a representation of alcohol and illicit drug use by
the status of working – working status – and in every case the red column is people who are unemployed,
the green column is people who are part time employed, and the blue column is people who are full time
employed. And you will notice that for people who are unemployed, the rates are higher for every single
category and that kind of makes sense. However, even for people who are employed full time, the base
rates are in many cases pushing or at 10%. For illicit drug use it’s somewhat less, but for alcohol it’s at
10%. And it’s about 50% higher for people who are unemployed. And the point I want to make with this
chart is that Alcohol and Drug use is endemic in this country. It does not differentiate whether you can be
employed or not employed. Many people are employed who routinely abuse substances. Unfortunately
when we’re talking about vocational rehabilitation, we’re talking about people who have other risk
factors, other challenges, in their lives, so when they use alcohol or drugs they may be less likely to get a
job or keep a job if they are using and I will go back to that in a little while. Carl?
Carl: The “other” category seems to be pretty large. Are they seasonal workers, migrant workers, what
falls into “other”?
DM: Actually there is only one other category, no, I’m sorry, there is another. I don’t know. I was
looking at the other category which is the total, the average across all. I’m not sure what entirely falls
into that category.
Carl: I would think seasonal or migrant workers and…
DM: And it could also be out of the workforce. Sometimes that shows up, which it can be a proxy for
disability, but it’s a little tricky to use that.
7. Employment Rates at VR Intake
We took a look at the employment rate at the time of intake into Voc Rehab for people with various
disabilities and what we did is we looked at the 9/11 data set, which is the large national Voc Rehab data
set that’s used. About 600,000 people per year are entered into that data set. If a person has a diagnosis
of substance use disorder, traumatic brain injury, or severe mental illness, their average of working
outside the home at the time of application to VR is 14.5%, whereas for people with most other disability
categories, 24.6% are employed at the time they apply to VR. That says quite possibly that people with
SUD, TBI, and mental illness are more challenged to find employment anyway and they enter the Voc
Rehab system almost a step behind in many cases because they’re not employed at the time that they’re
8. VR Consumer Profile: Persons with SUD
We took a look at a number of variables in a previous epidemiologic study that we conducted in six state
VR programs and these were located all across the US, from the rural west all the way to the east. What
we found is that a consumer in VR who has a substance use disorder has a 50% chance or more of
experiencing each of the following things: relationship problems due to their use, trouble at work or
school because of their use, being a victim of violence related to use or likely to have been hospitalized
because of use, so any of those can be warning signs that someone may have a substance use disorder.
9. Epidemiological Study of SUD Correlates
In the same study we looked at a number of variables that might predict who would be a substance abuser
and who wouldn’t, because many times it’s not obvious when somebody enters a VR program. And the
variables that are listed here are the ones out of an entire laundry list taken from the 9/11 data as well as
other things that ended up being correlated with the substance use: people tended to be younger rather
than average age or older in VR; they tended to be somewhat more male than female; they tended to have
a lower income or living in poverty; there was a higher association of abuse with people who reported
family use and also the best friend using (and both those make sense). The other interesting thing is that
we asked people if they felt entitled to use alcohol or drugs because of their disability and if people said
yes, it was more often correlated with the fact that they were already a substance abuser. It was
negatively correlated with self esteem. It was positively correlated with hostility and high risk-taking
scores, so I think you’re already seeing a profile and saying, yeah, a lot of this makes sense.
10. Recent Finding – SUD Prevalence
More recently we – as we were talking about in the last session – we’re validating the SAVRS, which is a
screening instrument for Voc Rehab that we developed, and we validated it with 1,000 consumers
primarily in Illinois and Ohio and we used trained interviewers and we used the diagnostic interview
schedule as a criteria for the DSM diagnosis. What we found is 22.1%, of all the consumers that we
interviewed, at the time that they were applying for services to VR, had an active substance use disorder
using the DSM criteria. By the way this finding is consistent with some previous studies. For example,
Diana DiNitto looked at Texas with a very extensive study a while back and she found about 1/3 of all the
consumers there had a substance use disorder when they applied for services…
11. Primary and Secondary Diagnosis of SUD
DM…so this is real. A lot of validation on it.
Audience: The DSM active?
DM: Active means that you have encountered problems within the last twelve months which qualifies you
for having that diagnosis.
Audience: Studies…I’m not familiar with that.
DM: Okay, I’m sorry. The 9/11 data are the reporting data at the Rehabilitation Services Administration
that report on all vocational rehabilitation services that are provided.
DM: Nationwide and there are about 600,000 people per year entered into that data set and nowadays
when you talk about 9/11 data it’s kind of confusing.
DM: Exactly. Well, bear in mind that 22.1% figure and then look at the chart that I have up here now.
This is a state by state percentage of SUD or substance use disorder that is either a primary or secondary
condition relative to all disabilities in the state. For example, the lowest state is Arkansas. Less than 1%
of all consumers they serve is diagnosed with a substance use disorder as either a primary or secondary
condition. Now let’s go to Neil Getsinger’s South Carolina at the other corner of this chart and 28.32% of
all their consumers are diagnosed with a substance use disorder as a primary and secondary. We’ve
looked at this particular pie from a number of different slices and there is no other disability in Voc Rehab
with this dispersion. There just isn’t. One of the things it says is this is very much a policy issue, it’s a
definitional issue, it’s a training issue, and a number of things that go with that. By the way, these data
were taken from 2005. Yes sir?
