Paper 1: Addiction and the Americans with Disabilities Act (ADA)

Westreich, Laurence M, Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York, University School of Medicine, New York, NY

On July 26, 1990, the United States Congress enacted the Americans with Disabilities Act (ADA), extending governmental protection against discrimination to those with physical or mental disabilities. The framers of this law intended a broad, civil rights-oriented mandate which would 1) "provide a national mandate for the elimination of discrimination against individuals with disabilities," 2) "provide clear, strong, consistent enforceable standards," 3) "ensure a central role for the federal government in enforcing the act" and 4) "use the regulation of commerce to protect persons with disabilities from discrimination." This paper addressed the successes and failures of the ADA in protecting individuals who suffer from addictive disorders; employment issues were the focus of investigation. After a case example and a brief explication of the basics of the ADA, laws which served as progenitors of the ADA were examined in light of their relevance to present-day protection of addicted persons. A more in-depth analysis of the covered conditions under ADA came next, along with sections on excluded conditions, reasonable accommodations made by employers and judicial enforcement of the ADAís provisions. The paper concluded with a review of present case law in ADA issues involved with addictive disorders and with some prognostications about future trends in addiction-related ADA litigation.

Paper 2: Practical Issues in Establishing Evidence-Based Clinical Practice

May, Linda, Bryn Mawr College, Radnor, PA; Grissom, G

Sophisticated treatment research in addictions historically entailed costly resources associated with negligible benefits for day to day clinical practice. Labor-intensive structured inter-views and self-report questionnaires, cumbersome protocols, data entry and analysis, and the absence of any immediate or near-term relevance to any individual patientís care put research far removed from the clinicianís sphere. Scientific and technological advances available today can 1) make data collection routine and relevant to the individual patientís treatment as it proceeds, 2) inform the development and implementation of evidence-based practice standards, 3) serve as an infrastructure for conducting a variety of scientific inquiries and 4) integrate seamlessly with regulatory and utilization processes such that unwanted administrative burdens associated with additional paperwork is eliminated. The development of a measurement culture within the treatment setting is necessary to fully implement such technology. Addiction psychiatrists in settings where standardized assessment is genuinely embraced as an aid to treatment can promote the detection, assessment, treatment and science of addiction in their numerous leadership roles in the field. Demonstrations of outcome management systems were provided, accompanied by examples of their implementation in a variety of settings and case studies illustrating clinical utility and scientific flexibility. The evolution of measurement culture was described in specific organizations. Applications include addiction detection (e.g., in a primary care physicianís office), initial assessment, evaluation of the need for ancillary services, treatment response assessment and determination of the patientís satisfaction with treatment.

Paper 3: Reliability and Clinical Utility of DSM-IV Substance Induced Psychiatric Disorders in Acute Psychiatric Inpatients

Ries, Richard K., University of Washington-Harborview Medical Center, Seattle, WA; Demirsoy, A; Russo, J; Barrett, J; Roy-Byrne, P

While substance induced syndrome designations were introduced under each of the major diagnostic categories in DSM-IV, there has been little clinical research on these categories in acute psychiatric populations. Results from a study to evaluate in 1,951 acute psychiatric inpatients the reliability, construct, convergent and predictive validity of substance induced syndrome ratings made by academic attending psychiatrists, using a structured and reliable instrument were presented. The primary admitting condition for each subject was rated by clinical attendings as not, mildly, moderately or mostly substance induced, at both admission and discharge. Ratings changed little between admission and discharge. Individual ratings were associated with characteristic demographic, clinical treatment response and length of stay findings indicating good construct and predictive validity. Given the important differences found between the four substance induced gradations (i.e., not, mildly, moderately and severely induced), a linear dimensional approach to rating substance-induced syndromes in acute clinical populations may be preferable to the simple dichotomous approach used in DSM-IV.

Paper 4: Alcohol Screening of Urban Native American Primary Care Patients

Shore, Jay H., University of Colorado Health Sciences Center, Denver, CO; Manson S; Buchwald, D.

Alcohol abuse is a major problem facing American Indian/Alaska Native (AI/AN) populations. No prospective studies have examined alcohol abuse among AI/ANs in primary care set-tings. The purpose of this study was to determine the rate of and risk factors for alcohol abuse among urban AI/AN primary care patients. A self-report survey was completed by 754 AI/ANs seen at a comprehensive urban primary care program. Medical records were abstracted to deter-mine physician diagnoses of alcohol use/abuse. Alcohol abuse was determined by a previously validated three-item screening instrument. Patients with and without abuse were compared on demographic, clinical and cultural characteristics; a logistic regression was used to determine the predictors of abuse. The proportion of patients screening positive was compared with the frequency of physician diagnosis of alcohol use/abuse. 423 (56%) of the respondents screened positive; al-most half of whom had current alcohol abuse, totaling 30% of the sample. The logistic regression model revealed that being male (p < 0.05), single (p < 0.05), having ever been mugged, robbed or assaulted (p < 0.001), and feeling sad, blue or depressed at least 2 weeks in the past year (p < 0.05) were all predictive of screening positive for alcohol abuse. Clinicians gave a diagnosis of alcohol use/abuse to only 16% of those who screened positive. Alcohol abuse is a significant problem among urban AI/ANs in primary care settings. Risk factors are similar to the general population. Further research is warranted to aid clinicians in the detection and treatment of alcohol abuse among this special population.

Paper 5: Outcome and Service Use Among Seriously Mental Ill Persons Who are Homeless and Have Substance Use Diagnoses

Gonzalez, Gerardo, Yale University Department of Psychiatry, New Haven, CT; Rosenback, R.

This study compared persons who were homeless and diagnosed with serious mental illness with and without comorbid substance abuse on baseline characteristics and clinical improvement after 12 months. Methods: The subjects were persons with mental illness who were homeless and participating in the first three cohorts that entered the Center for Mental Health Servicesí ACCESS program (n=5,432). Analysis of Covariance was used to compare dually diagnosed (DD) and non-dually diagnosed (NDD) clients and to determine the role of service use in fostering improvement. Follow-up data were available for 4,415 clients (81%). At baseline DD clients were worse off than non-DD clients on most clinical and social adjustment measures. They also had-poorer outcomes at follow-up on 15 of 24 outcome measures (62%). However, among dually diagnosed clients, those who reported extensive involvement in substance abuse treatment showed clinical improvement comparable or better than non-dually diagnosed clients. DD clients who had high levels of attendance at self-help groups (e.g. Alcoholics Anonymous/Narcotics Anonymous) had outcomes superior to other DD clients in their involvement in the criminal justice system and in augmented social support. Dually diagnosed persons who were homeless have poorer adjustment on most baseline measures and show significantly less clinical improvement than the non-dually diagnosed. However, those who receive extensive substance abuse treatment showed improvement at 12 months similar to that of non-dually diagnosed clients.


2000 Proceedings

2000 AAAP Annual Meeting Proceedings Copyright 2001 AAAP