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Drug Addicts and Disability Payments
by Sally Satel
In January 1997, Congress ended the classification of drug and alcohol abuse as a disability under the Social Security Administration's (SSA) disability programs. The story behind this change illustrates some of the problems inherent in trying to help people with active addictions.
While the new policy avoids the perverse incentives embedded in the old system of cash payments, a more sophisticated approach, based on the principles of contingency management therapy, could improve matters both for addicted individuals and society. However, summoning the political will and administrative capacity to make such a system a reality may be beyond our current capacity.
It is a clinical reality that giving cash payments to addicts is not in their best interests. Cash effectively equals drugs, and thus the money can be as toxic to them as cigarettes are to asthmatics or as excess sugar is to diabetics. Providing an income conditioned on continued disability is a disincentive for recovery. Cash is a powerful visual and symbolic cue for drug craving, a risk factor for relapse. Indeed, clinicians and researchers have observed that cocaine consumption of addicts on SSI disability displays a strong monthly periodicity, peaking on the day checks come out. Thus, the old system not only subsidized addiction, but it also fed money into the illicit economy.
There are three federal disability programs, two under the Social Security Administration (SSA) -- Social Security Disability Income (SSDI) and SSI, and one under the Veterans Administration. Only SSI developed a "Drug Abuse and Alcoholism" ("DA&A") program. Established by Congress in 1972, DA&A focused on managing benefits to those disable by addiction.
DA&A was intended to function as a "treatment scholarship"; it was supposed to provide cash to pay for addicts' basic needs while they attended treatment. Their money was to be managed by a "representative payee" designated by the recipient. It was assumed that treatment--which was a condition of receiving benefits-- would enable many of the DA&A recipients to enter the workforce and leave the rolls.
Unfortunately, none of these intentions were realized. First, few addicts went to treatment; second, representative payees, sometimes fellow addicts themselves, were often grossly irresponsible; and third, virtually no one left the rolls.
Congress rethinks DA&A The national spotlight was trained on DA&A in 1994 when Senator William S. Cohen (R-Me) released an investigative report. It found: (1) the increase in DA&A caseloads grew 300% from 20,000 in 1990 to 78,000 in 1993 (and subsequently up to 134,000 as of June 1996); (2) lump sum payments of several thousand dollars (money that had accumulated between approval and disbursement) spent on drugs; (3) irresponsible payees; (4) no consistent monitoring of treatment, no sanctions for poor compliance with treatment and no requirement that SSDI recipients have treatment or a payee; (5) absence of continuing reviews resulting in DA&A recipients remaining on rolls indefinitely.
The process for disability determination varied widely from state to state. According to the General Accounting Office (GAO), California accounted for about 33% of all DA&A recipients, followed by Illinois (17%), Michigan (10%) and New York (4%). Some states were especially aggressive in switching residents off state welfare rolls and onto the federal disability program. In some cases, assessment of disability was made only by reviewing medical records, and applicants were never examined directly by doctors hired by the disability determination agency.
Around the same time the Cohen report came out, massive media coverage of the issue was spurred by hearings in the U.S. House of Representatives, audits by the GAO and reports of the Inspector General of the Department of Health and Human Services (DHHS). Sensational accounts of abuse appeared in newspapers and on TV magazine shows, while reports from the GAO and DHHS documented that DA&A was inadequately managed. Specifically, SSA was criticized because it failed to track recipients' participation in treatment, did not terminate people for poor compliance with treatment and did not require continuing disability reviews.
From political, policy and clinical perspectives, the DA&A program was a failure. Objective data confirmed the obvious dangers of giving cash to a vulnerable population. The DHHS found that less than 1% of persons receiving benefits in 1990 under the DA&A program had left the rolls by 1994, by resuming work or recovering from addiction. Psychiatrist Mark Herbst and colleagues at the University of San Francisco found that treatment absenteeism among patients in a methadone clinic increased 360% after receiving their lump sum payment (abstract of the proceedings, College on the Problems of Drug Dependence, 1993). Andrew Shaner and co-workers at the West Los Angeles VAMC found that positive urines, hospitalizations and exacerbation of psychotic symptoms in cocaine-abusing schizophrenics all increased significantly at the beginning of the month, paralleling the receipt of monthly benefit checks (NEJM, vol. 333, pp 777 -83, 1995). Finally, Satel and others (Psychiatric Services, vol. 48, no. 6, 1997) found that receipt of lump sum payment was associated with greater likelihood of precipitous discharge from residential drug rehabilitation.