Audience: When you say time of intake you actually mean when people are certified as eligible?
DM: Correct. Yes. I’m glad you clarified that. When people actually are assigned a disability code and
that is reported to RSA. Those were the data that we pulled up.
Audience: Dennis, did you mean at application or certain eligibility?
DM: Whatever data get reported to RSA. Well…
Audience: Are these by the codes for disability or…
DM: Let me go on with one more point and then I can take your question, okay?
12. RRTC Findings – Rural Western State
In our last epidemiologic study, the six states that participated in our study were each sent an
individualized report on their state profile and one of the states that we reported to was from the rural
West and we told them based on 243 respondents, which was 27% of all the consumers they were serving,
in other words we got back a 27% return rate. Now normally when you’re doing survey research and you
get that low a number, you’re thinking, well, self selection will take out the substance abusers because
they don’t want to report on it. In spite of that, we found that 22.3% self reported they were alcoholics,
drug addicts, or both in recovery. That state for that year recorded 2.5% of their caseload as chemical
13. VR Policy Response to RRTC Findings
We sent the report to the state and obviously they digested it and they thought about it and I can just
picture some meetings happening, because this is what came out a couple of years later. They created a
policy for if a person was designated as having an SUD-related issue, that consumer was asked to sign
this contract. The contract said in effect that the individual has to show an ability to remain drug or
alcohol free for a period of time and in this particular time, they said it could be from 3-6 months, so they
gave some latitude there, with verification, be involved in an abstinence support program of some kind,
whether it be AA treatment, seeing a counselor, and again with verification, adhere to professional
recommendations regarding recovery, adhere to law enforcement requirements, participate in periodic
reviews with the counselor, and then have responsibility for promptly verifying the things that were
required. That’s one state’s response to this. Interestingly, when we look at the recent chart that I just
showed you of all the states, that particular state has jumped up five points from 2.5 to 7.5 in the
diagnosed substance use disorder in the state.
14. Policy Study Rationale
DM: So you had a question sir?
Audience: A definitional issue. Would it be possible that different states are applying substance use in
different way? Is it possible that to see how disparaging this is?
DM: Okay. The question is on definitional issues has there been any study into what that particularly
means? I’m going to be reporting on a little of that today, but not as much as I’d like because there are
different conditions, and I have a slide coming up here in a minute that will address your question a little
better so I’m going to defer it for a minute. Two years ago we began a policy study in our Voc Rehab, in
our RRTC that’s focused on Voc Rehab policy, and the reason why we did this policy study is that there’s
a (we know) an active substance use disorder rate that’s quite high in VR. We know that there’s wide
variability in the prevalence of SUD in VR as reported by the statistics through Rehab Services
Administration. We know that policies and practice really do change how SUD is identified, and also we
were developing a screening tool and we were essentially told by CSAVR, by a number of state directors,
are you developing a screening tool or a weapon? If this goes out and the wrong policies are
implemented, you’re going to end up eliminating people from VR service before they even have a chance
to get in the door. So that was one of the other things we had in mind when we went about looking at
15. Phases of the Study
We did this in three phases. We first took a look at all of the policy documents that we could find related
to VR or related to rehabilitation of people with disabilities that might apply, and in fact we’re almost
done with that compilation and we’re going to be posting that to our website sometime in the next five
months and that will be a list of all of the documents that we could find. The second thing we did is a
survey – we did a national survey of Voc Rehab and Alcohol and Drug state department directors. We
polled all of them and gave them an option of either responding online to a survey or sending a
paper/pencil form back to us. And then we also went to all of the counselors in Illinois and Ohio and
asked them a number of questions. We did not do that nationwide because it was too hard to do to begin
with and, secondly we needed to know more about Ohio and Illinois because we were implementing our
screening tool there. And then the third phase, as I mentioned in the other room, is we also are in the
process of completing six state-wide case studies where we went and worked for several days with the
Voc Rehab program people and also interviewed the Alcohol and Drug agency director and we’re in the
process of beginning to analyze that information now.
