Acknowledgments
My work on this project was supported by the National Center for Advancing Translational Sciences, Clinical and Translational Science Awards Program via a career development award from the New Jersey Alliance for Clinical and Translation Science (grant KL2TR003018 [P.I. Qiana L. Brown]), the National Institute on Drug Abuse grant T32DA031099 (P.I. Deborah Hasin, PhD), and TrendologyIT Corporation. I also acknowledge Dr. Charlene Le Fauve for writing the original version of this chapter, published in 2011 in the first edition of Addiction Medicine , and for offering me the opportunity to revise and update the chapter for the current edition of this book.
Introduction
The terms substance use disorders (which include both drug and alcohol use disorders) and addiction are sometimes used synonymously among professional and lay populations. However, there are important distinctions to consider. Substance use disorders, as characterized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), can range from mild to severe, and are a cluster of symptoms that can be cognitive, behavioral, and physiological in nature, indicating continued use of substances despite significant drug-related problems. Addiction, as defined by the National Institute on Drug Abuse, is a chronic, relapsing brain disease consisting of compulsive drug seeking and use regardless of harmful consequences, and is equivalent to a severe substance use disorder as defined by the DSM-5. Addiction, unlike substance use disorders, is not an actual diagnosis according to the DSM-5. However, in this chapter, substance use disorders and addiction are used interchangeably.
Substance use disorders affect the body and brain on multiple levels and may have long-term disabling effects on the ability to function independently and meet the demands of daily living. a
a References 30, 36, 38, 60, 61, 66, 92, 93.
The very nature of substance use disorders (e.g., seeking/using drugs despite harmful consequences) overlaps with the definition of disability—“a physical or mental impairment that substantially limits one or more major life activities”—as defined by the Americans with Disabilities Act Amendments Act of 2008. However, many people with substance use disorders are denied the protections of the Americans with Disabilities Act due to the Act’s exclusionary criteria of this population. For example, the Americans with Disabilities Act excludes from its definition of disability people who are currently engaged in the illegal use of drugs (i.e., not in recovery) defined as drug use not under the supervision of a licensed health care provider, and not under the provisions of federal law. This population is also prohibited from receiving disability entitlements provided by the Social Security Administration through Supplemental Security Income and Social Security Disability Insurance. Individuals in recovery (i.e., not engaging in the illegal use drugs) are covered. However, the varying definitions of what qualifies as “in recovery” often make the process of obtaining benefits or protections difficult. Some of the current policies governing entitlements and protections for people with disabilities raise fundamental concerns about civil rights, equality, and fairness for people affected by substance use disorders, both those in recovery and those currently using. These policies reflect varying understandings of what it means to have a disability. Given that disability is a legal and administrative term, as well as a medical one, this variation is not surprising.Discrimination Protections for Persons With Disabilities
Rehabilitation Act of 1973, Title V, Section 504
Historically, the legal protections for people with disabilities that are now in place began in 1973 in Title V of the Rehabilitation Act of 1973, Section 504. Section 504 titled “Nondiscrimination Under Federal Grants and Programs,” protected both persons who were currently addicted and those in recovery under federal law. Specifically, the act stipulated that any organization receiving federal funds could not discriminate against people who were currently addicted to drugs or alcohol or in recovery from either condition.
Americans With Disabilities Act
The Rehabilitation Act of 1973 was a significant milestone that recognized the need to protect the rights of those with disabilities. It was, however, not comprehensive, so lobbying continued on the part of people with disabilities and their advocates. Their efforts bore fruit, and the Americans with Disabilities Act was enacted on July 26, 1990. The primary objective of the Americans with Disabilities Act is to extend maximum opportunity for full community participation to persons with disabilities in both public and private sectors of the United States. The Americans with Disabilities Act prohibits employment discrimination on the basis of disability in both private and public sectors, extending the protections of the Rehabilitation Act of 1973 beyond federally funded and conducted activities. In particular, the Americans with Disabilities Act applies to private employment, all publicly funded services, and public accommodations and services managed by private organizations.
When the Americans with Disabilities Act was passed, protections for people who use illicit drugs that were present in Section 504 of the Rehabilitation Act of 1973 were dropped. Anyone who is currently engaged in the illegal use of drugs is not considered a qualified person with a disability under the Americans with Disabilities Act. However, persons who have completed or are participating in a supervised rehabilitation program and are no longer using illegal drugs are protected. The implication is that an individual who is addicted to heroin, for example, must be abstinent from the use of heroin to qualify for the protections afforded by the Americans with Disabilities Act.