What to do? Some thought the solution was to abolish the DA&A disability program altogether. Others preferred to re-direct the funds (cash payment and other entitlements linked with DA&A) to the treatment block grant. The principle here was that addicts don't need cash, they need treatment. Proponents of this view recommended that more residential facilities be created.
Another approach was to tighten the existing DA&A program. This is what Congress did in 1994, imposing a 3-year limit on benefits provided by SSA for those disabled by addiction alone. Also instituted were graduated sanctions for poor compliance with treatment; preference for institutional rather than personal representative payees; proration of lump sum back payments so as not to exceed the amount of the regular monthly benefit; and continuing reviews of DA&A disability.
The new law went into effect in March 1995. However, several months before these changes took effect, the new Republican Congress began planning to discontinue addiction as a disability under the two SSA programs. In March 1996, a new law went into effect mandating that SSA no longer recognize addiction as a disability. Since the 1994 legislation was active for only one year, we will never know how well it might have worked.
Notice of pending DA&A abolition greatly concerned advocates for addicts and the mentally ill. Advocates for the mentally ill were concerned that many of the DA&A recipients who also suffered from severe mental illnesses -- between 70 - 80% according to SSA -- would not find their way back onto the rolls. Clearly, such people were never intended for the DA&A program (though the treatment surveillance and representative payee requirements could have been beneficial to them); apparently they had been classified incorrectly.
As of this January, only two thirds of the recipients (140,000 out of 209,000) had applied to SSA for reclassification under another disability. Of these, slightly under half were reclassified. Thus 32% of the former DA&A disabled re-entered the SSA rolls. It is likely that some individuals are belatedly requesting reclassification and those already denied are undergoing appeal; thus more former DA&A recipients may ultimately reenter the SSI rolls.
The fate of those who failed to reapply or who were denied reclassification is unknown. While some may have taken denial of benefits as a wake-up call to sober up and enter the workforce, others -- perhaps the majority -- may have found a slot on the local welfare rolls or resorted to crime or landed on the streets.
In Chicago and nearby suburbs, for example, services for the homeless have been in great demand, since termination of DA&A. Barbara Otto, of the SSI Coalition for a Responsible Safety Net, and Maryann Mason, of the Heartland Alliance for Human Need and Human Rights, (both located in Chicago) are conducting a survey of area human services providers. Their preliminary evaluation reveals that the homeless shelter beds for men are often at full capacity, food pantries are busier than usual and 'clients' in transitional shelter programs are not moving out to live on their own because they cannot afford security deposits on apartments without the SSI check. There is no current evidence about how much, if any, of this temporal correlation reflects real causal effects or about the extent to which it is part of a national pattern. The federal Center for Substance Abuse Treatment and the Robert Wood Johnson Foundation are conducting outcome studies.
Not all addicts are excluded from receiving benefits, however. Individuals with independent diagnoses of physical or mental illness are still eligible for SSI and SSDI, and physician examiners have the capacity to deem an applicant "unable" to manage his funds, in which case the potential beneficiary will be automatically assigned a representative payee.
Policy implications Overall, the DA&A experience raises a number of interesting issues:
*What is the trade-off between cash entitlement as an enabler of drug use (wherein recipients either use more drug than they would without the cash payment or use the same amount but suffer less financial hardship due to drug use since they use public funds to purchase of drugs) vs. a cash entitlement as a buffer against crime and homelessness? Peter Reuter, professor of Public Policy at the University of Maryland, and some others think these buffer effects would be a justification even for an unreformed DA&A program, but everyone agrees that a reformed program would be better.