16. Policy Factors Identified
But several factors came out of these various processes where VR people are telling us what changes the
rate of how much you address substance use within your state as a VR agency. The most commonly
mentioned thing is Order of Selection. For people who are not familiar with that term, what that means is
a few years ago Voc Rehab agencies were provided the option in order to conserve resources and
essentially serve people better, they had a selection process where the most severely disabled were more
eligible than people who were less disabled. Nearly all of the Voc Rehab programs at one point or
another said yes, we’re going to Order of Selection. At the present time that’s backed off and I’ll show
you a slide on that. Another issue that has come up is: what are the functional limitations of chemical
dependency? I mean, if somebody’s in recovery, they’re better, there’s no problem, so it’s kind of like
this HIV issue. Well, we can serve you with HIV if you’re severely impaired enough to have AIDS, but
then of course you can’t work, so there’s some parallel there. We’re still finding there’s some confusion
over eligibility. The ADA and the Rehabilitation Act in particular are parallel documents but not the
same, and there are some things that apply with the Rehab Act that don’t apply with the ADA and in fact
we’re going to have a speaker tomorrow morning who’s going to be talking about that. And the Social
Security Administration also has some statutes that interface with Voc Rehab and sometimes create
confusion. A number of states have sobriety waiting periods. In other words, you can’t receive services
until you’ve proven that you’ve been abstinent for a certain period of time. And then some states have
different statutes or different policies or practices about how do you prove that you’ve been sober, and
that can range anything from going through a certified program to having people sign sheets for you at an
AA meeting to passing a urine test. Another policy issue actually has to do with the availability or, more
frankly, the lack of availability of accessible substance use disorder treatment. Many states have longer
waiting lists, especially for methadone and residential treatment and sometimes it’s very difficult to find
an accessible program for an individual with a physical disability or traumatic brain injury or MRDD or a
number of other conditions, so that was cited. Some states said that, well, the big difference is some
states have specialized SUD caseloads among their VR counselors and some don’t and that ought to
explain it all, so that’s another thing we entered in the mix. And then other people said, well, some
counselors just don’t feel that they’re successful in working with people with a substance abuse disorder
and so if they have that attitude, they’re not going to work with them and they’re not going to do a good
job and counselor competency was another issue where people cited that they, well, it’s really the more
experienced counselors who’ve been around twenty years who can do a better job with this than the
newer counselors. So those were some of the things we entered into the mix.
17. VR Director Responses
Well here are the responses that the VR agency directors gave us to some of that stuff.
18. VR Policy Manual Address Substance Abuse?
It was interesting that they were divided almost in half, where when we asked them: Does your VR policy
manual address consumer substance abuse? 41% of the states said yes and 53% said no, so it’s very
evenly divided. That’s interesting in a way that it would fall that way.
19. Order of Selection?
And then we asked them about Order of Selection and we did that by saying: From a practical
perspective, can you choose the Order of Selection description that best describes your agency? 50% said
yes, we have Order of Selection; 46.2% said no, we don’t have Order of Selection from a practical
perspective; and 3.8% said we have wide latitude in how we interpret it. So what we’re seeing now is
states are backing off from Order of Selection. They still have it on the books, but they’re opening it up
to wider and wider categories of people as they’re able to fill that need.
20. Pay for SUD Treatment?
Then we asked them the big money questions. Do you pay for substance abuse treatment? If your staff
refers someone to a substance abuse treatment facility, in what percent of the cases is VR likely to pay for
that treatment based on your experience? And we had a wide range from 0 to 100%, but the average was
12.2%. What that says, essentially, is VR is not used to paying for substance abuse treatment in most
cases and in most states that I’ve run into they pull out the orange card and flash it that says “payer of last
resort, sorry, go somewhere else.” And that seems to work.
21. MOU between VR & AOD?
We asked both the VR directors and the Alcohol and Drug agency directors if they had an MOU or a
working agreement with the other agency. In other words: does VR and AOD work together? We had
somewhat varying responses, which is interesting in itself. 15% of the VR directors said yes, we have an
MOU. 21.2% of the Alcohol and Drug directors said they had an MOU. I found out why now after
visiting so many states. MOUs tend to be a whole lot of different things and one of the things that state
departments do is create pro-forma MOUs saying we’re all going to play well in the sandbox together and
the directors sit down and they sign them and that’s kind of the extent of it. Getting to the heart of the
matter - do you share money? –we got a wide discrepancy. 3.8% of the VR Directors said yes, we share
money, but 18.9% of the Alcohol and Drug directors said we share money with that other department.
Now what does that say? I’m not sure, but one of the possible things is that the Alcohol and Drug
directors are more familiar with that formula thing that David Thompson mentioned in the last section
where he mentioned that, you know, we have you report on all these things. The Alcohol and Drug
director is thinking about, like, TANIF or some special section that they report on every year when that
money is actually a flow-through to Voc Rehab, but the VR director has lost track of that. But what this
says in the discrepancy is they’re probably not talking very much and certainly in our qualitative
interviews with the programs that we interviewed that was the case. Voc Rehab and Alcohol and Drug
have very different roles from their different perceptions and they don’t do a lot of talking generally.
22. Sobriety Waiting Period?
Let’s talk about another discrepancy that came up. We asked counselors, and, now granted, this is
counselors in Ohio and Illinois, and all of the VR directors, so it’s not a one on one comparison, but I
created this chart anyway because it matches everything that I have heard in this discrepancy. When we
asked if you had a sobriety waiting period, more of the VR directors will say no, they don’t, 79.5% of the
administrators say, we don’t have a waiting period, but only 50% of the counselors have that same
perception. And if we ask them, yes do you have one? Again in the field the counselors report that, yes,
we’ve got that waiting period, whereas fewer of the directors did. And of course the people in the field
are more unsure of it. Almost 22% of them said: I’m not sure if we have a waiting period or not. And
again that matches our counselor interviews where the counselor said, well, I don’t think it’s written
anywhere but I think it’s expected of me. And the other report we got back on that frequently is that,
well, it really depends on the supervisor, because our office is not like the one over in the next town.
They have a little different approach to this than we do.
