Disability and Health Journal 6 (2013) 107e115

Research Paper

Recent trends in substance abuse among persons with disabilitiescompared to that of persons without disabilities

Raymond E. Glazier, Ph.D.a,*, and Ryan N. Kling, M.A.badisAbility Research Associates, LLC, 59 Underwood Street, Belmont, MA 02478, United States

bAbt Associates Inc., 55 Wheeler Street, Cambridge, MA 02138, United States

www.disabilityandhealthjnl.com

Abstract

Background: Substance abuse (SA) is a grave and pervasive social problem associated with severe personal and social costs that affectpersons with disabilities disproportionally. Most previous research has found SA prevalence to be greater among persons with disabilitiesthan among those without disabilities.

Objectives: To compare prevalence between persons with disabilities and persons without disabilities for different substances of abuse,and recent SA trends.

Methods: The authors examined nine years of nationally representative data estimates from the National Survey on Drug Use andHealth, comparing previous month prevalence of self-reported SA on a per-substance basis among community residing persons withdisabilities and their peers without disabilities, using a logistic regression model that accounted for demographic factors.

Results: Prevalence of overall substance abuse (a composite measure) was level over time, at 34% for persons without disabilities and40% for persons with disabilities. The SA prevalence among persons with disabilities closely paralleled that of other persons over the period2002e2010 for each substance examined, but at a statistically significant higher level, with the exception of alcohol abuse, which wassignificantly lower. Time trends were relatively stable for both populations, with the exception of decreases in cocaine use and recentdramatic increases in marijuana use and oxycodone abuse.

Conclusions: Given that substance abuse among persons with disabilities is markedly more prevalent than among other persons formost substances, findings indicate a need for accessible, targeted prevention programs and a potentially overwhelming demand for acces-sible SA treatment services and facilities. � 2013 Elsevier Inc. All rights reserved.

Keywords: Disability; Substance abuse; Drug abuse; Survey

The World Health Organization1 has estimated the attrib-utable burden of disease from substance abuse in establishedmarket economies like theU.S. conservatively at greater than23%dfrom tobacco, from alcohol, and from illicit drugs (nomention of prescription drug abuse). Disease burden includesnot only additional health care costs, but also lost produc-tivity due to morbidity and mortality.1 Substance abuse espe-cially limits the potential productivity of affected persons

Financial disclosures: This study was funded internally by the U.S.

Health Division of Abt Associates Inc.

Conflict of interest disclosure: Neither author has any conflict of

interest, or appearance thereof, to disclose.

An early partial draft of this paper was presented to the Disability

Research Interest Group of Academy Health’s Annual Research Meeting

on 23 June 2012 at Orlando, FL.

* Corresponding author. Tel.: þ1 617 489 1009.

E-mail address: raymondglazier@gmail.com or ray_glazier@

post.harvard.edu (R.E. Glazier).

1936-6574/$ - see front matter � 2013 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.dhjo.2013.01.007

with disabilities, because, as Li andMoore note in their studyof disability and illicit drug use, ‘‘Compared to the generalpopulation, individuals with disabilities are more likely toencounter problems of personal adjustment and unemploy-ment, as well as the experienced medical and health difficul-ties.2’’ It seems self-evident that the widely documentedphysically and mentally debilitating effects of substanceabuse must further compromise the already impaired func-tional capacity of most persons with disabilities.

Previous research has found a much higher proportion ofpersons with disabilities affected by substance abuse than inthe general population, reportedly as great as 87%.3 Adecade ago, SAMHSA estimated that as many as 4.7million Americans with disabilities had a co-occurringsubstance abuse disorder, and Moore (2002) estimated that1.5 million persons with disabilities could be in need ofsubstance abuse treatment.4 It is asserted, in a recent(2010) review of the literature on substance abuse andphysical disability, that: ‘‘Persons with disabilities are at

108 R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

a disproportionately greater risk for substance abuse prob-lems than members of the general population. Substanceabuse prevalence rates [sic] in persons with traumatic braininjury, spinal cord injuries and mental illness in the UnitedStates approach or exceed 50%.5 This is in comparison toapproximately 10% of the general US population. Individ-uals with deafness, arthritis and multiple sclerosis showsubstance abuse rates [sic] of at least double general popu-lation estimates.6’’