*What should be done about drug users with primary mental and physical illness who are now receiving cash benefits under SSA programs? Given that fully one third of SSI recipients are mentally ill and anywhere between 25 - 50% of them also use drugs or alcohol, it is clear that the DA&A program was only a fraction of the afflicted population. I estimate that at least 10 - 20% of all SSI recipients are actively using drugs. This situation also occurs in the Veterans Affairs system. There as well, the mentally ill represent the largest single category of service-connected disability entitlement.
*Should individuals with an active addiction to drugs or alcohol ever receive cash benefits (e.g., AFDC; SSI and SSDI for disabled people with co-morbid addictions)? Ending the DA&A program did not eliminate other sources of income-support funds to addicted individuals who had some claim to an entitlement other than addiction, including addicted people on AFDC and those receiving federal disability payments for a physical or mental condition.
*Given the liklihood of diverting cash to purchase drugs and the fact that cash is a known trigger for cocaine craving, is it ethical to make cash payments to addicts?
*Doesn't a disability entitlement program for addicts create a perverse incentive, giving recipients the message that they are sick rather than emphasizing the possibility of recovery? Enforcing the notion of a treatment scholarship (as the 1994 legislation did) can counteract such a message, but would a bureaucracy devoted to monitoring and sanctioning ultimately be too expensive and cumbersome? *Is it constructive to view addiction as a disability when it results in the presence of a federal saftey net? Or should the government provide treatment only?
One promising approach is a behavioral intervention called contingency management. In this model, addicted disability beneficiaries would have their basic needs (e.g., rent, food) met via direct deposit of funds to landlords and stores; the remaining money would be considered discretionary. Individuals would 'earn back' this money through compliance with treatment, negative urines and participation in supported employment programs.
A modest literature now exists, pioneered by workers at the University of Vermont and Johns Hopkins University Medical Center, showing that addicts rewarded with material goods for clean urines are significantly more likely to remain abstinent during the course of a clinical trial and during the months-long follow-up period. Currently, a number of treatment centers for mentally ill patients who also abuse drugs, including Harborview in Seattle and the West Los Angeles VA, are conducting pilot projects using the patients' actual benefit payments as their reward for progress in treatment.
Current federal programs stand at the two possible extremes: on one hand, no money or specialized treatment for (and thus no leverage over) those who would have qualified for SSI disability by reason of addiction, and on the other hand money with no strings attached for those disabled for other reasons and for non-disabled people who receive other forms of public income support. There is a case to be made for providing treatment, and maybe some form of income support, for those whose addiction currently makes them unfit for work, as long as that assistance is conditioned on a serious effort at recovery. The same combination of help and control would also make sense for the addicted recipients of other transfer payments. Applying the principles of contingency management to these populations could both help them and shrink the illicit markets.
How Prevalent Are "Very Light" Drug Users?
by Jonathan Caulkins
Both in measuring the prevalence of illicit drug use and
in designing and evaluating programs to reduce it, a sharp
distinction is drawn between those who have ever used a
drug, even once, and those who have not. But surveys
suggest the existence of a substantial body of very occasional, weakly committed drug users, who never buy drugs
but may accept a friend's invitation to share. We know it is
important to differentiate "heavy" users from "light" users.
A similar case can be made for distinguishing these "very
light" users from those who at least sometimes contribute
their own money to the illicit drug economy. Very light users represent an important potential target
for "secondary prevention" programs, designed to convince
those who have experimented with drugs not to progress
to more committed levels of use. Also, when evaluating
primary prevention programs designed to prevent drug
initiation, subjects who become very light users do not
represent the same sort of failure as those whose participation in the drug scene is more active. Further, the existence of very light users also suggests that enforcement
against retail markets may have only indirect effects on a
substantial proportion of drug users.
Table 1: How Past-Month Users Obtained Their Drug
| Drug Source | Marijuana | Cocaine | Crack |
| None Avowed | 7.2% | 7.8% | 8.8% |
| Bought from Dealer | 18.0% | 32.8% | 45.4% |
| Bought from friends but not from dealer | 31.9% | 22.7% | 18.9% |
| Gifts, did not buy | 41.7% | 34.6% | 24.4% |
| Other | 1.2% | 2.1% | 2.6% |
Empirical Evidence Concerning "Very Light" Users
One way to measure how important something is to an individual is to ask how much that person would be willing to pay to obtain it. Surveys do not ask about willingness to pay (though perhaps they should), but the National Household Survey on Drug Abuse (NHSDA) does ask "About how much money did all the cocaine you used in the past 30 days cost you?" Similar questions are asked for crack and marijuana. Forty percent of past-month crack users and 50-55% of past-month cocaine and marijuana users do not report spending any money on the drug they used.