Many individuals who are impaired because of their addiction are unable to perform one or more major life activities. Therefore, at least one of the three criteria for disability as defined by the Americans with Disabilities Act has been met. The statute is particularly important for many people with substance use disorders who also have co-occurring mental health disorders. This population often faces difficulties in finding and holding jobs, in part because of the stigma attached to both addiction and mental health disorders. However, disabling psychiatric illnesses that meet any of the three criteria for disabilities are considered qualified disabilities under the Americans with Disabilities Act, whereas addiction is not.
In addition to the Americans with Disabilities Act’s exclusion of those currently using illegal drugs, the act has several barriers that are of concern to the substance use disorders services and treatment community and to individuals with these disorders who wish to claim protection under the Act. As noted earlier, people with substance use disorders who are not currently using illicit drugs can claim protection from employment discrimination under the Americans with Disabilities Act. However, the meaning of “current use” is vague. Some court decisions have been equivocal about when recovery begins, requiring a period of active stability of, for example, 6 months, to be considered in recovery, and therefore eligible for the Americans with Disabilities Act protections. Employees who have alcoholism or who use illegal drugs must meet the same standards other employees are held to, even if their unsatisfactory behavior is attributable to their use of substances. Finally, employees must not pose a “direct threat” to others because of their substance use—a term that, like “current” use, has been debated frequently in litigation.
Protections against discrimination for people who actively use drugs and alcohol are influenced by current law and can change depending on case law rulings. Several key decisions narrowed the focus of the Americans with Disabilities Act’s protections and increased the barriers that individuals who are disabled or impaired must overcome to obtain equal opportunities in the United States. Restrictive case law necessitated passage of the Americans with Disabilities Act Amendments Act of 2008 to reaffirm Congress’s original intent.
Key Case Law for the Americans With Disabilities Act, 1990
Interpretation of the Americans with Disabilities Act is established through trial law as individual cases are considered; therefore, the rights afforded to people who are in recovery and those who are actively using are often determined in an administrative law hearing or through precedents established by court cases. The Americans with Disabilities Act offers technical definitions of disability and delineates the applications of and exceptions to these definitions. Nevertheless, the US judicial system has the authority to interpret the act and to determine the extent to which a particular impairment qualifies as a disability.
Raytheon v. Hernandez
Raytheon v. Hernandez was a case that explored the extent to which employers can classify substance use disorders–related behaviors as workplace misconduct rather than behaviors related to the substance use disorder. This case eventually appeared before the Supreme Court, and the decisions from Raytheon v. Hernandez may have an impact on how the Americans with Disabilities Act protections are applied to people in recovery from substance use disorders. Joel Hernandez applied for a position at Raytheon in 1994. He had previously worked for Raytheon (at that time Hughes Missile Systems) from 1966 to 1991. During his employment, he had experienced on-the-job challenges related to substance use disorders, but treatment efforts supported by his company were unsuccessful. One day Mr. Hernandez came to work with alcohol and cocaine in his system, which his employers confirmed through a drug test. Mr. Hernandez was offered the option to resign or face termination. He resigned.
After 2 years in recovery from his substance use disorder, Mr. Hernandez applied for a position doing the same work he had been doing before his resignation, submitting letters from his church and his Alcoholics Anonymous sponsor with his application. The company had a no-rehire policy for ex-employees who had been terminated because of workplace misconduct, and Mr. Hernandez did not get the job. Mr. Hernandez surmised that he was being discriminated against because of his substance use disorder history. The Equal Employment Opportunity Commission supported his claim of discrimination and granted him permission to sue Raytheon for violating his rights under the Americans with Disabilities Act.
The case was heard by the US District Court in Arizona, which ruled in favor of Raytheon. Mr. Hernandez then appealed to the Ninth District Court of Appeals, which reversed the lower court’s ruling. Raytheon appealed the Ninth Circuit Court’s decision, and the case was eventually argued before the Supreme Court of the United States on October 8, 2003, and decided on December 2, 2003. The Supreme Court upheld the ruling of the Arizona District Court in favor of Raytheon, stating that Mr. Hernandez was not passed over because of his substance use disorder history and, therefore, was not the object of disparate treatment because of his disability, as he claimed in his arguments.
