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News and Notes   |    
Psychiatric Services 1999; doi:
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People with physical and cognitive disabilities continue to face many barriers that limit their options for substance abuse treatment or render their treatment experiences unsatisfactory, an expert panel convened by the Center for Substance Abuse Treatment concluded in a report released in January. The report is designed to help program administrators and clinicians recognize barriers that continue to stigmatize and discriminate against people with disabilities.

According to the report, nearly a sixth of all Americans have a disability that limits their activity, and countless others have hidden disabilities, mostly cognitive, that go unrecognized and undiagnosed. Reliable data are limited, but the prevalence rate of substance use disorders is thought to be twice as high among people with disabilities as in the general population—20 percent versus 10 percent.

Many people who suffer traumatic injuries, such as spinal cord and head injuries, have serious substance use disorders that often have led to the accidents that caused their disabilities, the report points out. Others begin to abuse substances after they become disabled, in part because of unemployment and poverty (30 percent of disabled individuals live below the federal poverty level), lack of recreational options, social isolation, homelessness, and victimization or physical abuse.

The report notes that some people with disabilities may perceive bars as the only social gathering places open to them, and drinking and drug use as their only recreational outlet or source of social support. Caregivers of disabled people—families as well as professionals, the report notes—often "look the other way" when a disabled person drinks or takes drugs, and they may even encourage substance use out of misguided feelings of pity.

A complicating factor highlighted in the report is that people with disabilities sometimes have great difficulty acknowledging that they have a substance use problem to overcome in addition to the struggle with their disability. Recognizing the substance problem may force them to cope with painful emotions related to recovery from the disability. Denial of both the substance use problem and the disability is not uncommon. Adjustment to severe disabilities is considered a lifelong process, the report notes. In addition, individuals with cognitive disabilities may be unable to recognize their functional limitations and substance use problem.

Substance abuse treatment programs should carefully screen persons entering treatment, as well as those already in treatment, for hidden disabilities, the report emphasizes. Functional limitations and symptoms related to hidden disabilities are likely to become apparent as clients participate in treatment, and providers should have a heightened awareness of signs and symptoms. The report includes a structured interview, the Impairment and Functional Limitation Screen, that includes suggestions for follow-up treatment.

A major barrier to treatment cited by the report lies in the attitudes of nondisabled people, which are often shaped by media stereotypes. Attitudinal barriers are especially problematic when they occur among treatment staff. Some staff members may believe that persons with disabilities do not abuse substances, while others may think they will make too many demands and use their disability as an excuse for not fully participating in treatment. Still others may fear that a person with a disability will sue the program or will make other clients uncomfortable. The report strongly emphasizes the importance of staff training. It includes an extensive appendix of resources for information, training, and technical assistance.

The panelists acknowledge that providers who have never worked with someone with an obvious disability may feel awkward or embarrassed, unsure of what to say or what help to offer. Thus the report includes many practical tips to help staff members feel more comfortable in asking questions and providing help. In addition to general tips on "disability etiquette"—such as asking "May I help?" and following with "How may I help?"—the report offers specific guidance on conducting intake interviews and developing treatment plans for people with different disabilities.

To help programs comply with the Americans With Disabilities Act (ADA), an appendix to the report reproduces a 25-page compliance guide for alcohol and drug programs published in 1996 by the Pacific Research and Training Alliance. The guide outlines a four-step plan for removing discriminatory policies and practices as well as attitudinal, communication, and architectural barriers. Included are answers to frequently asked questions about ADA compliance. A separate chapter addresses tasks for program administrators to undertake to open their doors to patients with disabilities.

The report emphasizes the importance of case management and interagency cooperation in the treatment of persons with disabilities and includes tips on building, formalizing, and maintaining linkages. The report cites studies showing that between 60 and 70 percent of people with disabilities are either underemployed or unemployed. Addressing and overcoming barriers to employment, with the aid of partners such as state vocational rehabilitation agencies, may be the most important way that treatment programs can enhance outcomes. The report was released at a press conference on January 13, the same day that President Clinton announced a coordinated and aggressive new national policy to bring adults with disabilities into the workforce (see box on page 435).