23. VR Counselors
Now let me back up a bit and talk about this not as necessarily a negative thing. I think one of the values
in VR, and one of the beautiful things, is the primary tool in VR is the counselor – and any of the other
stuff that they bring to bear, and by and large they’re not only well trained but they’re very well respected
by their consumers, but any time you have a system that relies on individual skill competency and
individualization, you will get a wider variation of how people interpret policy, so just because policies
are interpreted in different ways in and of itself may not be a bad thing. Not in the VR system. Am I
making sense? Okay.
24. Do You Screen for SUD?
Counselors told us some other things that were pretty interesting, too. We asked them: Do you screen for
substance use disorder at the time when somebody comes into the program? 17% said no, I don’t screen;
34% said yeah, sometimes; 28% said usually; and 21% said always. In my experience, I would have to
guess that that’s probably a more optimistic figure than I’ve run into with some other data that we’ve
collected and from some of the reports we’ve had from the field. I don’t think it’s screened for very much
other than those standard forms that you have in your intake, and a lot of VR agencies have one or two
questions and that’s it. And that’s typically how the screening is done.
25. VR Counselor Prediction of SUD Success
We asked them: Do you feel that rehabilitation for persons with a history of substance use disorder is
more or less likely to result in a successful closure than consumers with other disabilities? 38% weren’t
sure and 59.5% said no, it’s less likely to result in a successful closure and only 2.3% said that it would be
more likely. I could be a cherry picker here. I could be one of those 2.3% of the counselors and have a
relationship with a solid substance use disorder treatment program and I could get consumers graduating
from that program and pull them into my caseload and I’d blow everybody else out of the water with the
closures because the closures there will be higher and will, in fact, Neil Getsinger was talking about that
in the last session where he said that 67% of the people coming out of his residential program were “26”
closures or successful closures. It’s interesting.
26. How Do You Screen for SUD?
We asked the counselors: By the way, how do you screen for a substance use disorder? 74% said they
use their own questions; 0.9%, less than 1%, said they use a standard instrument; 5.6% use the VR intake
form; and again about the same number said they don’t screen, just under 20%.
27. Interest in a SUD Screening Tool
So then we asked them the question: If a reliable and valid low cost short screening instrument for
substance abuse were available to you in a VR setting, would you use it? 80% said yes. That was
interesting. Only 1.4% said no and 17% weren’t sure. What happens to that 80% when you take this
form out into the field and then it goes into the memo that Jeff writes in Illinois saying: thou shalt start
doing this along with the literacy test., I think, is what you were facing in your state, then the staff in the
state have a slightly different take on that wonderfully free, available form. They go, oh, more
paperwork. I don’t have any time. My caseload just went up twenty people in the last five months. How
could I possibly do this extra work? But part of it is just a knee jerk reaction to the fact that, oh, it’s
coming. One of the things, by the way, that we had done to assist states in transitioning to using a
screening instrument got mentioned in the previous session. We have met with the power brokers. In the
VR feudal system, it’s not the director, it’s not the field service coordinator, it’s down stream a little bit –
it’s either the managers or the supervisors, because they interpret a lot of the policy, so we meet with
them and talk about the intent and why it’s important and how it plays out and at the same time we give
them the opportunity to let off some of that steam that would otherwise be vented on their administration.
In some respects, we become the bad guys rather than the administration in the VR program. Having said
that, though, we did find that about half of the staff are ecstatic about the fact that this is coming and that
they have a new tool that they can use.
28. SUD Self Efficacy of VR Counselors
We asked people how effective they felt in working with a consumer who has a substance abuse problem
and again it’s the same thing: about 33% said they generally feel effective, but about almost 60% said
they felt somewhat effective or not effective, with 12% saying they didn’t feel effective in working with
substance abuse. I’m sure that doesn’t come as a surprise.
29. State AOD Agency Directors
Then we asked some different questions of the state Alcohol and Drug directors and a lot of these fall into
a policy area.
30. AODA ADA Compliance
One of them is, essentially, a question: How do you know you’re complying with the ADA? How do you
know your treatment programs are accessible in your state? And one way to ask that is: Who on your
staff is responsible for monitoring ADA compliance? Interestingly, HR was only listed for about 30%, or
human resources; 8% of them probably were very honest and said, well, we don’t have any staff assigned
to that right now; and 62% popped into the “other” category, whatever that means. But I can help
interpret that a little bit. Alcohol and Drug agencies, in comparison with VR agencies, have many people
who are multitasking and multitasking in very diverse areas. Now VR does that as well, but it’s not the
same thing. You get AOD agency officials who have eight areas, all of which are reportable to the
federal government, all of which are mandated in some way or another, and then somebody comes along
and says, oh, by the way, we have this complaint that we’re not accessible to people who are deaf. This is
number nine for you. And that’s kind of how this evolved in Alcohol and Drug Agencies. There are just
so many unfunded mandates that are going on for them right now.
Carl: I think that’s probably true of VR agencies, like people working at the state level and district levels
or however ... they all wear multiple hats.
Carl: When I was in charge of …
DM: Carl, let me take a minute here. Judson, would you mind grabbing the mike and handing that to
Carl: As I was saying, I think that at administrative level people in particular in the VR program wear
multiple hats too. When I worked in Pennsylvania VR, I was the ADA Statewide Coordinator. I was also
the Drug and Alcohol Program Coordinator and Mental Health and Transition and so forth, so I think
that’s very typical in the VR agencies that we wear multiple hats, so I think that that’s very natural that
would fall into other categories.