The opinion of the Supreme Court, as delivered by Justice Thomas, was that “Petitioner’s [Raytheon’s] proffer of its neutral no-rehire policy plainly satisfied its obligation under McDonnell Douglas [a previous decision] to provide a legitimate, nondiscriminatory reason for refusing to rehire respondent.” The opinion of the Court found that there was insufficient evidence to prove that Raytheon did not rehire Mr. Hernandez because of his substance use disorder history. In effect, the ruling allowed Raytheon to characterize Mr. Hernandez’s behavior on the day he came to work under the influence of alcohol and cocaine as workplace misconduct rather than as behavior consistent with a treatable substance use disorder.
The Sutton Trilogy
The “Sutton Trilogy” refers to three rulings issued by the US Supreme Court in Spring 1999. These cases addressed how the possibility of devices, medication, or even unconscious neuropsychological phenomena that mitigate a disabling condition can affect a person’s disability status. The first case, Sutton v. United Air Lines, Inc. , found that twin sisters with severe myopia that could be corrected to 20/20 vision with glasses were not protected under the Americans with Disabilities Act because the glasses mitigated the disability by improving their vision. The second case, Albertson’s Inc. v. Kirkingburg , found that Mr. Kirkingburg, a truck driver who was blind in one eye, was not protected under the Americans with Disabilities Act because he had developed the ability to compensate automatically for his lack of depth perception. His compensation mitigated his disability. The third case, Murphy v. the United States Postal Service, Inc. , found that Mr. Murphy, a mechanic also required to drive a truck who was dismissed because his blood pressure did not meet Department of Transportation’s health guidelines, was not protected by the Americans with Disabilities Act because, when medicated, his high blood pressure was near normal; in addition, he could still work as a mechanic, so he was not considered disabled.
In these three examples, mitigating factors included such things as medications, corrective lenses, and even neuropsychological phenomenon, all of which reduced the severity of the impairment. Recovery may be viewed as mitigation for people with substance use disorders, but a history of drug addiction still carries a significant burden of social stigma. People with substance use disorder histories may still require the Americans with Disabilities Act’s protections, even though their technical impairment has been mitigated.
Americans With Disabilities Act Amendments Act of 2008
The Americans with Disabilities Act Amendments Act of 2008, which was signed into law on September 25, 2008, and became effective on January 1, 2009, amended the Americans with Disabilities Act of 1990 to redefine the term “disability.” This change marks a broader interpretation of, and coverage for, individuals with a disability. The Americans with Disabilities Act Amendments Act of 2008 overturned the mitigating-measures holding of Sutton v. United Air Lines (1999), which had been applied to deprive many individuals with disabilities of the Americans with Disabilities Act’s protections. A key purpose of the Act was to reinstate the “broad scope of protection” Congress intended to be available. The new law clarifies that the effects of mitigating measures, such as hearing aids and prosthetics, could not be used in weighing how a person’s disability affects life activities. The 2008 legislation also overturned the restrictive interpretation of substantially limits, often narrowly interpreted by court rulings. These changes now create an easier path for establishing that a person has a disability within Americans with Disabilities Act guidelines, and for a disabled person to seek protection under this Act. Passage of the legislation also extends protections to people with disabilities not immediately evident in the workplace, such as those of the immune, digestive, and neurological systems. These changes still, however, exclude those with current substance use disorders from qualifying as disabled, arguably in a discriminatory way.
History of Entitlements for People With Disabilities and the Place for People With Substance Use Disorders
In the past, Supplemental Security Income and Social Security Disability Insurance programs provided monetary assistance as well as medical benefits to individuals with substance use disorders because substance abuse was considered a qualifying impairment. The level of oversight and scrutiny of Supplemental Security Income/Social Security Disability Insurance recipients with substance use disorders was much higher compared with that of other beneficiaries. In particular, a referral monitoring agency was enlisted by the Social Security Administration to ensure that Supplemental Security Income recipients with substance use disorders were compliant with treatment. People with substance use disorders did not receive their own entitlement checks. Instead, the checks were sent monthly to a representative payee, who disbursed the funds. The benefits were not to exceed 3 years.
There were problems associated with this method of organizing benefits for individuals with substance use disorders. At one point, the number of people with substance use disorders receiving disability benefits increased by more than 500% in a 4-year period, and the Social Security Administration found it difficult to establish whether recipients were in treatment. One study found that the rates of rehabilitation and returns to work were very low. In addition, there was evidence that representative payees were allowing income to be used to purchase drugs.