There is a robust, if fragmented literature on the multi-faceted relationship between disability and substanceabuse. One aspect is substance abuse as a causal factor indisability, e.g., intoxication leading to disabling injury,particularly in auto vehicle crashes: ‘‘Substance misuse/abuse is also a major contributing factor to many traumaticinjuries.alcohol intoxication rates at the time of traumaticbrain injury range from 36% to 51%.7,8’’

Another segment of the literature deals with substanceabuse as a mediating factor in rehabilitation and recovery,as in addiction impeding the recovery process both forpersons with physical and mental health disabilities; voca-tional rehabilitation is an example of an affected program.‘‘Post-injury, substance abuse undermines rehabilitationgain.. It may limit rehabilitation outcomes by contrib-uting to functional limitations. Indirect and direct self-destructive behaviors related to substance abuse.adverselyaffect the potential for positive rehabilitation outcomes.8’’It is posited that vocational rehabilitation (VR) systemicfactors compound individual ones, namely communityVR counselors’ lack of familiarity with substance abusedisorders and rigid requirements for sustained periods ofabstinence as a precondition to eligibility for VR services.9

Part of the literature on persons with disabilities treatsdifferent substances of abuse separately, viz. alcoholism,IV drugs, prescription drugs. Yet another, less studiedaspect is the insufficiency of accessible and appropriatesubstance abuse treatment services and facilities availableto persons with disabilities. Touching on all of the abovefactors are studies of the prevalence of substance abuseamong persons with disabilities in specific sub-popula-tionsdwomen, different racial and ethnic groups, specificdisabling conditions (spinal cord injury, traumatic braininjury, learning disabilities, co-occurring mental healthconditions like bipolar disorder).

The bigger picture is the overall prevalence of substanceabuse (SA) in the disability community and how that relatesto SA levels among Americans without disabilities, amongwhom it is a serious public health concern of major propor-tions. There are numerous published reports that substanceabuse is more common among persons with disabilitiesthan in the general population.8,10e12 In fact, some studieshave asserted that the prevalence is twice as high or greater(see above). Yet hard data have been difficult to obtainbecause surveys like the U.S. Census’ Current PopulationSurvey (CPS) that have clear markers for disability statusdo not track substance abuse. The Behavioral Risk Factor

Surveillance System, which does look at health status anddisability (beginning in 2004), examines only tobaccoconsumption and alcohol abuse, not drug abuse. Datacomparability is limited by varying definitions of disabilityand differing data collection methodologies.

Research objective

Our intent with this research was to examine trends insubstance abuse prevalence, on a per-substance basis,among community-residing persons with disabilities andthose without disabilities in order to: a) confirm or contra-dict previous reports of greater substance abuse prevalencein the disability population, and b) determine whethertrends in substance abuse among persons with disabilitiesdiverge from those of the population without disabilitiesby substance abused and over time.

Methods and materials

We examined 9 years (2002e2010) of data from theNational Survey on Drug Use and Health (NSDUH) tocompare difference in the previous month prevalence of:habitual cigarette smoking (6 or more per day, a levelSAMHSA seems to consider indicative of habitualsmoking), marijuana use, alcohol abuse (binge drinking),use of certain illicit drugs (cocaine, heroin, methamphet-amine, hallucinogens, ecstasy), and abuse of four specificclasses of prescription drugs (analgesics, sedatives, stimu-lants, and tranquilizers)dfor adults with disabilities,compared with the general adult residential population.

We use ‘abuse’ in connection with consumption ofalcohol in inordinate amounts and inappropriate utilizationof prescription medications and ‘use’ to refer to consump-tion of substances defined as illegal by federal statute; weuse ‘substance abuse’ as an umbrella term for all of theabove. We have defined previous month ‘overall substanceabuse’ as habitual cigarette smoking (an average of 6 ormore cigarettes per day), alcohol abuse (one or moreepisodes of binge drinking, i.e., 5 or more drinks at a singlesitting), the use of any illicit drug, or abuse of a prescriptiondrug (analgesic, oxycodone, tranquilizer, stimulant, seda-tive, or psychotherapeutic).

The NSDUH statistics are weighted cross-section timeseries data from a representative, nationwide, household-residing annual panel survey of in-person interviews withapproximately 70,000 randomly selected persons age 12or older. The NSDUH data are collected during householdvisits in which each selected age-eligible householdmember independently responds to the survey privatelyon a laptop computer.

