Correspondence

Disability Payments among Schizophrenic Cocaine Abusers

N Engl J Med 1996; 334:664-665March 7, 1996

Article

To the Editor:

I am deeply concerned that the report by Shaner et al. (Sept. 21 issue)1 and the accompanying editorial by Satel2 may further fuel an already acrimonious discussion about the “appropriate use” of publicly derived funds. Have the authors launched us down a slippery slope, with other populations being prohibited from using public funds that might support addiction or harmful behavior in a very small minority? Why shouldn't there be drug tests for others who receive public assistance, enforced healthy diets for the recipients of taxpayer-derived funds, and rigid policing to prevent any diversion of such funds to unhealthy activities? Why shouldn't investigators supported by the National Institutes of Health who use public funds (i.e., federal grants) to support their own tobacco or alcohol addiction be subjected to intrusive monitoring? Should drug screening become part of the grant process? Although it may seem irrational to facilitate cocaine use by schizophrenics, I am concerned that the study by Shaner et al. may provide more data that will be used in a negative manner in an already polarized national debate. Male schizophrenics may be considered an extreme population, but once it is set in motion, the guillotine to end public support for harmful behavior will be difficult to stop.

James Feldman, M.D.
Boston City Hospital, Boston, MA 02118

2 References

1. 1

   Shaner A, Eckman TA, Roberts LJ, et al. Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers -- a government-sponsored revolving door. N Engl J Med 1995;333:777-783
   Full Text | Web of Science | Medline

2. 2

   Satel SL. When disability benefits make patients sicker. N Engl J Med 1995;333:794-796
   Full Text | Web of Science | Medline

To the Editor:

Both Shaner et al. and Satel suggest that a partial solution to a “government-sponsored revolving door” is to redirect disability payments from recipients to representative payees. The adverse consequences of this type of intervention, however, are numerous and costly. On the basis of my recent experience with patients who have received the dual diagnoses of schizophrenia and substance abuse, examples of these adverse consequences include prostitution; trading prescription medications for street drugs (or for cash to buy street drugs); stealing from family members, acquaintances, or strangers; panhandling; bullying family members or other psychiatric patients; and making deliveries or carrying out acts of revenge (arson, for instance) for drug dealers in exchange for drugs.

Exercising control over patients with dual diagnoses by controlling their money will work only if we simultaneously offer them something meaningful. Negative sanctions must be accompanied by positive rewards for abstinence or else treatment of those with dual diagnoses is doomed. If we cannot give them something better than drugs, why should they give up the drugs?

Jeffrey L. Geller, M.D., M.P.H.
University of Massachusetts Medical Center, Worcester, MA 01655

To the Editor:

Shaner et al. ask a narrow question: Is there a temporal association between the receipt of disability payments, the use of cocaine, and symptomatic relapses, as evidenced by the rate of readmission to the hospital? This is similar to asking whether employed men are likely to drink greater amounts of alcohol in the period after payday than at other times. We suggest that, even if the answer is yes, the question is relatively unimportant.

In their discussion, the authors venture far beyond the narrow scope of their study. They suggest that disability payments may be a cause of relapses. To establish the causality of this association would require a comparison group of similar patients not receiving disability payments. Such a study would also require evidence of the strength of the association, its repeatability across studies, a clear temporal association, support from experimental studies, and a dose–response relation, none of which are convincingly shown. Instead, what the authors have shown is that people buy more (drugs in this case) at the time of the month when they have more money, which is very different from showing that having money makes people ill. It is therefore premature, and we think hazardous, for the authors to propose a change in national policy affecting Supplemental Security Income.

Graham Thornicroft, M.D., Ph.D.
Institute of Psychiatry, London SE5 8AF, United Kingdom

Ezra Susser, M.D., Dr.P.H.
Columbia University, New York, NY 10032

Author/Editor Response

The authors reply:

To the Editor: All three correspondents raise the same issue — namely, that our article might be taken as a rationale for stopping direct disability payments to needy persons, a change in policy that they believe might do more harm than good. Dr. Feldman refers to the “slippery slope” leading to oppressive bureaucratic intrusions that he fears might ultimately extend far beyond the population we studied. Dr. Geller, apparently writing from personal experience, confirms our speculation that addicted schizophrenics will continue to use drugs despite the appointment of representative payees, funding their purchases not only through panhandling (as we suggested) but through a variety of frightening acts, including crimes and violence to persons and property. Drs. Thornicroft and Susser question the depth of our causal analysis and suggest that a policy change may be “hazardous” in the absence of definitive evidence of a causal association. We, of course, suggested that the current system may be hazardous as well — thus, the dilemma to which we allude in our penultimate paragraph.

These comments provide a welcome opportunity to reemphasize an important conclusion we drew in our article. “Simply discontinuing the disability payments,” we wrote, “will not eliminate drug abuse and might exacerbate hunger and homelessness. . . . [E]ven payees cannot prevent the use of drugs purchased with funds obtained by other means.” The payee approach must be part of a comprehensive treatment program, including behavioral interventions that reward abstinence. As clinicians working to develop such programs, we view the payee approach not as an end in itself but as an intermediate step toward restoring health and autonomy.

Andrew Shaner, M.D.
West Los Angeles Veterans Affairs Medical Center, Los Angeles, CA 90073

Jim Mintz, Ph.D.
UCLA School of Medicine, Los Angeles, CA 90024

Citing Articles (2)

Citing Articles

1. 1

   James A. Swartz, Chang-ming Hsieh, Jim Baumohl. (2003) Disability payments, drug use and representative payees: an analysis of the relationships. Addiction 98:7, 965-975
   CrossRef

2. 2

   Laura A. Schmidt, Dennis McCarty. (2000) Welfare Reform and the Changing Landscape of Substance Abuse Services for Low-Income Women. Alcoholism: Clinical and Experimental Research 24:8, 1298-1311
   CrossRef