The 1992 and 1993 NHSDA surveys also asked: "How did you obtain any cocaine that you used during the past 30 days?" Again, similar questions were asked for crack and marijuana.1 Table 1 shows proportions of past-month marijuana, cocaine, and crack users who (1) did not report any source of drugs for the past month, (2) reported buying from a dealer, (3) reported buying from friends, acquaintances, or family but not a dealer, (4) reported having but did not buy the drug, and (5) other, i.e., obtained the drug only by theft, fraud, or in barter exchange for goods or services.
Even among past-month users about one-third claim the only drugs they used were given to them, and fewer than half purchased the drugs they used from a dealer.2 As one would expect, those who report receiving their drugs as gifts say they used smaller quantities and used on fewer days than those who purchased their drugs from friends, and those who purchased from friends in turn report using less often, than those who purchased from dealers.
Another piece of evidence suggesting that very light users represent a nontrivial proportion of all users comes from the survey questions, "About how many times in your life have you used [name of drug]?" Of those 25 and older who reported in the 1993 NHSDA that they had ever used, the proportions reporting they had used various numbers of times are summarized in Table 2. The majority of those vwho have ever used an illicit drug report using ten or fewer times in their lifetimes.
| Marijuana | Cocaine | Stimulants | Hallucinogens | Inhalants | |
| 1 or 2 times | 27.3% | 25.5% | 15.7% | 33.9% | 34.8% |
| 3 to 5 times | 14.4% | 16.5% | 16.2% | 21.5% | 28.7% |
| 6 to 10 times | 12.6% | 14.9% | 14.6% | 15.1% | 14.3% |
| 11 to 49 times | 13.6% | 18.1% | 21.0% | 18.2% | 11.1% |
| 50 to 99 times | 9.0% | 10.1% | 9.5% | 6.0% | 4.0% |
| 100-199 times | 5.1% | 5.7% | 7.8% | 2.5% | 2.4% |
| 200 or more times | 17.9% | 9.2% | 15.2% | 2.8% | 4.5% |
Policy Significance
To the extent that very light users exist, a focus on prevalence of use may give an exaggerated sense of the extent of demand. The very light vs. other user distinction helps underscore heterogeneity among drug users, as do distinctions between light and heavy users or whether or not users satisfy DSM-IV criteria defining need-for-treatment, but it operates at the "light" end of the spectrum. These distinctions have a variety of implications. A common prevention tactic is to reassure youth that only a modest proportion of people their age have used an illicit drug; the objective is to make such drug use appear deviant rather than normative. Use of a more stringent criterion, e.g., having purchased a drug, would underscore that committed drug use is even more deviant than is having ever tried a drug. The distinction may also be relevant for evaluating prevention programs. Project ALERT, for example, appears to have a greater effect on indicators of committed use (weekly, monthly, and past-month use) than on initiation, as reflected in lifetime prevalence.3
The distinctions may be important for understanding trends. If the relative number of light and very light users is constant over time, then simply tracking the number of light users would be informative. However, that assumption of constant proportions has not been investigated empirically. If observed declines in the prevalence of light users are primarily due to declines in very light use, then the actual progress in reducing drug use might be less than would be suggested by the decline in the total number of light users.
A recurring debate among drug analysts concerns what fraction of demand in street-corner drug markets is attributable to some variant of light users (suburban users, middle-class users, users in the household population, etc.). These data cannot resolve that debate, but they do suggest that street markets are not the primary source of drugs for the majority of drug users. They might be the secondary source. That is, users may buy drugs from friends who in turn visited street markets. Nevertheless, since the majority of drug users are not buying from dealers then the majority of drug users are probably not visiting street markets.