We examined survey responses of working age (18e64)persons, and we defined disability as: a) reported a workdisability, or b) age under 65 (non-aged) and Medicare-eligible. These two disability markers were the only onesconsistently present in the NSDUH over the time frame

109R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

of 2002 through 2010 (the most recent year for which datawere available). Psychiatric disability questions were addedto the survey in recent years, but we did not utilize these inthe interest of employing a consistent disability definitionacross the study time frame. Although the NSDUH surveymethodology has changed slightly from time to time, therewere no changes in the study time frame affecting any ofthe variables we chose to examine.

We sought to isolate the association of disability withsubstance abuse from other personal characteristics, so weused weighted logistic regression to adjust for demographicfactors (age group, gender, race/ethnicity, urbanicity ofresidence, education level, and income level) and dummyvariables for survey years. We ‘predicted’ SA for the twogroupsecommunity residing working age adults withdisabilities and those without disabilitiesefor eachsubstance studied, holding personal characteristics fixedat their overall means across the study time period.

Sample validity note

SAMHSA considers the NSDUH panel to be nationallyrepresentative of the overall U.S. community residing, non-institutionalized civilian population.13 In order to assess thecorrespondence of our disability sample, comprised largelyof persons who self-identified as having a work disability,to other extant data, we compared each year’s disabilitytotal that we obtained from the NSDUH with self-reported work disability estimates from the U. S. Census’Current Population Survey (CPS). Available disabilitytallies from other sources either were not aggregated forthe same working age population, were based on verydifferent questions, or were derived from very differentsurvey processes and protocols. On balance, our NSDUHdisability sample slightly exceeded the CPS estimates, withyearly proportions ranging from a low of 0.937 to a high of1.489. This was to be expected because we had added tothose with a work disability persons under 65 with Medi-care eligibility, who could be disabled dependents ofdisabled workers, or disabled workers who otherwise didnot consider themselves to have a work disability, e.g.,because of lengthy detachment from the workforce.

Results

For each substance studied, self-reported substanceabuse in the previous month was greater among personswith disabilities than among their peers without disabil-ities, with the sole exception of alcohol, for which thesignificant difference was in the opposite direction.(Persons with disabilities were significantly less likely thantheir peers to have engaged in binge drinking in theprevious month).

Table 1 presents the mean percentages of the total obser-vations for each variable in the regression analysis model:Dependent variables include each substance of abuse and

each grouping of substances, while independent variablesinclude the dummy variable for each survey year, three agegroups, gender, race/ethnicity, four education levels, sevenincome brackets, and three urban residence categories eachfor the 2002e2004 and 2005e2010 timeframes.

For each substance of abuse and grouping of substancesin the final year (2010) of this study, Table 2 summarizesthe odds ratio between persons with and without disabil-ities, the lower 95% confidence interval, the upper 95%confidence interval, and the p-value.

The following graphs are regression-adjusted estimatesof the percentage of the population admitting to previousmonth substance abuse, evaluated at the overall mean ofthe independent variables, evaluated separately for thosepersons with and without a disability (as we defineddisability). Note: These are national estimates, regression-adjusted for age group, gender, race/ethnicity, educationlevel, income level, and residential urbanicity.

The measure for previous month prevalence of overallsubstance abuse, graphed in Fig. 1 below, is inclusive ofhabitual cigarette smoking (6 or more per day), bingedrinking (5 or more drinks at a single sitting), illicit druguse (powder cocaine, crack cocaine, heroin, methamphet-amine, hallucinogens, or ecstasy), and prescription drugabuse (analgesics, oxycodone, sedatives, stimulants, ortranquilizers). Substance abuse in some form is alarminglyprevalent and stable over recent years, involving more thana third (34%) of the population without disabilities and40% of persons with disabilities. Consistently across all9 years, persons with disabilities were more likely thanthose without disabilities to admit some form of substanceabuse; for example, the 2010 odds ratio for overallsubstance abuse was 1.28, with a 95% confidence intervalof 1.19 to 1.37 ( p ! 0.001).

Among persons without disabilities, the previous monthprevalence of habitual cigarette smoking (6 or more ciga-rettes per day) decreased from about 14%e12% over thenine years. However, for persons with disabilities, the prev-alence began at 20% in 2002, rose to a high of 22% in2004, and then fell back to 20% once again. Consistentlyacross all 9 years, persons with disabilities were much morelikely than those without disabilities to smoke 6 or morecigarettes daily; the 2010 odds ratio was 1.83, witha 95% confidence interval of 1.68e1.99 ( p ! 0.001). Overtime, the general trend for cigarette smoking at this levelper day decreased significantly ( p ! 0.0001) for both pop-ulations, although the decrease was not as great amongpersons with disabilities.