Entitled Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities, the report is number 29 in the Treatment Improvement Protocol (TIP) series developed by the Center for Substance Abuse Treatment. TIPs are available on the CSAT Web page at www.samhsa.gov. They can be ordered free of charge by contacting the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.

Senators Introduce Legislation to Allow Disabled Persons Who Work to Keep Health Coverage

A bipartisan group of U.S. senators has introduced legislation that would allow employed people with disabilities to buy health insurance through the Medicare and Medicaid programs even if their incomes or improvement in their medical status make them otherwise ineligible. Passage of such legislation was a major recommendation of the Presidential Task Force on Employment of Adults With Disabilities (see the February issue, page 279).

Sponsors of the legislation, the Work Incentives Improvement Act of 1999, are Senators James Jeffords (R.-Vt.), Edward Kennedy (D.-Mass.), William Roth, Jr. (R.-Del.), and Daniel Moynihan (D.-N.Y).

President Clinton announced the legislation at a White House news conference in mid-January and promised to include funding for it in his proposed budget for fiscal year 2000 (see page 436). Besides permitting states to extend Medicaid coverage to employed persons with disabilities, the legislation would provide a $1,000 tax credit for work-related costs such as special transportation. It would also double the federal investment in technology designed to help disabled people become productive workers.

President Clinton's budget request to Congress for fiscal year 2000 includes a $70 million increase in funding for the mental health block grant to states and provides funds to expand Medicare and Medicaid coverage to working persons with disabilities who previously were at risk of losing their coverage because of their earnings.

The budget proposal, released on February 1, would provide a total of $2.6 billion in federal funding for programs operating under the Substance Abuse and Mental Health Services Administration (SAMHSA) and more than $1.4 billion in funding for research on alcohol, drug abuse, and mental disorders within the National Institutes of Health (NIH).

The $70 million in new funding for the mental health block grant, which is administered by SAMHSA's Center for Mental Health Services (CMHS), would bring the total appropriations to $359 million in fiscal year 2000, which begins October 1. The additional funds, a 24 percent increase over fiscal 1999, would boost federal spending on community mental health services above $300 million for the first time. But the proposed budget calls for no increases in year 2000 funding for most other SAMHSA programs, holding the overall SAMHSA increase to 5.6 percent.

CMHS would receive a $5 million, or 19 percent, increase in funds for the Projects for Assistance in Transition From Homelessness (PATH) program, a state formula grant program, permitting an additional 13,000 client contacts and an improved quality of services. Funding for the CMHS Knowledge Development and Application program, children's mental health services, and the protection and advocacy programs would remain at 1999 levels.

Funding for the Targeted Treatment Capacity Extension program in the Center for Substance Abuse Treatment (CSAT) would be doubled to $110 million. The program is designed to support rapid and strategic responses to the demand for treatment services. The substance abuse block grant, which provides support for more than 7,000 community-based treatment organizations, would receive an additional $30 million, a 2 percent increase, to total $1.6 billion. The funding level for the Knowledge Development and Application program in CSAT would remain unchanged.

Funding for the Knowledge Development and Application program under the Center for Substance Abuse Prevention would be reduced by $26 million, to $53 million, a 33 percent decrease. Funding for the program for high-risk youth would remain at $7 million.

For the three NIH research institutes on mental and addictive disorders, the budget proposes a funding increase of only about 2.5 percent, considerably less than the 15 percent increases approved by Congress in fiscal 1999. The National Institute of Mental Health would receive an additional $18 million, for a total of $759 million; the National Institute on Drug Abuse, $10 million, for a total of $429 million; and the National Institute on Alcohol Abuse and Alcoholism, $6 million, for a total of $249 million.