DM: Okay, thank you. And I agree. We’re all doing too many things nowadays. There’s no two ways
31. VR Need for AOD Clients?
Another very telling question of the Alcohol and Drug Directors is: is there a need for more Voc Rehab
services for alcohol and other drug clients in your state? And there was an interesting split. 37.8% said
there was a great need and 49.5% said they weren’t sure, and I think this reflects the change in the
watershed that is occurring because workforce development and employment-related issues are just now
getting to the Alcohol and Drug agencies. SAMHSA has some initiatives now that are going on that are
really championing this cause. They have some effective practices on their website that promote this
approach, especially for people with co-occurring disorders, but it’s just now catching on. I remember a
few years ago I was asked to go to New York State and talk to Alcohol and Drug treatment directors
about vocational rehabilitation and I agreed to do it and then later somebody came to me and said, we
really need to explain to you what you’re walking into. These were with Alcohol and Drug directors and
treatment providers who have just been told they must include work and vocational rehab in the treatment
plan for every person going through their facility. They are not happy. So I found somebody better to
take that speaking engagement, somebody from New York City who could duke it out with them very
well, but they’re just now catching onto this and it’s a good thing.
32. AOD Disability Tracking
Another telling thing that strikes a theme that is a policy issue is: are you collecting data on people with
disabilities? And half of the Alcohol and Drug agencies are not. What we said is: does our agency
management information system include disability-specific client variables required of your providers?
And then we gave them examples: Deaf, Blind, Traumatic Brain Injury. Only 48.6% said yes. 45.9% said
33. Disability Reported at SUD Intake
Let me tell you why this is important from another perspective. About the same time that I got invited to
the New York State to talk with them there, I got access to their treatment episode data from all their
Alcohol and Drug treatment programs. And we took a look at almost 147,000 unique admits to treatment
in New York State in 1999. This is people going into a substance use disorder treatment program. On
their form they had to check off at the time of intake if this individual is hearing impaired or Deaf, are
they Blind, and they hit quite a number of categories. In fact they had close to ten at that time. We found
some things that surprised me. 30% of all people entering treatment had been listed as having a co-
occurring disability of some kind. Well I thought, okay, 30%, it’s got to be mental illness. Well actually
it wasn’t. If they had just one disability and substance use disorder, mental illness was not part of that
except in 28% of the cases. But if they had two disabilities and substance use disorder, then 92% of the
cases involved mental illness as one of the diagnoses. What that means, and I hope this is the next slide, I
don’t remember, it’s not. Okay, I’m going to just go back and explain it then. What this means is we
have a group of people who are the trifecta of disability. They have mental illness, they have substance
use disorder, and they have chronic medical conditions or physical disability. And it goes back to the
comment that was made earlier today about silos. These are not separate people assigned to different
programs. These are people – one of the people on my staff says, Dennis, in Dayton, Ohio, there are only
two hundred clients and every four years they change their names and their labels so they can get recycled
again. And there’s some truth to that. And this slide will show this in a minute, but essentially 90% of
our resources in systems like Alcohol and Drug systems are used by 10% of the consumers and these are
the people who are a real problem and they end up getting into Voc Rehab and not being diagnosed at the
time they’re getting in.
34. Additional Policy-Related Issues
The policy work that we did up to that point, which were the national surveys, and some focus groups
including a focus group we conducted at CSAVR among VR directors, and a look at the documents,
generated some additional policy related issues for us. One of the issues was: Should substance use
disorder screening be mandatory in Voc Rehab? It is mandatory in some other programs that are in some
respects comparable, such as some TANIF programs in the country. Some programs related to the Social
Security Administration. Pretty much the policy response I’ve heard from VR directors in CSAVR and
so forth is no, it should not be mandatory, that the VR system is based on client choice, it’s based on self
determination, it’s based on a number of other principles that conflict with this particular approach. This
got mentioned in a past session as well. Are SUD screening results available for record request? Can
they be subpoenaed? Is a person filling out a SAVRS’ screening form in our program jeopardizing their
application to Social Security because Social Security determination will ask for our records if that person
goes to Social Security after they’ve been here? That’s an issue that’s yet to be worked out in full. On
the other hand, we do know that if they manage to get that SSDI, their probability of returning to the
workforce right now is less than 3% because that’s about what the national average is for people on SSDI.
The other big issue that’s come out when we talk with counselors is: how do we deal with this whole
thing of client choice. I’m going to give you a screening tool and the consumer says no, I don’t want to
take that, that’s fine, okay, you don’t have to. The consumer comes in and maybe they’re intoxicated for
a visit or smelling of alcohol, maybe they’ve missed a visit, maybe they fail a drug test with an employer.
