Key Researchers


Key Results: Substance Abuse & Welfare Reform

Citations Listed in Key Results

  • Over different years, in many different surveys, approximately 20 percent of TANF recipients report that they have used an illicit drug at least once in the past year.
    The National Household Survey of Drug Abuse (NHSDA), and its successor, the National Survey of Drug Use and Health (NSDUH) provide the best available nationally-representative data regarding the self-reported prevalence of substance use. Within the 2007 wave of NSDUH, we find that 20 percent of women TANF recipients age 18-49 reported recent illicit drug use. In contrast, 10.3 percent of women with dependent children who did not receive TANF reported recent illicit drug use. These rates have proved relatively stable over time, and remain similar to those obtained using earlier waves of NSDUH/NSDHA data, covering periods before and after the 1996 reforms (Jayakody et al., 2000).

    Similar results were obtained in the Women’s Employment Study (WES), a longitudinal survey of current and former TANF recipients in one Michigan urban county. At the Fall 1999 WES survey wave, 22 percent of continuing TANF recipients and 16.6 percent of former TANF recipients reported that they had used an illicit substance at least once during the previous year (Metsch and Pollack, 2005), (Pollack et al., 2002). Approximately half of reported illicit substance use reflected the exclusive use of marijuana, with the remainder reflecting use of some other illicit substance (Jayakody et al., 2000). Approximately one out of five of WES respondents reported that they had used an illicit substance other than marijuana at least once over their lifetime (Phinney et al., forthcoming).
  • The prevalence of self-reported illicit drug use among welfare recipients has remained relatively stable post-reform, and remains below observed prevalences of the early 1990s.
    As indicated, self-reported prevalence peaked during the early 1990s and thereafter remained stable before and after the 1996 welfare reform. NSDUH data are not directly comparable to NHSDA data due to improvements in survey methodology. However, analysis of more recent NSDUH data indicate continued stability in patterns of self-reported use. Specifically, we examined the six waves of cross-sectional NSDUH data between 2002 and 2007 regarding substance use behaviors among women age 18-49 with children. These data indicate that consistently one-fifth of women TANF recipients age 18-49 reported recent illicit drug use. This is approximately twice the prevalence reported by women with dependent children who did not receive TANF. Because TANF recipients are a somewhat younger group than non-recipients, we followed Pollack and Reuter (2006) to present age-adjusted prevalences, whereby data for non-TANF recipients were weighted to represent the age distribution of women receiving TANF aid.

    The top line shows self-reported past-year illicit drug use by TANF recipients. The bottom line shows the comparable prevalence among non-recipients, with the middle line reflecting age-adjusted prevalence among nonrecipients.
  • Approximately 4 percent of TANF recipients reported illicit substance abuse or dependence. Approximately 4.3 percent of TANF recipients reported alcohol abuse or dependence.
    Simple use of alcohol or illicit substances should be distinguished from patterns of substance use that create medical or social difficulties for the user or for others. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) establishes explicit criteria for substance abuse and dependence which provide the foundation for clinical and epidemiological study (APA, 1994).

    Within the 2007 NSDUH, 3.9 percent of TANF recipients satisfy criteria for illicit drug abuse or dependence; 4.3 percent of TANF recipients satisfy criteria for alcohol use disorders (Metsch and Pollack, 2005), (Pollack and Reuter, 2006). These prevalences are slightly below those found in pre-reform surveys of welfare recipients (Jayakody et al., 2000), (Grant and Dawson, 1996).
  • AFDC/TANF receipt has declined as rapidly among low-income mothers who report recent substance use as among the broader population of low-income mothers.
    During the 1996 welfare reform debate, many observers noted that low-income mothers with substance use disorders would be penalized by the new law. To the extent that substance use poses an employment barrier, PWRORA provisions that discourage employable recipients from joining or remaining on the TANF rolls would tend to increase the concentration of substance users among remaining recipients.

    At the same time, substance users might be disproportionately affected by work requirements, sanctions, and lifetime time-limits designed to deter TANF receipt and to remove non-compliant recipients from the rolls. Substance users might also be disproportionately affected by stringent new regulations such as the Gramm Amendment, which imposed a lifetime ban on Food Stamps and TANF on many individuals convicted of drug-related felonies (PL104-193, 1996). Given these opposing pressures, advocates, researchers, and policymakers have been unsure whether PWRORA would increase or decrease the concentration of substance users among those receiving TANF aid.

    Pollack and Reuter examined this question, again using NHSDA data. They show that welfare receipt declined faster among substance users than among other low-income women. Schmidt and colleagues find similar patterns (Schmidet et al., 2006). We replicated this analysis in NSDUH 2007 data, and obtained extremely similar results. Of low-income mothers who reported illicit drug use in the past year, 38.9 percent reported receiving public cash aid, and 34 percent of low-income mothers who satisfy screening criteria for substance use disorders are TANF recipients. In contrast, 29.4 percent of low-income mothers who reported no illicit drug use in the past year reported receiving public cash aid. Drug users were somewhat more likely than non-drug-users to report receiving TANF aid. However, less than 40 percent of low-income mothers who report recent drug use receive such assistance.
  • Low-income women who are not working, are TANF-sanctioned, or are experiencing housing instability are more likely than others to report substance use disorders.
    Although substance use disorders are rare in the overall population of TANF recipients, they appear more common within key disadvantaged subgroups that come to the attention of policymakers, administrators, and clinicians.