In addition to the funding for SAMHSA and NIH, the budget includes funds for both the Medicaid and the Medicare programs that would enable persons with disabilities to work without losing their health care coverage, the focal point of legislation introduced in the U.S. Senate in January (see page 435). A total of $450 million over five years would be allocated to expanding coverage for disabled persons under the Medicaid program. Of that amount, $300 million would go to a demonstration program that would allow participating states to provide Medicaid coverage to individuals with health conditions that would reasonably be expected to become severe enough to qualify them for disability benefits in the future.

Former APA Medical Director Walter Barton Dies

Walter E. Barton, M.D., 92, a former medical director and president of the American Psychiatric Association, died January 26 at his home in Hartland, Vermont.

Dr. Barton became APA medical director in 1963 after 17 years as superintendent at Boston State Hospital. After his retirement from APA in 1974, he moved to Vermont, where he became a senior staff physician at the Veterans Administration Medical Center in White River Junction and professor of psychiatry at Dartmouth Medical School in Hanover, New Hampshire.

Dr. Barton served as APA president in 1961-1962. A leader in the field of mental health administration, he was the author of several books on the subject, some written with his daughter, Gail M. Barton, M.D., also a psychiatrist. His books include The History and Influence of the American Psychiatric Association, which traces the association's role in the development of American psychiatry.

Naltrexone, the first drug approved by the Food and Drug Administration for the treatment of alcohol dependence in nearly 50 years, has received the endorsement of a consensus panel convened by the Center for Substance Abuse Treatment (CSAT). In a report issued in December, the panel said that naltrexone therapy improves treatment outcomes when used as an adjunct to psychosocial treatment.

The panel, which included some of the country's leading experts on naltrexone, based its conclusions on experience with patients in naltrexone treatment and a review of evidence from controlled trials. Its report, >Naltrexone and Alcoholism Treatment, is designed to help clinicians use the medication safely to enhance outcomes for those already in treatment and expand treatment capacity for the more than 18 million persons in the United States with alcohol problems.

Naltrexone, first marketed in 1984, is one of a number of opiate antagonists that have been in use since the 1950s to treat addiction to heroin and other opioids. By blocking endogenous opiate receptors in the brain, opiate antagonists greatly reduce the rewarding effects of heroin and other narcotics. Although alcohol is not an opiate, the efficacy of naltrexone in controlling alcohol craving and preventing relapse in alcohol dependence was established in clinical trials in the early 1990s.

According to the report, the most impressive results of the clinical trials were in the area of relapse prevention. A significantly smaller proportion of the naltrexone-treated patients experienced a full-blown relapse to heavy drinking. Based largely on these findings, the FDA approved naltrexone for alcoholism treatment in 1994.

The report provides guidelines for selecting suitable candidates for naltrexone treatment. Because the medication is an adjunct to psychosocial treatments, appropriate candidates should be willing to be in a supportive relationship with a health or mental health care provider or support group to enhance treatment compliance and work toward the goal of sobriety.

The report points out that research has not yet conclusively identified patient groups for whom naltrexone is most effective. However, early studies suggest that patients with strong craving, poor cognitive abilities, little education, or high levels of physical and emotional distress may benefit most from the addition of naltrexone to their psychosocial treatment. Such patients are often those most likely to drop out of psychosocial treatment, the report observes.

Despite naltrexone's demonstrated efficacy, clinicians have been slow to adopt its use, the report notes. One barrier may be that some substance abuse counselors and self-help groups view taking medications as substituting a pill for self-empowerment. However, most 12-step programs support the use of nonaddicting medications, and evidence from controlled trials indicates that naltrexone is not addictive.

The cost of naltrexone $4.50 per day or $400 for three months may also be a barrier to more widespread use. However, the report points out that total costs for naltrexone may be less than the costs of the alcohol used by many patients who seek treatment.

Naltrexone and Alcoholism Treatment is number 28 in the Treatment Improvement Protocol (TIP) series developed by CSAT. All TIPs are available on the CSAT Web page at www.samhsa.gov. They can be ordered free of charge by contacting the National Clearinghouse for Alcohol and Drug Information at 800-729-6686.




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