Alcohol was the only substance in this study for whichestimates of the previous month prevalence of abuse (bingedrinking) was lesser for persons with disabilities, rangingfrom 18% in the early years to 19% in later years, than thatof persons without disabilities, which averaged about21.5% in the study’s early years and reached its peak of24% in 2009. Persons with disabilities were less likely thanthose without disabilities to admit having engaged in binge

Table 1

Means of NSDUH regression analysis variables, 2002e2010

Variable Without disability With disability

Number of observations (unweighted)a 316,746 20,904

Dependent variables’ mean prevalence

Any substance abuse in past month (prescription or illicit drugs, binge alcohol,

or habitual cigarette smoking)

0.355 0.403

Average of 6 cigarettes a day, past month 0.156 0.276

Binge drinking in past month 0.248 0.179

Marijuana use in past month 0.061 0.067

Cocaine, crack, heroin, or meth, past month 0.010 0.020

Powder cocaine use in past month 0.008 0.016

Crack cocaine use in past month 0.002 0.009

Powder or crack cocaine use in past month 0.008 0.016

Heroin use in past month 0.001 0.003

Methamphetamine use in past month 0.002 0.003

Hallucinogens use in past month 0.004 0.003

Ecstasy use in past month 0.002 0.001

Any illicit drug use in past month (marijuana, powder or crack cocaine,

heroin, methamphetamine, hallucinogens, or ecstasy)

0.065 0.077

Alcohol abuse or any illicit drug use, past month 0.266 0.214

Analgesics 0.018 0.028

Oxycodone 0.002 0.003

Tranquilizers 0.007 0.013

Stimulants 0.004 0.005

Sedatives 0.001 0.003

Psychotherapeutics 0.025 0.037

Independent variables’ mean frequencies

Year dummy: 2002 0.108 0.088

Year dummy: 2003 0.109 0.087

Year dummy: 2004 0.110 0.091

Year dummy: 2005 0.111 0.095

Year dummy: 2006 0.113 0.097

Year dummy: 2007 0.113 0.108

Year dummy: 2008 0.112 0.137

Year dummy: 2009 0.113 0.142

Year dummy: 2010 0.113 0.155

Age 18e25 0.153 0.081

Age 26e34 0.166 0.102

Age 35 or more 0.681 0.817

Male 0.483 0.464

Female 0.517 0.536

White 0.704 0.593

Black/African American 0.105 0.219

Hispanic 0.129 0.139

Other race 0.062 0.049

Education: Less than HS 0.150 0.325

Education: HS graduate 0.309 0.370

Education: some college 0.257 0.208

Education: college graduate and higher 0.284 0.097

Income: less than $10,000 per annum 0.058 0.211

Income: $10,000e$20,000 per annum 0.107 0.274

Income: $20,000e$30,000 per annum 0.114 0.152

Income: $30,000e$40,000 per annum 0.118 0.109

Income: $40,000e$50,000 per annum 0.117 0.082

Income: $50,000e$75,000 per annum 0.186 0.091

Income: more than $75,000 per annum 0.301 0.081

Large urban area, 2004 or earlier 0.148 0.101

Small urban area, 2004 or earlier 0.108 0.088

Not an urban area, 2004 or earlier 0.070 0.077

Large urban area, 2005 or later 0.354 0.334

Small urban area, 2005 or later 0.276 0.333

Not an urban area, 2005 or later 0.043 0.067

a The maximum number of observations for the analysis. Some variables (e.g., oxycodone) have fewer.

110 R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

Table 2

2010 odds ratios for differences between persons with and without disability

Measure (abuse in past month) e 2010 results Odds ratio Lower 95% CI Upper 95% CI p-value

Any substance abuse (prescription or Illicit drugs, Binge alcohol, or Habitual cigarette smoking) 1.280 1.194 1.371 !0.001

Ave. 6 cigarettes/day in month 1.828 1.682 1.987 !0.001

Binge drinking in past month 0.780 0.716 0.849 !0.001

Marijuana use in past month 1.430 1.258 1.625 !0.001

Cocaine, crack, heroin, or meth. 2.340 1.805 3.033 !0.001

Powder cocaine 2.190 1.632 2.937 !0.001

Crack cocaine 2.599 1.683 4.012 !0.001

Powder or Crack cocaine 2.190 1.632 2.937 !0.001

Heroin 4.715 2.581 8.612 !0.001

Methamphetamine 2.630 1.622 4.266 !0.001

Hallucinogens 0.924 0.619 1.380 0.700

Ecstasy 0.799 0.439 1.455 0.463

Any illicit drug (marijuana, powder or crack cocaine, heroin, methamphetamine,

hallucinogens, or ecstasy)