At what point can the counselor say, you know, we really need to address this issue even though you’re
saying no, this is not what I’m here for. And this is a policy practice issue that VR certainly at the field
level really struggles with. The other issue that came out that was mentioned in the previous session is
due diligence. Can I refer somebody who has a substance use disorder to an employer when that
individual may be operating hazardous, dangerous, or heavy equipment? And what is my obligation as a
counselor representing my agency in that respect? That’s very much policy issue and it’s one that we’re
working on some documents that address. And then one of the other policy issues that came out is how
does a consumer with a substance use disorder inform their employer, when and how? Under the ADA,
you can’t get an accommodation unless you identify yourself as somebody who needs one. In my
experience operating an Alcohol and Drug treatment program, the last thing on Earth our consumers learn
is whether or not they need an accommodation because they don’t recognize some of their own functional
Audience: What kind of accommodations?
DM: Some of the accommodations that are listed would be things such as getting time off from work or a
flexible schedule in order to attend treatments, a meeting, or pick up methadone, being diverted from a
high-risk of relapse environment to a lower-risk for relapse environment. In the construction industry, in
factories, in places like that, there are certain shifts of the day. Second shift is the safest, by the way, is
what I’m told, for someone who has a substance use disorder, or there are certain places where you don’t
want to work because like everybody in that shop is in the bowling league and the second goal of the
bowling league is bowling and we know what the first goal is. A consumer going into that environment
may not be aware of those things and that’s our job as VR counselors and Alcohol and Drug providers is
to get them in touch with those things as relapse risks that they really face in the work environment.
Another accommodation that people need that’s harder for them to talk about – in fact it’s a bear to work
with people on this issue – is memory related things. A number of people who go through substance use
disorder treatment have multiple conditions that have impaired their memory probably permanently.
Some of that will clear up after they detoxify and some won’t, but the fact of the matter is they’re not
going to learn as well from modeling, so they can’t watch somebody down the line do a job and then pick
it up. They may need supportive employment. They may need things broken down into discrete steps or
they may need other approaches to help them learn their job better and teaching people how to ask for that
and what to ask for is a real challenge.
Audience: I’d like to see a successful program that does that.
DM: I’ll send you the stats. I agree with you. It’s a real challenge. What we’ve discovered in our – our
treatment program by the way was set up specifically to serve people with coexisting disabilities. We
have a census of about three hundred people on an outpatient basis. A third of the individuals have a
traumatic brain injury, close to a third or a half have mental illness, and then we have many people with
physical disabilities as well. We can get people in touch with the fact that they’ve got to quit using,
reluctantly they’ll tell us, okay, I’ll quit the crack but I’m going to keep with the marijuana and the
alcohol, so we’ve got to work through that, but the thing that’s hard for them is figuring out how to ask an
employer for something they really need and why they need it.
35. National Responses
Okay. Let’s talk about some national responses to some of the policy issues that I’ve…
36. Conceptualizing SUD within VR & AOD
…brought up today, but again I want to go back and differentiate. We’re really talking about at least two
types of individual here. One needs rehabilitation, the other needs habilitation. The first person is the
person who is an individual who is attempting recovery and rebuilding their life, including work, and they
come in and say, I want a job, send me to community college. I want to be a counselor just like the one I
had in treatment. That actually is a pretty good bet for a closure and it’s a quick closure, doesn’t cost you
much as a Voc Rehab, and more chances are than not this individual will make it. And then the stats bear
us out on that. The second individual is the individual with a trifecta and this person may well have
gotten through the screening, is in the VR program already, but the substance abuse is not identified and
it’s much more difficult to address.
37. Workgroup Recommendations to CSAT/SAMHSA
So with those things in mind, let me give you some ideas and now that SAMHSA’s here, I’m going to put
you on the spot. These are actually recommendations to SAMHSA. SAMHSA has not considered them
officially yet. I’m on an external work group on disability with SAMHSA and this is what we
recommended in that process of providing them feedback and how best to reach out to people with
disabilities. We recommended that they train SAMHSA staff in disability and in fact they’re doing that
next week, coming back to town next week to do that, and that’s a wonderful thing. The second thing
was improve data collection across the country, both with the treatment episode data set and the national
survey on drug use and health, to include disability labels. Now this is like asking for another mission to
Mars from NASA. I mean, changing national surveys is so hard and so costly and if you think about if
someone went to all the Voc Rehab programs in the country and said we’re changing all of the 9/11 data
or we’re adding these ten variables you’ve got to report on next year – think about the cost and what that
would do to the MIS system. It’s very daunting, but it’s very critical.
David: I was recently on the Severity of Needs…
DM: David, go ahead. Grab the mike.
David: I was recently on the Severity of Needs for Ryan White reauthorization and they were looking at
all of the variables on core services and the data supports that. Guess what one of the weakest was on
national data? On HIV? They said just anything out of our database was very – doesn’t have hardly
anything – we have only the good states have been consistently reporting and we have good data, but
nationally there is none and we almost got cut out of core services out of Ryan White reauthorization.
Our residential was cut out. Even though it was residential treatment, it was cut out of Ryan White, but
outpatient was left in, and that was because of lack of data and it’s just another thing. You’re starting
about asking questions of VR, try asking it of HIV and other issues. It’s not there and I think Mars would
be easier. We could get there faster.
DM: By the way, the CDC, when they drafted Healthy People 2010 and all of the national health goals
that were going to be monitored, has an entire chapter on people with disabilities that’s probably – what?
– half an inch to three quarters of an inch thick, just on measurable outcomes for people with disabilities.
