Benefits with SISC - Self Insured Schools of California-

How Does an Addiction to Prescribed Narcotics Affect Disability Benefits?

This is a complex question to answer, because while Social Security does consider prescription drug abuse to be a substance abuse disorder (for which benefits are not available), Social Security will not treat an addiction to prescription drugs in the same way as it treats an addiction to illicit drugs (or drugs that are abused rather than taken as prescribed).

With illicit or abused drugs, a disability applicant cannot receive disability benefits for a problem caused by drug use if that problem would be reversed if the applicant stopped abusing the drugs. Social Security makes what's called a drug addiction or alcoholism determination ("DAA determination") to decide whether the limitations caused by drug use (such as depression or anxiety in a mental disability claim, or fatigue, nausea and abdominal pain in a claim for liver disease) are reversible. If the limitations are found to be reversible that is, the limitations would improve if the drug use stopped the agency won't even consider whether the limitations caused by the drug use are disabling.

With a dependency on prescription drugs, taken as prescribed, Social Security will not ignore the limitations and side effects caused by the prescription drugs when the agency is considering whether a patient is disabled.

Addiction to Prescription Drugs as a Disability

Federal law does not exempt the use of prescribed medications from being considered as drug abuse, and substance abuse disorders themselves cannot be the basis of disability. Only irreversible damage caused by such disorders can be the basis for a disability. This means that:

1. Disability benefits will not be granted for an addiction to prescribed drugs, even if the drugs are taken as prescribed and the drug use keeps a disability applicant from being able to work, but
2. Disability benefits may be granted in cases in which a physical or mental disorder that's different from the drug addiction is being treated with prescribed drugs.

It’s important to keep this distinction in mind for the following discussion of prescribed medication.

Prescription Drugs Aren't Subject to a DAA Determination

Why doesn't Social Security treat addiction to prescribed medication in the same way as addiction to illicit drugs? Agencies like the Social Security Administration (SSA) have broad discretion in implementing federal laws, and to be consistent with the evaluation of physical and mental impairments in general, Social Security will not refuse to consider the symptoms and limitations caused by prescription drug use as they would with symptoms or limitations caused illegal drug abuse.

So if an individual applies for disability based on a physical or mental condition and also has limitations caused by prescription drugs used to treat that condition, Social Security can take into account the disabling effects of the prescription drug use. To clarify this rule, in Social Security Ruling 13-2p, the SSA states that a DAA determination is not to be applied in cases of “addiction to, or use of, prescription medications taken as prescribed, including methadone and narcotic pain medications.”

Since Social Security will not consider the legitimate use of prescription medication as a DAA issue, if a person is receiving prescription narcotics or other drugs and takes them as prescribed as part of a legitimate doctor-patient relationship, then any ill effects of those drugs should be included when considering the severity of an applicant's medical condition. It does not matter whether the person is actually considered “addicted” because of the treatment or not. If the applicant experiences side effects like severe fatigue and difficulty focusing, Social Security will consider these symptoms when deciding if an applicant's limitations are severe enough to be disabling.

When Are Narcotics Taken as Prescribed?

The phrase taken as prescribed is crucial. For medication to be taken as prescribed, it requires there to be an ongoing patient-physician relationship (by logical inference from state laws and Social Security regulations). And “physician” means a licensed medical doctor or osteopath as a treating source and no one else.

When a physician appropriately prescribes a reasonable amount of medication to a patient for legitimate purposes, and the patient doesn't seek out extra quantities of the medication from elsewhere, the medication is taken as prescribed. To the extent that increased doses of narcotics are necessary to control pain due to an increase in tolerance to a drug or increased pain, the physician is still treating a physical disorder requiring narcotics, and any ill effects of these drugs and any drug side-effects should be included in assessing the severity of a disability applicant's medical condition.

Medication That Isn't Taken as Prescribed

Social Security must decide if there is a real doctor-patient relationship in any disability claim, and that also applies when a claimant is taking narcotics. Social Security is under no obligation to ignore DAA issues when the doctor-patient relationship is clearly broken and “taken as prescribed” has lost its meaningful context.