1.480 1.308 1.675 !0.001

Alcohol binge or any illicit drug 0.892 0.821 0.969 0.007

Analgesics 1.648 1.350 2.010 !0.001

Oxycodone 3.035 1.760 5.233 !0.001

Tranquilizers 2.038 1.595 2.606 !0.001

Stimulants 1.638 1.186 2.262 0.003

Sedatives 3.008 1.817 4.978 !0.001

Psychotherapeutics 1.625 1.402 1.884 !0.001

Fig. 1. Overall substance abuse e any drug abuse (prescription or illicit),

smoking, or binge alcohol in previous month (regression-adjusted esti-

mates from NSDUH, 2002e2010).

111R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

drinking (5 or more drinks in one sitting) at least once inthe previous month; the 2010 odds ratio was 0.78, witha 95% confidence level of 0.72 to 0.85 ( p ! 0.001).

Note the more finely gradated scale of the X-axis, reflec-tive of the lesser prevalence.

There is a dramatic relative decline in the previous monthprevalence of abuse of this group of four illegal drugs, withthe trend for persons with disabilities very closely parallelingthat for other persons. For persons without disabilities, theprevalence estimates fell rather steadily from 1.1% in 2002to 0.4% in 2010. Comparatively, prevalence estimates forpersons with disabilities declined to essentially the samedegree over the period, from an initial high of 1.7% to1.0%. Persons with disabilities were much more likely toadmit to use of these four major illicit drugs than personswithout disabilities, even as use declined in both populations;the 2010 odds ratio was 2.34, with a 95% confidence intervalof 1.81 to 3.03 ( p ! 0.001).

Both groups started the time period with very compa-rable estimated prevalence of marijuana use: 4.4% amongpersons without disabilities and 4.5% among persons withdisabilities in 2002. However, over the nine-year span,persons with disabilities were much more likely to admitto having used marijuana in the previous month thanpersons without disabilities; the 2010 odds ratio was 1.43,with a 95% confidence interval of 1.26 to 1.63( p ! 0.001). There was a statistically significant upwardtrend overall ( p 5 0.0090) for marijuana use in both pop-ulations. However, the trajectory for persons with disabil-ities diverged from that of other persons ( p 5 0.0167)and showed a markedly steep path, ending at 6.6% in2010 for a major (43%) difference in usage between thetwo populations in the last year of the study.

Among the individual illicit and prescription drugs westudied, the 2010 odds ratios for difference in self-reported use/abuse between persons with disabilities andthose without disabilities were in some cases strikinglylarge and statistically significant (Reference Table 2above.). For example (in descending order):

� Heroin, with an odds ratio of 4.72, 95% confidenceinterval of 2.58 to 8.61 ( p ! 0.001);

� Oxycodone, with an odds ratio of 3.01, 95% confi-dence interval of 1.76 to 5.23 ( p ! 0.001);

� Sedatives, with an odds ratio of 3.02, 95% confidenceinterval of 1.82 to 4.98 ( p O 0.001);

� Methamphetamine, with an odds ratio of 2.63, 95%confidence interval of 1.62 to 4.23 ( p ! 0.001);

� Crack cocaine, with an odds ratio of 2.60, 95% confi-dence interval of 1.68 to 4.01 ( p ! 0.001);

112 R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

� Powder Cocaine, with an odds ratio of 2.19, 95%confidence interval of 1.63 to 2.94 ( p ! 0.001);

� Tranquilizers, with an odds ratio of 2.04, 95% confi-dence interval of 1.60 to 2.61 ( p ! 0.001);

� Analgesics, with an odds ratio of 1.65, 95% confi-dence interval of 1.35 to 2.01 ( p ! .001);

� Stimulants, with an odds ratio of 1.64, 95% confi-dence interval of 1.19 to 2.28 ( p ! 0.001) and;

� Psychotherapeutics, with an odds ratio of 1.63, 95%confidence interval of 1.40 to 1.88 ( p ! 0.001).

Discussion

Substance abuse of all types, including abuse ofprescription drugs, is an even greater problem in thedisability community than in the U.S. population at large.However, trends over the study time frame for both popula-tions were pretty much parallel, with the notable exceptionof marijuana use (recreational or medical) and oxycodoneabuse in the later years of the study; both marijuana useand oxycodone abuse accelerated sharply in the later years,and the prevalence among persons with disabilitiesdiverged widely upward from that of other persons.