Under the Clinton Administration, enactment of the Contract with America Advancement Act of 1996 (PL 104–121) made important changes that affected people with substance use disorders. In particular, the Social Security Administration terminated payments for Social Security Disability Insurance and Supplemental Security Income on the basis of addiction alone. When someone has a co-occurring disabling condition and an active substance use disorder, the Social Security Administration must currently determine whether the disability being claimed is the result of a medical condition or the result of the effects of active drug use. The disability must be present even if consumption of alcohol and drugs has ceased. This determination is made by theoretically removing the limitations resulting from the substance use disorder and then deciding whether the remaining limitations from other impairments would still be disabling. Only after such an analysis can a determination of disability be made. This situation points to the complexities in classifying addiction as a disability.
Before PL 104–121, people with substance use disorders who received Supplemental Security Income and Social Security Disability Insurance for at least 2 years were eligible to receive Medicaid (for Supplemental Security Income) and Medicare (for Social Security Disability Insurance). A significant amount of federal funds for substance use disorder treatment flowed to the states through the two programs. With the new legislation, determination of benefits is now made by the states, and states vary to a considerable degree in how they fund substance abuse treatment. Some states fully cover a course of treatment, whereas others only partially reimburse substance abuse treatment.
The clinical and social effects of the decision to eliminate Supplemental Security Income and Social Security Disability Insurance benefits for substance use disorders in 1996 are substantial for people with substance use disorders who are now ineligible for this resource. Although the problems inherent in the previous legislation were removed by eliminating the entitlement, an important issue remains: The substantial prevalence of people with substance use disorders and co-occurring mental illnesses b
b References 23, 26, 40, 41, 42, 44, 47, 60.
creates a challenge for the Social Security Administration. For example, it is difficult to make materiality determinations if the agency cannot separate the functional limitations that each condition imposes. There is no evidence in the scientific literature that indicates whether and how the limitations from substance use disorders can be completely separated from the limitations of a mental health condition when both are present. This paradox calls into question the reliability and validity, or lack thereof, in the disability determination process when people with co-occurring disorders apply for disability benefits; many cases may remain undetermined or delayed in the decision-making process. In the meantime, a person who is truly disabled may not be able to gain access to the resources that he or she needs to make a recovery that would help improve quality of life and potentially reduce costs to society.Policy, Treatment, and Medical Coverage
People with disabilities who also have current substance use disorders tend to enter drug treatment at a much lower rate than those without co-occurring disabilities. Some barriers to care include lack of transportation, difficulty with physical access to the treatment center, and limited knowledge among treatment providers about the special needs of people with disabilities. Two important policies that have implications for treatment and medical coverage for people with substance use disorders (and mental health conditions) are the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, and the 2010 Patient Protection and Affordable Care Act. On October 3, 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (usually referred to as the Parity Act) was signed into law. The Parity Act requires covered health plans to provide the same financial terms, conditions, and requirements for mental health and substance use disorder benefits as provided medical/surgical conditions. The Affordable Care Act extended the Parity Act to apply to individual health insurance markets (as opposed to only group plans), and requires the coverage of substance use disorder and mental health services as essential health benefits. There is overwhelming evidence that substance use disorders take a great toll on the lives of individuals, their families, and their communities. Numerous studies have demonstrated the disabling neurological, physiological, and genetic dimensions of addiction, and the effectiveness of treatment. The 2008 Parity Act and the 2010 Affordable Care Act affirmed these findings.
Substance Use Disorders and Comorbid Disability
Drug and alcohol use disorders (collectively referred to as substance use disorders) are associated with adverse health and mental health conditions. If a person has discontinued drug use, the source of a disabling condition is immaterial to the protections provided by the Americans with Disabilities Act and eligibility for benefits from the Social Security Administration. Disabling conditions that are protected under the Americans with Disabilities Act can include infectious diseases and psychological illnesses, as well as substantial physical impairment. This section describes the association between disability and different classes of drugs of abuse, with details about neurological, physical, sensory, and functional impairment from each class. Prenatal substance use and associated disability and consequences are also discussed.
Alcohol
Alcohol use disorder accounts for a high proportion of disability in the United States and globally. There is extensive literature on the many disabling conditions, to include physical and mental health conditions associated with alcohol misuse use and disorders. c
c References 1, 2, 21, 29, 34, 41, 47, 81.