This has implications for our understanding of drug
enforcement. One goal of street-level enforcement is to
disrupt markets enough to increase "search time," the non-dollar cost and effort users incur obtaining drugs.4 Substantially increasing search time for experienced users who
have developed relationships with multiple dealers may be
difficult, but one would expect "lighter" users to be more
vulnerable. Unfortunately, it appears that the majority of
light users do not visit street markets at all, so increasing
search times may have its greatest impact only on the
minority of drug users who are involved enough to be
buying from dealers but not so much as to have developed
contacts with very many dealers. Likewise, sell-bust
operations are primarily a risk for just this subset of users.
On the other hand, the transition to buying from dealers
may be particularly important, suggesting that retail
enforcement might usefully focus on markets where such
first purchases are likely to occur.
Suggestions for Future Data Collection and Analysis
Insofar as "very light use" is a significant phenomenon, it might be useful to change ways in which drug prevalence data are collected, reported, and analyzed. In particular, the emphasis on the presence or absence of drug use (ever, past year, or past month use) might be augmented with an equal emphasis on the presence or absence of indicators of some commitment to that use. Such indicators might include having spent money (or traded goods or services) for drugs, owning drug paraphernalia, using frequently or regularly, and use in settings that indicate that the drug was the focus of the event rather than an afterthought. ("Have you used the drug while you were alone?", "Have you attended a party in which using the drug was a central or the central activity?", etc.)
Distinguishing between very light and light use might be important for understanding careers of drug use. In studying escalation, one typically thinks of "capture rates" as the ratio of the number of people who became dependent (or who used in some problematic manner) divided by the number of people who ever tried the drug. Perhaps it would be more meaningful to think about capture rates as the ratio of people who became dependent divided by the number who ever progressed beyond some measure of very light use. Similarly, it is worth investigating whether progressing to some degree of committed use at an early age (e.g., buying from a dealer) is an even better predictor of subsequent dependent use than is initiation into any level of use at an early age.
Legally we do not distinguish between very light use and light use. One is equally guilty of drug possession whether the drugs were a gift or were purchased. Owning rolling papers is not an aggravating circumstance that influences sentencing decisions. The absence of a legal distinction does not mean, however, that there is no meaningful behavioral distinction or that there are not insights to be obtained by collecting and analyzing data which separate very light users from other users.
References:
1 Marijuana also had as a possible response "Grew it yourself." That response is not analyzed here both because it was relatively rare and to maintain consistency across drugs.
2 Male users were more likely to buy from a dealer than female users, and less likely to receive their drugs as gifts, but all patterns observed in the aggregate data also appear in the data for male and female users analyzed separately.
3Phyllis L. Ellickson and Robert M. Bell, "Drug Prevention in Junior High: A Multi-Site Longitudinal Test," Science, Vol. 247, pp.1299-1305, 1990.
4 For marijuana, search time is generally not a barrier to use and is thought to be difficult to raise, so these comments pertain primarily to enforcement against other drugs.
The Problem of Replacement and the Logic of Drug Law Enforcement
by Mark Kleiman
On the surface, drug law enforcement resembles the enforcement of other laws: violators are detected, apprehended, tried, and punished. This, it is hoped, prevents crime indirectly, by providing a disincentive for violations (deterrence), and directly, by confining some of those who have shown a propensity to violate so that they cannot re-offend (incapacitation).
Consistently with this line of thinking, drug enforcement officers and units tend to be evaluated, and to evaluate themselves, as other police units do: primarily on the number and quality (defined in terms of the seriousness of the offense) of prosecutable arrests made.
But when it comes to drug sellers, the economic logic of the drug markets tends to defeat both deterrence and incapacitation. As long as there are drug buyers looking to "score," scaring off or locking up one dealer simply creates a market niche for another dealer to fill. Since retail dealing demands no special skill and pays substantially better than other forms of unskilled work or crime, the supply of potential dealers, especially in poor urban neighborhoods, seems to be effectively unlimited. That explains the otherwise paradoxical result that a tenfold increase in the number of cocaine dealers in prison has failed to increase the price of cocaine.