It is notable that abuse of different classes of prescrip-tion drugs ranks prominently in the 2010 per-substanceodds ratios between self-reports of persons with disabilitiescompared to that of other persons.

Overall substance abuse (Please see Fig. 1.)dThefinding of significantly higher abuse prevalence (33%greater) among persons with disabilities is largely drivenby their greater levels of habitual cigarette smoking, greateruse of cocaine, and more frequent abuse of psychothera-peutic prescription drugs. There was no statistically signif-icant time trend on this multi-factor measure, either forpersons with disabilities or other persons.

Cigarette smoking (Please see Fig. 2.)dSince WHO1

attributes the lion’s share of disease burden (19.2% of theroughly 23% total) to tobacco, the downward trend amongpersons without disabilities is somewhat encouraging,whereas the rather level trend in cigarette smoking by

Fig. 2. Cigarette smoking e average 6 or more cigarettes per day in

previous month (regression-adjusted estimates from NSDUH, 2002e2010).

persons with disabilities is not. This is a key substance ofabuse, and in the world at large, it is on a steep trajectoryas a major risk factor for greater morbidity and mortality.1

Some psychosocial research has attributed the higher levelof smoking among persons with disabilities, and the greaterprevalence of overall substance abuse, to a sense ofpersonal ‘entitlement’ among persons with disabilities.2

In their research with Midwestern vocational rehabilita-tion consumers with significant disabilities, Li and Moore(2001) applied the concept of ‘secondary deviance’ in theirexamination of disability, ‘entitlement,’ and illicit drug use,concluding that: ‘‘.perceived discrimination and accep-tance of disability play important roles in illicit drug useby persons with disabilities.14’’ They relate this phenom-enon to the stigma, discriminatory labeling, and internaliza-tion of negative stereotypes experienced by other minoritygroups. Moore and Li measured the degree to which theirsurvey sample felt that their stigmatized status ‘entitled’them to engage in substance abuse by degree of agreementwith the following survey statements: ‘‘1) People withdisabilities have more reasons to use alcohol or other drugsthan those without disabilities; 2) Because I havea disability, I sometimes feel that I have less to lose andmore to gain from using alcohol or other drugs; and 3)People with disabilities already have many problems, soalcohol or drug use is not a big deal.’’

Alcohol abuseebinge drinking (Please see Fig. 3.)dThelesser prevalence of binge drinking among persons withdisabilities is a consistent and notable counter trend tothe general pattern observed for other substances of abuse.Prevalence of binge drinking has remained essentiallyconstant and parallel over this 9-year time frame for bothpopulations.

The National Health Interview Survey found a compa-rable alcohol abuse percentage (22.8) for the generalcivilian non-institutionalized population in 2009.15 TheBehavioral Risk Factor Surveillance System (BRFSS)found a lower adult binge drinking prevalence, 15.2%, for2009, probably due to the inclusion of persons over 65,who engage in this activity much less frequently. But theBRFSS also found an even lower prevalence (14.3%)

Fig. 3. AlcoholeBinge drinking (5 or more drinks at one sitting) in

previous month (regression-adjusted estimates from NSDUH, 2002e2010).

Fig. 5. Any marijuana use, including medical use in later years (regres-

sion-adjusted estimates from NSDUH, 2002e2010).

113R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

among persons with disabilities.16 Other researcherscomparing earlier binge drinking prevalence estimates fromboth the BRFSS and the NSDUH imply that the more confi-dential NSDUH interview process may account for thatsurvey’s higher numbers.17

‘‘Big Four’’ substance abuse (powder cocaine, crack,heroin, or methamphetamine) (Please see Fig. 4.)dAbuseof one of this group of four major illicit ‘street drugs’ isan indicator of serious drug addiction with criminal justiceimplications, not only because their very use is illegal, butbecause users often need to engage in other criminal behav-ioretheft or prostitutioneto support their habits. Note that,although the overall percentage admitting to use is muchsmaller for both populations than with other substances ofabuse, the absolute numbers of users are strikingly large.In per-substance analyses, we found that the illicit drugtrends for both groups were largely driven by the decreasein cocaine use (both powder and crack cocaine).