Alcohol use disorder can harm most of the body’s organs, including the liver, the immune system, the cardiovascular system, and the skeletal system.Injury
Alcohol use is a leading risk factor for intentional and unintentional injury. In addition, a significant proportion of disability-adjusted life years (DALYs) from injuries, in the United States and globally, is attributable to alcohol use. Alcohol-related injuries and their circumstances are wide ranging to include, but not limited to, falls, automobile crashes, and fires. There is a positive association between alcohol consumption and injury (i.e., the more a person drinks, the higher the risk for injury), especially among frequent heavy drinkers and binge drinkers. The increased risk for injury due to alcohol stems from impairments in cognitive capacity, physical coordination, and performance, in addition to increased risk-taking behavior associated with drinking.
In a literature review that examined the role of substance abuse in the cause of injury for patients using physical rehabilitation services, Hubbard and colleagues found that up to 79% of rehabilitation patients had alcohol-related traumatic injuries and that 35% of automobile injuries, 55% of motor vehicle deaths, 40% of drownings, and 30% of noncommercial airplane crashes were related to alcohol. Up to 72% of patients with head injuries from car crashes had positive blood alcohol levels; and males were more than twice as likely as females to have positive blood alcohol levels at the time of head injury. Drinking or intoxication is also associated with up to 79% of spinal cord injuries. Furthermore, a retrospective cohort study of medical claims data on patients with alcohol- or drug-related primary or secondary diagnosis by Miller and colleagues estimated the excess risk of medically treated and hospitalized nonoccupational injury for people younger than age 65 with medically identified substance abuse. They found that people who were medically identified as abusing substances had a higher risk of injury in a 3-year period. People who abused alcohol and drugs were almost four times as likely as controls to be hospitalized for an injury during the 3-year period, and the risk of injury was substantially higher for female than male users of substances.
Liver Disease
Alcohol consumption is causally related to liver disease (e.g., cirrhosis), and accounts for nearly a third of liver cirrhosis worldwide. Risk of liver disease is positively related to alcohol consumption and varies by race and gender. For example, a higher proportion of men than women have alcohol-related cirrhosis ; however, women may be more susceptible to the cumulative effects of alcohol on the liver. In addition, Hispanic-white males have higher age-adjusted mortality rates from liver cirrhosis than non-Hispanic white males, non-Hispanic black males, Hispanic-black males, and females. There are three forms of alcoholic liver disease: fatty liver, which is usually reversible with abstinence; alcoholic hepatitis, characterized by persistent liver inflammation; and cirrhosis, characterized by progressive scarring of liver tissue. More than one type of liver disease can be present at the same time. Individuals with both cirrhosis and alcoholic hepatitis have a death rate of more than 60% over a 4-year period, with most deaths occurring within the first 12 months of diagnosis. Alcohol initially causes liver injury by generating harmful metabolites, and continuing alcohol use exacerbates the initial injury. Chronic alcohol use leads to inflammation and weakens the ability of the liver to repair itself. It also leads to increased fibrogenesis, a major source of cirrhosis.
Neurological and Social Functioning
Alcohol-related limitations in neuropsychiatric and social functioning contribute to a significant proportion of disability. Neurological complications from alcohol can lead to substantial long-term disabling conditions. Lasting cognitive impairment in people with alcoholism can be direct, through brain damage from long-term alcohol exposure, or indirect, as a result of head trauma, central nervous system infection, hepatic failure, or nutritional deficiency. Direct neurological consequences of long-term alcohol use include Wernicke-Korsakoff syndrome, Marchiafava-Bignami syndrome, and central pontine myelinosis. Wernicke syndrome, in which decreased attentiveness, alertness, and memory are usually accompanied by disordered eye movements and ataxia, is often followed by Korsakoff psychosis, a lasting amnestic disorder. Marchiafava-Bignami syndrome and central pontine myelinosis are related to damage to the myelin sheath of neurons in the corpus callosum and pons, respectively. Studies have shown that alcohol also directly damages the cerebrum sufficiently to cause dementia.
A study by Hasin and colleagues, using data from wave 1 (2002–2003) of the National Epidemiological Survey on Alcohol and Related Conditions, further highlights the relationship between alcohol use disorders and poor social and mental functioning. Hasin and colleagues measured the prevalence, correlates, disability, and comorbidities associated with alcohol abuse and dependence in the United States. When adjusted for sociodemographic characteristics and other disorders, alcohol abuse was associated with lower social functioning (e.g., limitations due to emotional problems) and role emotional functioning (e.g., role impairment related to emotional problems). Alcohol dependence was associated with lower social and role emotional functioning, as well as with poorer mental health; and disability increased with severity of alcohol dependence. Results were similar in the National Epidemiological Survey on Alcohol and Related Conditions-III (2012–2013), such that after adjusting for sociodemographic characteristics and psychiatric comorbidity, people with alcohol use disorder had lower social and role emotional functioning and poorer mental health than people without alcohol use disorder; and disability generally increased with severity of alcohol use disorder.
