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Current course:  SSI/SSDI Outreach, Access, and Recovery (SOAR) Online Course: Adult Curriculum

Co-Occurring Substance Use: Material to Disability?

How substance use is considered in the disability determination process has changed substantially over the years. This article dispels several widely-held myths about how DDS views substance use (such as you have to be clean and sober to get benefits), and its impact on the application process.

Providing DDS with a complete picture of a person with mental illness who is experiencing homelessness can be difficult. Frequently, substance use complicates this picture. Over the years, SSA has changed how they consider substance use, referred to as "drug addiction and alcoholism (DAA)". Prior to August 22, 1996, some people with disabilities whose alcohol or drug use contributed to their illness(es)/condition(s) were able to receive benefits. Since 1996, regulations have become increasingly strict. For further details, refer to the February 2013 Social Security Ruling, SSR 13-2p, which consolidates information from a variety of sources to explain current DAA policy.  You can also review the SOAR TA Center document: Understanding and Documenting Opioid and Other Substance Use Disorders for SSI/SSDI Claims (PDF).
 

Myth Busting

There are a lot of commonly held misconceptions about how SSA handles substance use.
  • MYTH: You have to be clean and sober for 6 months to receive SSI
  • MYTH: You can’t receive SSI if you are currently drinking or using drugs
  • MYTH: People used to receive SSI just for alcohol or drug addiction
  • MYTH: If you fail a drug test your benefits will be cut off

The Concept of “Material”

Determining if Substance Use Is Material

Currently, the law states: if substance use is deemed “material” to a person’s disability, benefits will be denied.
  • “Material” is similar to “contributes to” or “an important part of” or “significant or substantial part of”
  • Consider: would the person be disabled by one or more disorders if he or she were clean and sober?
  • If yes, then the person is potentially eligible for benefits
    • It is not necessary to be clean and sober to receive benefits
  • If no, then substance use is material and the person would not be eligible for benefits
  • We do not ask if the substance use “causes” the disability because someone with cirrhosis of the liver could be found disabled even though extensive alcohol use “caused” that condition

Do Not Assume Automatic Denial

A person with a co-occurring substance use disorder is not automatically ineligible.
  • It is not relevant which disorder emerged or was treated first
  • Impairment from other disorders and illnesses is relevant
  • SSA does not consider the following conditions to be material: fetal alcohol syndrome; fetal cocaine exposure; addiction to or use of prescription medications taken as prescribed (includes methadone and narcotic pain medications); occasional maladaptive use of alcohol or illegal drugs; and nicotine or caffeine-related disorders 

What is a “Co-occurring Disorder”?

Synergy of Mental Illness and Substance Use

When a person has co-occurring disorders, the two disorders occur simultaneously. They interact, one impacting the other with synergistic effects. 
  • The two disorders may have evolved independently
  • The idea of a primary diagnosis is not applicable – different disorders do not exist hierarchically within a person
  • More often, people with histories of trauma or mental illness begin to use alcohol and other drugs as a way to cope
  • It is more socially acceptable to abuse alcohol or drugs than to have a mental illness, so people may seek treatment for the substance abuse but not the mental illness

Providing Evidence

It is important to be able to illustrate to the DDS examiner that the person would still be disabled even if they were clean and sober.  We often have to do this while the person is still drinking or using drugs.
  • Do not try to “hide” current or past substance use
  • DDS will find evidence in the medical records and need to make a materiality determination
  • Be sure that it is fully explained in your Medical Summary Report
  • Look for periods of time when the person was sober
    • Hospitalized
    • In jail or prison
    • Participating in treatment programs
  • Were they experiencing symptoms of their mental illness and struggling with their functioning despite sobriety?
  • Describe the context of their use
    • Does he drink to quiet the voices so he can sleep
    • Does she smoke crack to escape the pain of trauma
    • When she stops drinking/drugging does she become more depressed and have thoughts of hurting herself

Summary

Document the substance use and provide information that helps DDS make a decision as to whether or not the substance use is material to the disability. If the person would still be disabled even if they were clean and sober, substance use is not material to the disability.