PATTERNS OF SUBSTANCE USE AND SUBSTANCE-RELATED IMPAIRMENT AMONG PARTICIPANTS IN THE AID TO FAMILIES WITH DEPENDENT CHILDREN PROGRAM (AFDC)
Sponsored by the Office of the Assistant Secretary for Planning and Evaluation, the Public Health Service, the National Institutes of Health / National Institute on Drug Abuse, and the Substance Abuse and Mental Health Services Administration of the
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
December 1994
EXECUTIVE SUMMARY
This report provides data on substance use and substance-related impairment among participants in the Aid to Families with Dependent Children (AFDC) program. The study is based on data from the 1991 and 1992 National Household Surveys on Drug Abuse (NHSDA), and was sponsored jointly by the Office of the Assistant Secretary for Planning and Evaluation, the Substance Abuse and Mental Health Services Administration, and the National Institute on Drug Abuse. Estimates from the NHSDA should be regarded as conservative because of potential underreporting of both drug use and program participation.
Another study has examined the prevalence of drug and alcohol use in households participating in AFDC, medicaid, and food stamps.,1> This study expands on that work and examines not only the prevalence of substance use in households participating in AFDC, but importantly further analyzes a combined 1991 and 1992 data set to examine extent of use and impairment related to that use.
Substance abuse issues are generally not part of the eligibility/intake process for AFDC at this time, and usually do not arise even in a family needs assessment process, although they may be suspected. Instead, such issues are more likely to be recognized if a recipient has a high absentee rate in a training program or other activity. In this way it is similar to substance abuse in the work place. A 1992 report of the HHS Office of Inspector General found that only 14 percent of states' AFDC intake forms and 55 percent of JOBS intake assessment forms included questions on substance abuse problems2>. In addition, because denial of the disease is typical in substance abusers, problems may not be easily detected simply through intake questions.
Because proposals for welfare reform would require participating parents to take part in education and job training programs and benefits would be time limited, intervention with substance abusing beneficiaries takes on an importance it has not held previously. Substance abuse is clearly a barrier to self sufficiency for some welfare recipients. In the absence of intervention, at the end of two years beneficiaries with substance abuse problems could be ineligible for the program without the ability to be self supporting.
As family self sufficiency becomes an increasingly important goal within the welfare system, treatment and rehabilitation of substance abusers becomes a focus. The question then arises, how many AFDC recipients might be expected to need such treatment, and for how many would intense treatment needs preclude concurrent participation in education, training and employment activities?
Typically, analyses of substance abuse focus on prevalence and frequency of individuals' use of particular substances. While prevalence rates of drug and alcohol use are important indicators, the questions of greater interest in the context of welfare reform and potential intervention are ones of impairment and need for services. Drug and alcohol use prevalence analyses by themselves do not address the question of the extent to which substance abuse interferes with individuals' ability to work or participate in job training. Such an impairment oriented analysis, however, represents a more complex approach than, for example, an analysis of prevalence of drug use in the past month.
The impairment analysis described in this study was undertaken to answer the more specific question of the extent to which recipients' substance abuse problems might pose a barrier to the employment related objectives of welfare reform. The methodology employed in the impairment analysis represents a new approach to the use of data from the National Household Survey on Drug Abuse. This report represents an attempt to use questions in the National Household Survey on Drug Abuse about individual functioning and problems associated with substance use and combine them with prevalence data to approach more closely the issue of functional impairment and need for treatment. As part of the impairment analysis a new ratio estimation procedure was used to improve estimates of so-called "hard core" drug use by accounting for the underestimation of these populations in the Household Survey. For comparative purposes, this report also includes prevalence data on the AFDC population from another analysis3> which focused primarily on past-month and past-year use.
The impairment analysis divides the population into groups according to their patterns of alcohol and other drug use. Those identified as having "significant impairment" include persons identified as dependent on alcohol and drunk at least weekly OR as dependent on an illicit drug other than marijuana AND used an illicit drug at least monthly or used heroin at least once in the past year. Those identified as having "some impairment" include individuals identified as not dependent on an illicit drug but used an illicit drug at least weekly OR not dependent on alcohol but was drunk at least weekly OR dependent on an illicit drug other than marijuana but used an illicit drug less than monthly and did not use heroin OR dependent on marijuana OR dependent on alcohol but was drunk less than weekly.