Immune System
Alcohol use disorder can lead to impaired immune response, which can increase vulnerability to certain diseases. Genetic factors may also contribute to individual vulnerability to reduced immune functioning related to alcohol consumption. Autoimmune-related diseases associated with alcohol consumption (e.g., alcoholic liver disease) can be life-threatening. Alcohol-related immunodeficiency can also exacerbate diseases and health conditions such as pneumonia, tuberculosis, and organ damage—particularly in the liver. Furthermore, people who abuse alcohol, compared to those who do not, are more susceptible to infections like septicemia, empyema, lung abscesses, cellulitis, and meningitis.
Cardiovascular System
Chronic heavy drinking is a leading cause of cardiovascular illnesses such as cardiomyopathy, coronary heart disease, high blood pressure, arrhythmias, and stroke. In alcoholic cardiomyopathy, long-term heavy drinking can enlarge the heart and impair its ability to contract. Symptoms of cardiomyopathy include shortness of breath and insufficient blood flow to the rest of the body. Women may have a greater risk than men of developing alcoholic cardiomyopathy. The condition may be at least partially reversible with abstinence. Some studies report potential benefits of light to moderate drinking in relation to cardiovascular diseases. However, these benefits are off-set at higher drinking levels and by irregular heavy drinking, which are associated with increased morbidity and mortality.
An association between heavy alcohol consumption and increased blood pressure has been observed in more than 60 studies in diverse cultures and populations. Heavy drinking can disrupt the heart rhythm both acutely (during an episode of drinking) and chronically (during long-term use). Intoxication can cause certain types of arrhythmia in both those with alcoholism and otherwise healthy individuals. Sudden death attributable to arrhythmia is one of the causes of mortality in people with alcoholism with or without preexisting heart disease. Such deaths often occur during periods of abstinence, suggesting that arrhythmias are more likely to develop during alcohol withdrawal.
Skeletal System
Epidemiologic studies have found a significant association between alcohol consumption and bone fracture risk. In addition to the increased risk of accidental injury from impaired gait and balance, people with alcoholism may also have a generalized decrease in bone mass. Heavy drinking may lead to osteoporosis, characterized by severe back pain, spinal deformity, and increased risk of wrist and hip fractures.
Drugs of Abuse
Drug use disorders are associated with increased disability and comorbidity, some of which are detailed in this section. There are several drugs of abuse and drug classes. This section provides an overview of a few and related disability.
Cocaine
Cognitive deficits are of the many disabling factors associated with cocaine use. People who abuse cocaine often exhibit lasting cognitive deficits even after cessation of use. In a study comparing 20 people in recovery who chronically abused with controls matched for age and education, O’Malley and colleagues used a series of standardized neuropsychological assessment procedures to assess cognitive impairment. They found that people who abused cocaine were 35% more likely than the control group to score in the impaired range of the neuropsychological screening exam. Those who abused cocaine also performed more poorly on tests for abstract thinking and reasoning and verbal memory. Neuropsychological performance was directly related to the severity of cocaine abuse, suggesting that cocaine played a direct role in affecting cognitive functioning. Cognitive deficits from cocaine are often related to perfusion abnormalities or changes of blood flow in the brain. A study by Browndyke and colleagues showed the relationship between cognitive performance and the magnitude of perfusion abnormality. Their findings indicated significant regional perfusion abnormalities among people who abused cocaine relative to controls, and substantial deficits in neuropsychological functioning for people who abused cocaine.
Heroin
Injection drug users, as well as noninjection drug users are at risk for consequences associated with heroin use. For example, in an epidemiological study conducted in Baltimore, Maryland, that identified three classes of heroin and cocaine users—crack/nasal-heroin users, polysubstance users, and heroin injectors—found that crack smoking/nasal heroin users had lower odds of hepatitis C virus than heroin injectors, but these groups did not differ on HIV status. The lack of significant difference on HIV status between these two groups highlights a potential equal risk for disability regardless of route of administration. Other risk factors associated with infectious diseases and potential disability varied by route of administration. For example, polysubstance users had more than a 2.5 times higher odds of sharing needles as compared to those who injected heroin; and the odds of high-risk sex behaviors were 2.5 times higher among crack smoking/nasal heroin users as compared to polysubstance users.