Any marijuana use (Please see Fig. 5.)dIn both popula-tions, there was an increase in previous month prevalence inthe later years, an especially marked one for persons withdisabilities. The trends for the two populations divergedramatically in the later years, following medical marijuanalegalization legislation in certain states (16 states þ D.C. by2010), which might mean readier, perhaps subsidizedmedical marijuana availability for persons with disabilities.

Strengths and limitations

Among the great strengths of the NSDUH are its regularannual administration, the confidentiality provisions forself-reporting, and its great detail on the many forms ofsubstance abuse, as well as its purposefully low 6th gradeliteracy level. For purposes of research focusing on thedisability population, a significant limitation is its dearthof detail on the disability status of respondents. And, whilethe survey sample is selected to be nationally representativeon various demographic dimensions, disability status is nota sampling factor. As noted earlier, the only questiondirectly addressing disability consistently across the period

Fig. 4. ‘Big Four’ substance abuse (powder cocaine, crack, heroin, or

methamphetamine) use in the previous month (regression-adjusted esti-

mates from NSDUH, 2002e2010).

2002e2010 is whether the respondent is not workingbecause of ‘work disability’.5

Our measure of disability is generally driven by workdisability. This is in part a matter of practicality, as that isthe measurement consistently available in the data across thetime frame of the analysis. But this ‘limitation’ is also fortu-itous, as the working age population constitutes an interestinggroup for policy study, and potentially for policy interventionsrelated to the improvement of national economic productivityand the preservation of the Social Security Trust funds.

Since having a work disability is often associated withvery painful conditions like musculoskeletal disorders,our estimated odds ratios for those drugs, which are mostprescribed for pain (analgesics, oxycodone) may be largerthan if we had a differently defined disability population.Similarly, our estimated odds ratios for drugs which aremost often prescribed for psychiatric conditions (psycho-therapeutics) may be lower than if we had a differentlydefined disability population, e.g., if we had used themental health markers introduced in the 2007 NSDUH.

Overall, we may be generally understating the differencein substance abuse between those with and without disabil-ities, since it appears that NSDUH does not capture anyonewhose disabilities are too burdensome to allow them toparticipate in the interview. Some of these non-respondentscould have been those with the most significant physicaland mental disabilities. Furthermore, the data reports makenote of interviewer codes for ‘physically/mentally incompe-tent,’ classifications implemented at interviewer discretion,5

which may have introduced distortion through under-inclusion of persons with severe disabilities; it is unclear inwhat ways this may have affected the findings of this study.

Another complication arising from the NSDUH surveyprotocol is inaccessibility or potential loss of confidentialityfor respondents with sensory disabilities because the instruc-tions for self-administration of the survey are provided in anaudio file inaccessible to persons who are deaf or severelyhard of hearing, whereas the self-administered questionsand response options on the laptop are provided visually,inaccessible to persons who are blind or have severe vision

114 R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

impairment. Personswith severemotor impairments likewisecould have had their confidentiality compromised by beingunable to register their self-reports without assistance fromthe interviewer or a fellow household member. Non-responses or loss of confidentiality could also contribute tounder-reporting of substance abuse. Furthermore, the exclu-sion of institutionalized persons is an understandable limita-tion that could have mixed effects on our findings, as thesepersonsmay have ready access to certain substances of abuse(e.g., cigarettes) and more restricted access to others (e.g.,alcoholic beverages and prescription drugs that are adminis-tered in a carefully controlled manner).

The survey’s inclusion, beginning in 2007, of mentalhealth status measures opens up new avenues for research,e.g., utilizing NSDUH data to examine the complex rela-tionship between different psychiatric disabilities anddifferent forms of substance abuse, including trends overtime. Similarly, the relationship between different non-psychiatric disabilities and different types of substanceabuse would become possible if the NSDUH were toinclude a comprehensive battery of disability questions.Access improvements in survey administration couldimprove the response rate among persons with disabilitiesand affect self-reported substance abuse in this populationby ensuring improved confidentiality of responses.

Conclusions

Over the period 2002e2010, the substance abuse trendsfor persons with disabilities, with a few notable exceptions,closely paralleled those for other persons in the U.S. residen-tial population, but at a significantly higher level. Thecomprehensive substance abuse trend was level for both pop-ulations, but trends were down for: cigarette smoking,cocaine (both powder and crack), hallucinogens, and ecstasyfor both persons with and without disabilities. The implica-tion of these findings is that over time there are shifts in pref-erence among specific substances of abuse that neither raisenor lower the overall abuse profile of either group.