This "replacement effect" is much less marked when it comes to predatory crime (theft and assault, in all their variations). Muggers do not compete for the same street corner, or burglars for the same house, nearly as directly as crack dealers do for the same customer. Neither street corners to use as mugging locations nor houses to break into are scarce compared to the number of potential muggers or burglars.
So locking up or scaring off one predatory criminal does not, in any direct way, create an opportunity for someone else to commit the same crime instead. Any replacement effect for predatory crime acts indirectly, through reduced precaution of potential victims: insofar as deterring or incapacitating some burglars makes homeowners feel safer and therefore reduces the density of alarm systems, the opportunities for a burglar will improve somewhat as the number of burglars on the street shrinks. (Replacement is a bigger factor for predatory crimes committed by groups of offenders, such as bank robbery, where the group can recruit a substitute for a missing member.)
This operational distinction between "predatory" and "consensual" or "transactional" crimes is much clearer than the moral distinction sometimes asserted. It is by no means obvious that a drug dealer in an open street market does less damage to the neighborhood he operates in than a shoplifter; if you ask the neighbors, they are likely to be much more afraid of the dealer. But predators tend to drive away their prey, while potential transaction partners tend to attract their customers. That's why illicit drug markets flourish in the same neighborhoods where shopkeepers close up early and businesses move out for fear of crime.
The fundamental logic of the drug markets and enforcement against them has strong implications for the design of drug enforcement efforts. It explains why retail drug markets are robust in the face of routine street sweeps, unsystematic buy/bust operations, and long sentences. It implies that changing the conditions supporting the existence of a market in a particular location (such as traffic patterns) can be more effective than increasing the number of arrests. It suggests that low-cost, high-volume enforcement efforts against drug buyers may be an attractive alternative to arresting dealers.
But with about a quarter of the nation's scarce prison and jail cells filled by drug law violators, the most important implication of this analysis is that the capacity of prisons to incapacitate is best used on predatory rather than transactional offenders. The small increase in what would otherwise be the price of cocaine consequent on locking up retail cocaine dealers for three years instead of two is simply not worth the opportunity cost of keeping them in while letting predatory offenders out. Building and filling more cells, even if the voters remain willing to tolerate the expense, changes the amount of incapacitation that can be achieved, but does not eliminate the tradeoff between incapacitating dealers and incapacitating burglars.
True, most of the drug dealers who go to prison also commit predatory offenses, but on average at a lower rate than those imprisoned for burglary or robbery. As long as that remains the case, imprisoning dealers rather than thieves and assailants will have the tendency to increase the crime rate, especially since some of the violence committed by dealers relates to their roles as dealers, and will therefore be committed to more or less the same extent by their replacements. The idea of replacement does not imply that locking up dealers never pays off. Enforcement can still play an important role in changing the conduct of market participants for the protection of the neighborhoods now devastated by the side-effects of the drug markets.
Not all drug dealing is equally bad in its neighborhood effects. Discreet indoor dealing in multi-purpose locations is less disruptive than outdoor dealing or the use of dedicated dealing locations such as crack houses. Dealing without gunfire is much less disruptive than dealing with gunfire. The use of adolescents as dealing accomplices- effectively encouraged by the lighter sanctions provided under the juvenile laws-does enormous damage to the young dealers.
By concentrating on flagrant dealing, or dealers who use violence, or dealers who use juveniles, rather than simply making the cases that are easiest to make, police and prosecutors can force dealing activity into less noxious forms: not an undiluted success, but a success nonetheless.
Implementing such strategies requires not only changes in operational doctrine but also changes in the way drug enforcement agents and units are evaluated. Ideally, they should be scored not on output measures such as arrests, but on outcome measures in the drug markets: price, availability, violence, disorder, and the involvement of juveniles. That, in turn, would require the sort of consistent and careful measurement of drug markets that we now make of some aspects of drug use and its consequences.
Drug Policy Analysis Bulletin is edited by Mark A. R. Kleiman of the School of Public Policy and Social Research at UCLA. For specific comments on the contents of this newsletter, or if you would like to join in the work of the FAS Drug Policy Committee, contact Dr. Kleiman at (310)206-3234 or at kleiman@ucla.edu. Members of the Editorial Board include (affiliations for identification only):