Methamphetamine
Methamphetamine use is associated with physical, cognitive, and psychiatric deficits. For example, the prevalence of ADHD was higher among people with methamphetamine use disorder compared to those without methamphetamine use disorder. Physical impairments like neck and back injuries were commonly reported among methamphetamine users. In addition, long-term methamphetamine use is associated with impaired performance on a number of cognitive tasks, including verbal memory and motor function, manipulation of information, abstract reasoning, and task-shifting strategies. The cognitive impairment observed in people who abuse methamphetamine may also be related to abnormalities of frontal lobes of the brain. Chung and colleagues reported that decreased gray-matter densities and glucose metabolism in the frontal region of the brain were correlated with impaired frontal executive functions in people who abuse methamphetamine. Executive functions are necessary for goal-directed behavior and come into play when adapting to change, in planning for the future, and in abstract thinking. In a study comparing people who abuse methamphetamine with healthy subjects, Chung and colleagues used diffusion tensor imaging to describe the differences in frontal white-matter integrity and assessed differences in frontal executive functions with the Wisconsin Card Sorting Test. They found that frontal white matter was compromised in people who abuse methamphetamine and that these people showed more errors in the Wisconsin Card Sorting Test relative to healthy subjects. They also noted that the neurotoxic effect of methamphetamine on frontal white matter may be less prominent in women than in men, possibly because of estrogen’s neuroprotective effect.
3,4-Methylenedioxymethamphetamine (“Ecstasy” or “Molly”)
3,4-Methylenedioxymethamphetamine (also known as Ecstasy or Molly) and related compounds have serious acute and chronic toxic effects that resemble those seen with other amphetamines. Neurotoxicity to the serotonergic system in the brain can also cause permanent physical and psychiatric problems, including confusion, depression, and impaired memory. The brains of people who used Ecstasy/Molly over a long term, when examined while free of the drug, have abnormally low levels of serotonin and its metabolites in the cerebrospinal fluid and other significant alterations of neurotransmitter functioning. Among this population there is upregulation of serotonin receptors during abstinence, in response to the decrease in serotonin release caused by the action of the drug. Electroencephalographic studies show changes similar to those seen in aging and dementia and a change in response to auditory stimuli. The prolactin and cortisol responses to stimulation of the serotonin system were reduced in the people who used Ecstasy/Molly. These changes persisted for up to a year or more after the last use of the drug.
The demonstrated neurotoxic effects of Ecstasy/Molly on the serotonin system may be associated with a variety of mental health and behavioral problems that outlast the actual drug experience by months or years. These problems are quite varied, but they all involve functions in which serotonin is known to play an important role. Some persistent problems include impaired verbal and visual memory, decision-making, information processing, logical reasoning, and simple problem solving, as well as greater impulsivity and lack of self-control, recurrent paranoia, hallucinations, depersonalization, flashbacks, and psychotic episodes. In addition, past-year Ecstasy/Molly use is associated with anxiety and personality disorders.
Inhalants
The term inhalants is typically used in reference to a wide range of substances to include solvents, aerosols, gases, and nitrites, which are primarily inhaled and rarely taken by other routes of administration. Long-term abuse of solvents, for example, can cause damage to most organ systems, including the central and peripheral nervous systems and hepatic, renal, pulmonary, and cardiovascular systems. Solvent abuse can also affect bone marrow formation and lead to anemia. Cognitive effects include confusion, forgetfulness, and irritability. The psychiatric and neurological sequelae of chronic solvent abuse are serious and potentially irreversible.
To measure the consequences of long-term exposure to inhaled solvents, Yücel and colleagues reviewed neuroimaging and neuropsychological studies, examining chronic toluene misuse in humans. They found that toluene preferentially affects white-matter structures and periventricular/subcortical regions in the brain. They hypothesized that the lipid-dependent distribution and pharmacokinetic properties of toluene would likely explain the pattern of abnormalities, as well as the common symptoms and signs of toluene encephalopathy. The commonly observed neuropsychological deficits such as impairments in processing speed, sustained attention, memory retrieval, executive function, and language are also consistent with white-matter pathology.
Anabolic Steroids
The abuse of androgenic anabolic steroids can cause high blood pressure, heart attacks, and liver cancer. Long-term use of anabolic steroids may cause a range of adverse cardiovascular effects, some of which may be irreversible, including cardiomyopathy, dyslipidemia, and other atherosclerotic effects, hypertension, myocardial ischemia, and arrhythmias. Anabolic steroids are capable of increasing vascular tone, arterial tension, and platelet aggregation and may give rise to atherothrombotic phenomena. Although there are few reports of ischemic stroke related to anabolic steroid abuse, Santamarina and colleagues reported a case of a 26-year-old male amateur athlete who had a posterior territory ischemic stroke, whose only known significant risk factor was nonmedical use of stanozolol, an anabolic steroid.