The previous month prevalence of substance abuse amongpersons with disabilities differed from that of other persons insignificantly higher percentages of overall substance abuse,habitual cigarette smoking, use of the group of major illicitdrugs, and marijuana use, with a significantly lowerpercentage of binge drinking. These differences were persis-tent across the time frame (2002e2010). There is good reasonto believe (see study limitations above) that the under-reporting of substance abuse is a more frequently occurringphenomenon among persons with disabilities than amongthe general population.

Implications

There seems to be no reason to question the face validityof the NSDUH self-reports of substance abuse, but only the

volume of them. Respondents have nothing to gain byprivately admitting to behaviors generally regarded associally deviant. Nor is there reason to believe that personswith disabilities have any reason to exaggerate theirsubstance abuse behaviors. Therefore, it is apparent thatoverall substance abuse, while it is not normative behavior,is very common in the general population (1 in 3 persons)and even more common among persons with disabilities (2in 5 persons).

Examination of the substance-specific trends for thedisability community can inform differential messagingand appropriate, accessible substance abuse preventionprograms for persons with disabilities. Given the findings re-ported herein, the multitude of debilitating effects of ciga-rette smoking, and both the direct health care costs and thelost productivity implications of smoking, combined withthe relatively low cost of tobacco cessation programs, theimportance of promoting smoking cessation through cultur-ally competent messaging via accessible media cannot beoveremphasized.

Other major substance abuse prevention priority targetsfor appropriate messaging to the disability community viaaccessible media include: 1) dangers of heroin use andinherent addiction (including the HIV/AIDS hazard fromshared needles) and the benefits of methadone treatment; 2)the powerful addiction potential of oxycodone in the variousforms in which it is abused (ingestion, inhalation, IV injec-tion) and treatment and recovery options; 3) the problemsassociated with use of highly addictive methamphetamineand cocaine (powder and crack) and treatment/rehabilitationoptions; and 4) preventing abuse of prescription drugs towhichmany personswith disabilities have legitimate accessesedatives, tranquilizers, analgesics (painkillers), stimulants,and psychotherapeuticsein the form both of self- abusethrough misuse, overuse, super-dose, as well as facilitatingabuse by others through inattention to missing medications‘borrowed’ by friends or family, or intentional diversion ofprescription medications into street trafficking for profit.

Similarly, the trends document the increasing need foraccessible substance abuse treatment facilities and programs,and appropriate treatment and recovery services that accu-rately target persons with disabilities’ different forms andpatterns of abuse. The woeful inadequacy of accessible SAtreatment facilities and programs in the U.S. was recentlydocumented in a nationally representative survey: ‘‘Most re-sponding facilities self-reported a variety of barriers to phys-ical accessibility, as well as the lack of services and physicalaccommodations for persons with sensory limitations. Suchwidespread inaccessibility may be a factor that promotesthe low representation of personswith disabilities in the treat-ment population.18’’

Extrapolating the prevalence we found to the U.S.Census 2010 estimate that there were 19,048,426 civiliannon-institutionalized persons with disabilities,19 if all suchpersons with any form of substance abuse (40.3%) hadsought treatment, the national caseload for only persons

115R.E. Glazier and R.N. Kling / Disability and Health Journal 6 (2013) 107e115

with disabilities would have been 7,676,516. If, moreconservatively, only persons who reported that they usedillicit drugs or abused alcohol in 2010 (21.4%) appliedfor alcohol or drug abuse treatment services, that disabilitycaseload would have been 4,076,363.

For some substances of abuse, there are day treatmentprograms, new detoxification protocols, new pharmaceuti-cals (e.g., Naltrexone, introduced over a decade ago for treat-ment of alcoholism and opioid dependence), 12-stepprograms, alternative therapies like acupuncture, and otheroptions short of inpatient treatment. Peer support and peercounseling can be crucially important in the treatment andrecovery process. We suppose that many persons withdisabilities who are in recovery might have difficulty findingtrue peers with whom to share their experience and provideneeded social support, other persons with the same type ofdisability and the same substance abuse issues.

The message of hope for recovery through the variousavailable substance abuse treatment modalities is some-thing all affected persons need to hear. Persons with disabil-ities, their families, and friends must be afforded the sameopportunity.

Acknowledgments

Credit is due to the Substance Abuse and Mental HealthServices Administration (SAMHSA) of the U.S. Depart-ment of Health and Human Services for its long-termcommitment to sponsoring the National Survey on DrugUse and Health (NSDUH) and its predecessor, the NationalHousehold Survey on Drug Abuse (NHSDA).

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