The Government Accountability Office (GAO) recently issued a report examining 1) what is known about the relationship between trends in prescription opioids and disability claims, and 2) how the Social Security Administration (SSA) considers potential prescription opioid misuse in is disability determinations. The GAO found agency staff needed help to understand and follow SSA’s policies related to prescription opioid misuse. GAO-20-120.
The study was requested by Congress. According to the GAO, prior reports have considered the use of prescription opioids within federal programs, particularly Medicare, but less was known about opioid use in relation to SSA disability programs. The GAO analyzed data on opioid prescriptions and disability claims from 2006 through 2017. It focused on eligibility decisions in Alabama, Kentucky, and West Virginia, based on those states’ high rates of opioid prescriptions and percentage of adult populations on disability benefits.
The report dissects data and trends, finding a correlation between rates of opioid prescriptions and disability claims, although not necessarily a causal connection. It also reviews SSA’s policies for considering potential substance use disorders in disability claims, detailing Social Security Ruling (SSR) 13-2p and SSA’s evaluation process for drug addiction and alcoholism (DAA).
The GAO found that in reviewing sample cases and interviewing staff in the three selected states, substance use disorders are seldom the key factor in disability eligibility determinations. Among the reasons cited by staff: claimants with only substance use disorders did not have qualifying impairments; medical records did not include enough evidence of substance abuse to warrant a DAA evaluation; some claimants had qualifying impairments despite substance use disorders (non-materiality); and substances were prescribed. Staff interviewed by the GAO complained about the complexity of evaluating substance use disorders and understanding SSA’s policies.
The GAO concluded that SSA needed to clarify its policies and better train and supervise staff about them. In particular, it found staff was confused about when to evaluate substance abuse disorders. Many believed they should not conduct a DAA analysis unless there was an official diagnosis in the medical evidence of a substance use disorder. But according to SSA, its official policy does not require a diagnosis. Rather, an evaluation is required if there is a potential disorder that is considered a medically determinable impairment in accord with the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) and that is documented by an acceptable medical source.
The GAO found that despite SSA’s requirement that staff document a rationale for why substance use disorders did not affect the impairment, more than half the cases studies failed to do so. SSA’s policies require sufficient information about the decision, not just a simple finding that “DAA is not material.” SSA agreed that these poorly documented rationales could lead to reversals or remands.
The GAO recommended that SSA 1) clarify its policies and procedures to help staff better evaluate substance use disorders, and 2) ensure staff document their rationale. SSA agreed with the recommendations.