Neuroendocrine effects from anabolic steroid abuse are associated with infertility and depression. In a study of the long-term side effects of high doses of self-administered anabolic steroids, Bonetti and colleagues observed 20 male bodybuilders who voluntarily self-administered anabolic steroids. The participants were tested every 6 months over 2 years. Physical examinations, and hematological, metabolic, and endocrine tests were performed, as well as semen analysis, hepatic and prostate ultrasounds, and echocardiographic evaluations. Long-term adverse effects observed included lower fertility and sperm counts and impaired lipid profiles associated with increased cardiovascular risk.
More rarely, the long-term use of orally active anabolic steroids can have adverse hepatic effects, ultimately resulting in hepatocellular adenomas or carcinomas, although these hepatic effects are often reversible. In vitro studies have shown that concentrations of anabolic steroids comparable with those likely present in many people who abuse steroids can cause apoptosis in human endothelial and neuronal cell lines, as well as apoptotic death of myocardial cells in rat models, suggesting the possibility of irreversible neuropsychiatric toxicity, as well as a mechanism for the cardiovascular effects already noted. Steroid abuse also appears to be associated with a range of potentially prolonged psychiatric effects, including dependence syndromes, mood syndromes, and progression to other forms of substance abuse.
Prescription Medications
Drugs classified as prescription medications have become a major category of abused substances. For example, the high prevalence of nonmedical prescription opioid use and associated morbidity and mortality are major public health problems. For example, in 2014, more than 10 million people in the United States reported nonmedical use of prescription opioids. Underlying this epidemic is the association between increasing rates of opioid prescribing and increasing opioid-related morbidity and mortality.
Sedative-hypnotic medications, which include benzodiazepines, barbiturates, and nonbenzodiazepine anxiolytics, are generally prescribed to treat insomnia or anxiety. In current practice, the term “sedative-hypnotic” often refers to benzodiazepines (e.g., diazepam and lorazepam). Neuropsychiatric effects of prolonged sedative-hypnotic abuse include deficits in memory, motor coordination, visuospatial learning, processing speed, and verbal learning. These phenomena have been difficult to study because some of the cognitive difficulties may result from sedation while others result from inattention or abnormally high plasma levels. However, meta-analyses have demonstrated that these effects can occur even after drug discontinuation. After drug discontinuation, cognition improves but may not return to the baseline level of function.
Prescription stimulants, such as dextroamphetamine and methylphenidate (which are often prescribed to treat ADHD), are classified as controlled substances with a high potential for dependence or abuse when used outside of appropriate medical supervision. With long-term use, stimulants may cause insomnia, irritability, aggressive behavior, and psychosis. Medical complications of acute intoxication with stimulants include altered mental status, autonomic instability (e.g., hyperthermia), seizures, or development of serotonin syndrome. Methylphenidate and dextroamphetamine have been associated with cerebral arteritis, renal necrotizing vasculitis, and systemic and pulmonary hypertension.
Prenatal Substance Use: Associated Disability and Consequences
Prenatal substance use and associated disability can affect both mother and child. For example, tobacco, alcohol, and marijuana are the most commonly used substances among pregnant and reproductive age women who may become pregnant, and are preventable causes of adverse health outcomes for both mother and baby. d
d References 5, 17, 24, 45, 48, 51, 62, 63, 68, 85, 90.
Adverse outcomes associated with prenatal alcohol use include, but are not limited to, fetal alcohol syndrome, spontaneous abortion, neurodevelopment problems, and pre- and post-natal growth deficits. Prenatal tobacco use is associated with pre-term and low birth-weight deliveries and infant mortality. Likewise, prenatal marijuana use is associated with low birth-weight, poor school achievement, and impaired neurodevelopment and executive functioning.Opioid and other illicit drug use disorders are also problematic among pregnant women, and can lead to increased risk for disability. For example, sex trade (a risk factor for disabling infectious diseases) and psychiatric comorbidity were prevalent among pregnant women in treatment for cocaine and opioid use disorders. In this sample, both sex trade and psychiatric comorbidity were associated with higher odds of sexually transmitted infections, which have potential implications for long-term disability.
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