I sat in on a number of meetings when those goals were formulated, but because of the lack of national
data on substance use by people with disabilities, the only objectives that made it into that entire chapter
was reduce alcohol use by pregnant women with disabilities. That shows you how far behind the curve
we are in just collecting data to baseline some of this stuff. That’s a policy issue. Go back in the slide
and there are three goals in purple. They’re in purple because they’re all directed at states. States should
have some kind of compliance matrix in their block grants related to serving people with disabilities and
that’s something that could be done easier than creating a database or recreating a database. Identify a
national cadre of national trainers skilled in disability related interventions who can go and help the states.
CSAT and SAMHSA offers what they call “state based technical assistant” where a state can apply to
SAMHSA and get money to have experts come to the state and address specific questions. I’ve been
involved in three state TAs in the disability area and I know some other people have as well and I think
that could be really ramped up to help out. And then also related to that, develop an ADA compliance
curriculum for states and treatment organizations. And number five, developing that ADA compliance
curriculum, I think that should be delivered, taught, or jointly experienced by the Voc Rehab program in
that state. That should be the partner involved with the ADA thing. Probably as well as the Independent
Living movement. Now those are three friends sitting in a row, isn’t it? But that’s what it’s going to
take. The other two recommendations from the work report: develop a website for persons with
disabilities specific to substance use disorder and also create grant opportunities for doing large
demonstration programs in how best to serve people with disabilities within substance use disorder
treatment. On that note, I would like to tell you, and I’m especially pleased, SAMHSA has just awarded a
grant to Wright State University to create statewide substance use disorder enhanced treatment for people
who are Deaf in Ohio and we’re going to be doing that using e-therapy, video phones and video
conferencing equipment and I’m terribly excited about it. I think it’s going to be really great, but that’s
the kind of models that we need to be building.
38. Possible Federal Response in VR
Let me turn to the Voc Rehab side and suggest some things that we ought to do at the federal level. I
think we ought to form a workgroup similar to SAMHSA and what they’re doing in the disability area
and look at substance use disorder in particular. And that workgroup might – or should be – run by RSA
and CSAVR or those partners and some other agencies. Support increased training for substance use
disorder in the VR field and inculcate it into rehabilitation training programs. Right now substance use
disorder, as all of you are probably very familiar, in most training programs in the country, if you are in
the VR rehab track, you’re not in the chemical dependency track. It’s almost like two different worlds
and somewhere we’ve got to get them together a little better. And then, again, from the RSA, CSVAR,
and NIDRR side, we need to strengthen national and federal partnerships at data collection so that we can
better represent people with disabilities. We need to promote substance use disorder detection and
appropriate rehabilitation planning within VR systems. I think RSA or some entity should come out and
say, essentially, you know we need to better identify these people coming in the front door so it doesn’t
kick us in the butt and the consumer going out the back door. One of the things that Voc Rehab is facing
is that RSA and the federal state VR system moves about half a billion dollars per year to unsuccessful
closures. Five hundred thousand dollars, rather, five hundred million dollars. Not all of that is related to
substance abuse and I would be the first to recognize it, but some of it probably is, and if we do anything
to relate successful closures that’s a good thing. And the other thing is is to include substance use
disorder effective and best practices in that white book of other things that are going to be compiled. So
that RSA jointly funded an RRTC quite recently with NIDRR that’s going to be focused on Voc Rehab,
Voc Rehab systems, and effective and promising practices, and I think now is the time to start building
our experiences and our research in the substance use disorder field.
39. RRTC – NIDRR Assist with National Plan
And there are some things that I think NIDRR and my RRTC in particular can help with. I’m going to
mention the three briefly. We’re going to facilitate a national work group on this in some form at least for
some initial meetings and we’re probably going to do it through the Interagency Committee on Disability
Research. The ICDR is an officially statutorily established interagency committee that NIDRR chairs and
I think this would be one good vehicle to begin looking at this. We’re going to publish and disseminate
as much information as we can find on Voc Rehab and substance use disorder training materials. We
have a website up now that’s called “myvrtraining.com.” VR counselors can go to that site and for free
sign in, log in, and find themselves a password and go through eight CEUs (right now it’s six CEUs;
we’re going to have another module up in a while). They can go through those CEUs and learn about
substance abuse and disability, how to screen, how to write rehabilitation plans and a number of things
that are related to that. We’re also halfway through developing a tool kit for VR professionals that will
respect how everybody has to learn nowadays, which is you pull out your cell phone and you read three
lines or you pull out the label and you read two lines and you press this button. Well we’re essentially
going to write manuals that look like that. None of the topics we cover will be more than a page and that
way people will have a quick reference for what’s the basis for this, what’s the groundwork, what are
some of the bottom lines, and then if you want more information here’s where you go. So it will lead to
other things as well. And then along that same line we’re going to be publishing more policies and
policy-related materials for Voc Rehab directors and administrators, because some of the programs really
are in a conundrum. They want to do more, but every step they take there’s this new thing that comes up.