There are two ways this can happen, so that the drug addiction might become a material issue even if the claimant is seeing a doctor and taking legal drugs. These instances require Social Security to exercise medical judgment to decide whether a doctor-patient relationship exists only in form, not actuality.

When the Patient Breaks the Doctor-Patient Relationship

One exception would be an individual with a physical disorder who “doctor shops” a number of physicians to obtain narcotics, such as oxycodone, in larger amounts than they would otherwise be able to obtain, because of increasing dependency or for other reasons. In these cases, the person has gone outside the physician-patient relationship and used subterfuge with other doctors to obtain drugs those physicians otherwise would not be willing to prescribe. (In an attempt to decrease doctor-shopping for narcotics, some states have laws allowing doctors to easily check online whether patients have been obtaining narcotic drugs elsewhere.)

The desired narcotic might also be obtained without any doctor’s knowledge, such as over the Internet. The individuals in these cases are definitely not taking narcotics as prescribed, and they are not under prescribed therapy for such excesses. Therefore, Social Security can make a DAA determination on their cases; their abuse of drugs might be material to the disability determination and may cause a denial in some cases. Of course, if the person’s physical condition being treated is severe enough on its own to be a disability, without considering the narcotic side-effects, then DAA materiality is not an issue and the claim will still be allowed.

When the Doctor Breaks the Doctor-Patient Relationship

What about the situation where a doctor prescribes narcotics to someone who doesn’t need them? Thankfully, these types of cases are unusual, but they do happen. In this case, the drugs are not given for a legitimate medical purpose and the fact they are only technically prescribed doesn’t matter.

In regard to doctors prescribing large amounts of narcotics to someone beyond any reasonable medical need, the doctors in these situations are not practicing medicine but something else, and medical boards and law enforcement treat them accordingly. Typically, doctors’ medical records in such cases are skimpy or even non-existent, and they have no realistic explanation for why such large doses are needed. The patient could just as well be buying drugs from a non-physician. While it is not Social Security's position to second-guess the medications and doses given by treating doctors, some narcotic prescriptions are so obviously inappropriate in frequency and dose that it is impossible for any reasonable person to consider a legitimate doctor-patient relationship actually exists.

How Social Security Assesses a Claim When There Is No Real Doctor-Patient Relationship

If there is no doctor-patient relationship in practical terms, then Social Security may perform a DAA determination, even though the patient is addicted to prescription medicine rather than illicit drugs. In this case, Social Security will consider only the applicant's non-drug-related impairments as well as any permanent, irreversible effects of the prescription medication (more on this below). These problems may qualify the applicant for disability, while whatever limitations are imposed by the drugs themselves – the reversible narcotic effects simply wouldn’t be taken into account.

Social Security's Duration Requirement

Note that, for many cases, any disabling effects of prescribed drug use won't satisfy Social Security's duration requirement – impairments must have a duration of at least 12 months to be eligible for disability benefits. For example, patients recovering from a bone fracture or spinal surgery, who may experience disabling effects from narcotic use, will not require long-term narcotics for pain, and so their impairments will not meet Social Security's duration requirement.

The one-year duration requirement is most likely to be satisfied by chronic disorders that can cause severe pain, like deforming arthritis, cancer, chronic pancreatitis, arachnoiditis, spinal stenosis, and ankylosing spondylitis, which might require long-term narcotic use. In cases like these, the debilitating effects of prescribed chronic pain medication, such as sleepiness, difficulty concentrating, and easy fatigability, should be taken into account and may result in a finding of disability since they can prevent someone from working.

Irreversible Damage From Drug Addiction

Any irreversible damage caused by prescription or illicit drug abuse is always considered as a legitimate cause of limitations in the disability determination. For example, intravenous injection of narcotics and other drugs can result in serious viral and bacterial infections, with both reversible and irreversible complications. While narcotic drugs are much less likely than alcohol to result in permanent organ damage, advances in brain imaging show abnormalities associated with chronic use of codeine compounds, and this may extend to other types of narcotics. Any permanent limitations caused by the drug-induced damage can be considered as disabling assuming they are severe enough.