The impairment analysis found that4>:
? Approximately 4.9 percent of female AFDC recipients are estimated to have significant functional impairment related to substance abuse. These individuals' substance abuse problems may be sufficiently debilitating to preclude immediate participation in employment or training activities. When both female and male AFDC recipients are included, the estimated rate of impairment is slightly higher (5.2 percent). It is important to note, however, that the vast majority of individuals identified in this significant impairment category are not AFDC recipients. An estimated 204,600 AFDC recipients and 2,662,600 non-AFDC recipients ages 18-44 were estimated to have this level of impairment. In addition, while we believe that many of these individuals will need intervention prior to other activities, it should be recognized that in the general population many individuals with this level of impairment report being employed.
An additional 10.6 percent of female AFDC recipients are estimated to be somewhat impaired by substance abuse problems, indicating a likely need for substance abuse treatment concurrent with participation in employment and training activities. When male AFDC recipients are included as well, the rate rises slightly to 11.2 percent.
AFDC recipients have somewhat higher rates of substance abuse related impairments than persons not receiving AFDC. Because the AFDC population is poorer than the general population, this is not surprising. Persons living in poverty are known to have higher rates of drug and heavy alcohol use than do those with higher incomes, regardless of program participation.
The vast majority of persons impaired by substance abuse are not AFDC recipients. Just seven percent of all adults (age 18-44) estimated to be significantly impaired by substance abuse report receiving AFDC.
Because women make up such a large proportion of adults receiving AFDC, a women only comparison is also relevant. Analysis again finds that most women in the group we have defined as significantly impaired by alcohol and other drug use are not AFDC recipients. Of these women, only 20 percent receive AFDC.
Impaired AFDC recipients are more likely than other impaired persons to report receiving treatment for their substance abuse in the past year. Half of AFDC recipients estimated to be significantly impaired by substance abuse reported receiving some form of substance abuse treatment in the past year. Only 23 percent of the non-AFDC household adults (age 18 - 44) in this impairment category reported receiving any treatment for their substance abuse problem in the past year.
The study of the basic prevalence of substance use in the AFDC population5> found that:
The prevalence rates of self-reported non-medical drug use are somewhat higher among persons who participate in AFDC than in the general population. In 1991, past-month drug use for persons 15 years of age and older is 10.5 percent for those in AFDC households compared to 6.5 percent in the overall population in that age group. Marijuana is the most frequently reported illicit drug, with nearly 9 percent of individuals in AFDC households reporting past-month use. Past month cocaine use is reported by 1.0 percent of the general population age 15 and older and by 1.6 percent of individuals in AFDC households.
Three or more episodes of binge drinking in the past month is reported by 8.2 percent of women in AFDC households and 3.8 percent of all women age 15 and older. Among men and women combined, this level of heavy episodic drinking is reported by 8.6 percent of all persons 15 years of age and older and 8.7 percent of those in AFDC households. Binge drinking is defined as having had five or more drinks in a row.
The vast majority of past month drug users are not AFDC recipients. Among the past-month users, 2.7 percent of males and 9.2 percent of females live in households participating in AFDC. In fact, a previous analysis of substance use among parents has shown that more parents who have used illicit drugs in the past month have incomes above 300 percent of the poverty line than have incomes below poverty6>.
The findings of relatively higher rates of reported drug and binge alcohol use among AFDC program participants is not surprising. This program serves persons in poverty, and poor people are at a higher risk for a number of problems including alcohol and drug abuse.
These findings suggest that AFDC program administrators should recognize the presence of persons with substance abuse problems in their caseloads, in order to improve the ability to serve these persons and better focus prevention and treatment efforts.
1. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation and the National Institute on Drug Abuse, Patterns of Substance Use and Program Participation, 1994.
2. U.S. Department of Health and Human Services, Office of Inspector General, Functional Impairments of AFDC Clients, OEI-02-90-00400, 1992.
3. op. cit, U.S. Department of Health and Human Services, Patterns of Substance Use and Program Participation.
4 It should be noted that preliminary analyses reported on in the press contained slightly different figures from those reported here. The numbers reported here are different for two reasons. First, the earlier analysis used 18 - 64 year olds as the basis for analysis while the current estimates focus on younger individuals, age 18 - 44, in order to be more consistent with the younger age composition of the AFDC population. In addition, the ratio estimation technique used to produce this report's estimates has been refined since the preliminary figures.
5. op. cit. U.S. Department of Health and Human Services, Patterns of Substance Use and Program Participation.
6. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation and the National Institute on Drug Abuse, Substance Abuse Among Women and Parents, July 1994, p. 37.