    Morgenstern and colleagues have extensively explored substance use disorders among sanctioned recipients, and found significantly elevated patterns of substance dependence (Morgenstern et al., 2006). In a specialized screening program of sanctioned recipients in one New Jersey County, 49% of those interviewed met criteria for abuse or dependence (Morgenstern et al., 2001). Phinney and colleagues reported that WES respondents who had used "hard" illicit drugs (defined as the use of any illicit substance other than marijuana) were significantly more likely to report that they had experienced homelessness or eviction (Phinney et al., forthcoming).
  • Substance use is associated with increased duration (and cycling) of TANF receipt.
    Meara and Frank (2006) analyzed longitudinal data on low-income women from the 3-Cities study (conducted in Boston, Chicago, and San Antonio) and compared the labor market and welfare experiences of women with four employment barriers: poor mental health, moderate to heavy drug and alcohol use, a child with a behavior problem, and child under the age of 3 (Meara and Frank, 2006). These researchers found that women with poor mental health and drug and alcohol users were much less likely to move into work than other groups, and more likely to be sanctioned for noncompliance with welfare requirements in 2000-2001 as federal work participation requirements increased.

    Pollack and collaborators (2002) found that work status was a powerful predictor of substance dependence among respondents in the Women’s Employment Study (WES). Current and former TANF recipients who worked less than 20 hours per week were more likely than others to satisfy criteria for drug or alcohol dependence (Pollack et al., 2002). There is also evidence that illicit substance use is correlated with duration (and cycling) of welfare receipt. Researchers report that WES participants who reported illicit substance use in multiple years were more likely to accumulate additional months on TANF (Seefeldt and Orzol, 2003). Data from African-American women in one Chicago community indicate that women who received AFDC or TANF for at least 5 years were more likely than non-recipients or short-term recipients to report recent marijuana or cocaine use (Williams et al., 2004).

    Cook and colleagues (2009) suggest that a significant proportion of TANF recipients have untreated substance use disorders (Cook et al., 2009). These researchers assessed a random sample of 333 women welfare recipients in their final 24 months of eligibility for TANF and found that approximately 9% had used illicit drugs in the past 12 months, 4.2% met the criteria of drug dependence, and 2.7% met the criteria of alcohol dependence. These proportions are similar to those found in nationally representative data.

    However, there is research that suggests that substance use has little or no effect on welfare to work transitions. Schmidt and colleagues examined the role of drug use disorders in transitions from welfare to work and back again between 2001 to 2003 in northern California (Schmidt et al., 2007). They found that while education, work history, and family size (parenting demands) consistently predict transitions from welfare to work and back again, substance-use related problems do not. Zabkiewicz and Schmidt (2007) showed that substance use does not prevent people from looking for work while on aid. Schmidt et al. (2007) show that former welfare recipients in general (regardless of substance use) obtain low-paying and short-term employment.
  • Substance use is only one of many barriers to well-being and social performance among low-income mothers and often co-occurs with other significant barriers such as psychiatric disorders.
    Substance use disorders are more common among mothers who receive TANF aid than among non-recipient mothers. However, these disorders are less prevalent than are other barriers such as low educational attainment, transportation difficulties, physical and other mental health disorders (Pollack et al., 2002), (Danziger et al., 2000), (Danziger and Seefeldt, 2002), (Montoya et al., 2001).

    Gutman and colleagues assessed the prevalence of potential employment barriers and their relationship to later employment for 366 substance using TANF-recipients who were enrolled in the CASAWORKS for Families demonstration program. At program entry, these recipients averaged six out of 14 potential barriers assessed (2003).

    Psychiatric disorders such as depression, anxiety disorders, and post-traumatic stress disorders (PTSD) commonly co-occur with substance use and use disorders (Pollack et al., 2002). Several researchers also note that substance users report sharply elevated incidence of domestic violence (Lown et al., 2006).
  • Some former welfare recipients have failed to find stable employment and may spend prolonged periods without work and cash welfare. These women are more likely to have used illegal drugs or meet the diagnostic screening criteria for alcohol dependence.
    Turner, Danziger, and Seefeldt (2006) used data from the 1997 - 2003 Women’s Employment Study (WES) to examine the "chronically disconnected" defined as former welfare mothers who did not have employment and cash welfare during at least one-quarter of the months during the 79-month period (Turner et al., 2006). About 9 percent of 503 WES respondents fit the definition of "chronically disconnected." Having used illegal drugs or having met the diagnostic screening criteria for alcohol dependence were significant correlates of disconnected status.
  • Screening and assessment of substance use disorders remain central administrative challenges, with great variation across service sites.
    Existing research indicates that many individuals with substance use disorders will not seek treatment on their own accord (Danziger and Seefeldt, 2002), (Morgenstern et al., 2003), (Morgenstern et al., 2001), (McCrady and Langenbucher, 1996), (Weisner and Schmidt, 1995). Screening for substance use disorders and subsequent referral to appropriate treatment are therefore essential.