I had a real kick with Kentucky lately. We just started doing the SAVRS in Kentucky. They’re screening
all of their applicants to VR with the substance abuse screener. Every single day the Assistant Director of
the agency sends me a new email from one of their staff who sent her an email, well, how many people
lie? What percentage of people lie on this? Well another day they ask: What does it mean if this thing is
reliable and valid? Does that mean the person really is what this thing says is expected? Or the next day:
Should I tell the employer that this person has tested positive for this? So there’s all this dialogue going
around. So essentially every day I write this out and send it back to Kentucky, but I’m compiling it,
because we’re going to send it to the other states involved as well because it’s all good stuff. And then
again we are going to continue to help educate and advocate for more disability-related variables.
Having said all of that about the national level, do you know where policy change happens now? States.
40. Policy Change Falls to the States
The Governor of California set the standards. Even before the feds can get to it, he’s got a policy that’s
half the time in violation of what the coming federal statute is going to be and so the feds have to figure
out how they’re going to respond to that and whether or not they’re going to charge him with something
and, what do you mean, you’re going to legalize medical marijuana? We’re going to take away all of
41. Evidence Suggests Solutions…
Audience: We want to start a needle exchange, etc.
DM: Yeah, needle exchange is the same way. Other states are running the same way. But anyway states
are setting a lot of policy so this is where we really need to focus and so far our evidence is telling us that
the states need to be collecting this disability-related data in their Alcohol and Drug treatment programs,
in their TANIF program, in other programs that impact this population. VR programs need to probably
push their policies and practice guidelines relative to substance use disorder. One of the things that
happened in Ohio after we started the screener there is they created a policy workgroup comprised of
people at every level in the agency and the workgroup is meeting monthly for quite a long time each time.
They get together to hammer through what policies look like, what practice looks like, and the original
draft of what came out (versus what’s coming out two and a half months later) reflects quite a change, but
one of the things that’s happening is the circle’s widening so the Alcohol and Drug agency’s now playing.
And other really informed entities in Ohio are helping the VR program to come up with the same policy.
We also have to recognize that at the state level no single state agency can do it - it is not possible - and
therefore we have to reenergize the MOUs and the other things that really get things served and that’s an
important policy decision and in fact we need to identify and come out with models on how best to do
that because it’s difficult to do nowadays. I’ve worked with a number of states in doing things like this
and invariably they get to the 11th hour, it’s November out of the calendar year starting in January, and
one of the two state directors is gone and then this whole shuffle happens and everybody goes to a new
job, so all the people working on the project are now on other things or they’re picking up double duty, all
of that sort of thing. Somehow we have to figure out how to put that into the mix, because if we’re going
to work in an agency we have to accommodate the fact that nobody’s in their jobs very long right now.
And then of course the other thing is we need to have more of a focus on training in both substance use
disorder and in fact people with disabilities. And one of the things we’re doing in Ohio when we start up
the Deaf related services grant is we’re training all of the Alcohol and Drug providers in Ohio on Deaf
related services. Those trainings will be provided entirely by people who are Deaf and it’s going to be
really cool. I think it’s going to be very eye opening. And then we’re going to the Deaf related services
and training them in how to do the SAVRS, the screening instrument, and actually that’s serving two
purposes. As was mentioned earlier today, we don’t have an ASL related version of the SAVRS that
we’ve released to VR now. I wanted to, but the research team working on it basically said, it’s not
validated yet. We really can’t release it. So part of the money from SAMHSA is helping to validate the
instrument in settings that serve people who are Deaf, so within a year we are going to be able to release
an ASL CD version of the substance abuse screener. So anyway, that’s what I would recommend for
states. I am done with the slide show. We went from the federal to the state level and that’s where I left
it. Do you have any questions or comments? We’ve got just a couple more minutes if you’d like to stay.
42. Q & A
Audience: Just to refer back to that slide that you had all of the states, went from 2% up to like 30%...
Audience: And then you had a slide…
DM: Judson, could you grab the microphone please?
Audience: I’m going back to that slide that you had that showed the ranges from 2% up to about 30% and
then you had another slide with formal policy and I think it was like 50-50 saying no, there was no formal
policy, yes there was a formal policy. Did you do any sort of correlation to see those states reporting
higher rates of SUDs in the VR population that have formal policy in place?
DM: Not yet.
DM: We do plan on doing that. Part of the problem with doing that is the metric. How do you rate the
states in terms of how well they’re doing or how many policies are in place? Is having a policy in place
the best thing? I don’t know frankly. I interviewed a counselor who had a background as an Alcohol and
Drug provider, he was relatively new as a VR counselor (he’d been in his job five years) and he was
touted as being one of the best and most promising counselors in this field office. And one of the
questions I asked him in the interview was, do you ever screen for substance use disorder among
consumers coming in to meet you? He said no, never.
DM: How come? Well, it’ll become obvious and it’s their responsibility and they need to own it and so
we talked about that for a while and he said, I never use drug testing but if the issue comes up I will talk
to the consumer about it. And having a background as being an Alcohol and Drug treatment person, I
could see that he would probably be very effective at it. He had a very laid back attitude and an attitude
that, hey, it’s your decision. It’s not mine. Let me just help you look at this. And I could see for him that
that particular approach might be very, very effective at helping a consumer buy in, but that’s not
typically how you think of this. Normally you’d think, yeah, you want to know early on and you want to
press it a little more, but he had a very discrete personal policy that, by golly, I’m not going to ask, but if
it comes up then we’ll deal with it.
DM: Okay. Well thank you very much.