    Existing data indicate that TANF agencies demonstrate great variation in how they detect, evaluate, and address alcohol and drug problems. While some state programs screen for substance use and some facilitate access to substance abuse treatment, many do not provide adequate training to TANF workers on how to identify alcohol and substance use disorders among TANF recipients. Some programs do not effectively address the myriad of other barriers facing substance-using welfare recipients (LAC, 2002).
  • Specialized screening and case management appear promising in identifying substance use disorders in welfare offices and integrating them into substance abuse treatment.
    Specialized screening has been shown to be an efficient approach for identifying substance use disorders in welfare offices Both care coordination and intensive case management are useful in integrating substance abuse treatment into welfare programming. Morgenstern et al. have shown that intensive case management (compared to the standard practice of screening and referral) was more successful in engaging women with substance use disorders into outpatient care and retaining them once they enter treatment (2006). Morgenstern et al.’s recent findings also provide support for the effectiveness of intensive case management in increasing rates of longer-term abstinence and employment among drug-dependent women receiving TANF compared with those in the screening and referral model (Morgenstern et al., 2009).
  • Work conditions, relationships between welfare workers and clients, and the stigma surrounding substance use influence the success of screening, assessment, and intervention.
    Ethnographic research and in-depth interviews with welfare workers have revealed distinct perceptions among workers towards substance users. In general, welfare workers have a positive attitude to welfare reform policy and believe that these new policy changes have allowed them to stop "enabling" substance abuse and to assist substance abusers in becoming more self-sufficient (Metsch et al., 2003).

    Findings from the California Welfare Client Longitudinal Survey report that the new welfare reform policies did not deter persons with substance abuse problems from applying for TANF nor did they find that TANF workers discriminated against substance abusers in considering them for aid (Schmidt et al., 2006).
  • TANF receipt may facilitate treatment entry among women with substance use disorders.
    Pollack and Reuter (2006) analyzed patterns among mothers aged 18 - 49 from the 2002 National Survey of Drug Use and Health (NSDUH). The analysis showed that TANF recipients who satisfied abuse or dependence criteria were more likely to have been in substance abuse treatment compared with others (non-TANF) who satisfied substance abuse or dependence criteria. TANF receiving mothers who needed substance abuse treatment had almost three times the adjusted odds of receiving such services as those who also needed services but did not receive TANF aid.

    Such patterns pose a new challenge for policymakers: TANF is a traditional conduit to identify and to serve low-income mothers with substance use disorders. Post-reform, TANF assistance reaches approximately one-third of these individuals. These patterns necessitate the development of alternative strategies outside of TANF to identify and to serve these women.
  • Comprehensive services for women and children may improve treatment outcomes.
    Evaluations conducted before and after PRWORA find that substance abuse treatment is associated with improved work outcomes among welfare recipients. These improvements reflect both increased employment and increased earnings among clients who find employment. Studies have recognized time spent in treatment as the most important predictor of improved work and welfare outcomes. More recent studies have recognized treatment completion as being another important predicto (Metsch et al., 2003), (Wickizer et al., 2000).

    Women with substance use disorders often experience multiple barriers to employment and job retention and therefore require multi-faceted interventions. These multiple and complex challenges fit uneasily into a vision of time-limited public aid. Most welfare-to-work programs emphasize acquisition of job search skills and rapid employment.

    CASAWORKS for Families provides one example of a multi-faceted intervention for substance-using TANF recipients. The program combines substance abuse treatment, work-related services (including work readiness and vocational training), mental health, parenting services, and case management to integrate services. Additional services available through case management include medical care, childcare, transportation, shelter, and clothing assistance. This and similar programs are designed to address multiple barriers and problems by integrating the efforts of many social service agencies to deliver comprehensive, concurrent services. Pilot demonstration data from 10 CASAWORKS sites suggest that 12 months of comprehensive, concurrent services, with treatment as core, would reduce substance abuse and improve work, family, and social functioning (Turner et al., 2006), (Morgenstern et al., 2003), (McLellan et al., 2003).

    Current TANF rules and authorizing legislation constrain the length of time substance abuse treatment can count towards state work participation rates. As a component of job search and job readiness assistance, such services are limited to six weeks per fiscal year (with a 12-week overall time limit applying to designated "needy states"), of which no more than four weeks can be consecutively provided. How effective treatment is best provided within these constraints remains a challenge for both clinicians and policymakers (Dohan et al., 2005).
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