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Stephen  Bevan

Substance Abuse & Obesity – Carrot or Stick?

Authors: Stephen Bevan Director of the Health at Work Policy Unit

29 July 2015

The announcement today of a government Review to examine how to support people with substance abuse or obesity challenges back to work raises a number of important issues.

First is that of the link between welfare benefits and substance abuse. There seems to be clear evidence (predominantly from the USA) that being in receipt of welfare benefits does not lead to substance abuse.  In addition, there is mixed evidence about the success of terminating benefits (in terms of increasing participation in treatment) for those whose primary condition is alcohol or drug abuse. Swartz et al (2004) found engagement in treatment increased, though there were negative consequences for other aspects of health and homelessness.  Gregoire and Burke (2004) found a three-fold increase in engagement in ‘recovery-oriented’ behaviour. However, Watkins and Podus (2000) and Stapleton et al (1998) found that abuse remained static among those whose benefits were withdrawn and reduced significantly among those whose benefits were continued.

A study conducted for the Department for Work and Pensions (DWP) by Bauld et al in 2010 reviewed the evidence relating to the benefits system and employment outcomes among people with alcohol problems in the UK context. This study involved a literature review and interviews with experts. The authors concluded:

“In our view there is inadequate evidence from either the literature or qualitative research that making treatment a condition of benefit receipt would improve treatment outcomes for clients or result in more alcohol misusers re-entering employment.” (Bauld et al, 2010)

Second, the evidence suggests that substance abuse and obesity are rarely ‘volitional’. The evidence that substance abuse and obesity are ‘lifestyle choices’ is very weak, despite public perceptions (Beeken and Wardle, 2013).  Most studies show that the causes of substance abuse and obesity are complex and multi-factorial (including mental health and other comorbidities; housing problems, abuse, social exclusion). Treating the symptom without addressing the related challenges faced by individuals presenting with these health problems is likely to be unsuccessful in most cases. This is especially the case if the presumption underpinning treatment is that the health condition results from a ‘choice’.

Third, a ‘Biopsychosocial’ approach is usually the most effective. In some studies people on benefits who are living with substance abuse or obesity have an average of six comorbidities – most often psychiatric in nature, though obesity is also a risk factor for osteoarthritis, type 2 diabetes and CVD, of course. In general, the notion that people with such conditions can be treated and then made more ‘job ready’ is simplistic.  The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM IV) includes ‘substance use disorders’ as psychiatric conditions rather than behavioural choices, for example.

Finally, interventions should focus on Job Retention and Return to Work. The proposed Review is likely to focus on existing benefit claimants, for understandable reasons. However, attention should also be given to Job Retention among people already in employment with health conditions related to substance abuse and obesity to prevent them falling out of work as a result of their condition. Existing services and interventions with a Job Retention focus (e.g. the new Fit for Work service, the Fit Note and Access to Work) should ensure that early support which helps premature job loss is targeted at people with complex, multi-morbid long-term conditions. Current provision is not flexible or specialist enough for these people. Similarly, interventions aimed at supporting people back to work (Work Capability Assessment, Work Programme, Work Choices, etc.) should be able to signpost people with these health conditions to specialist and tailored support. The re-commissioning of the Work Programme should, for example, offer an opportunity to improve access to specialist employment support. In addition, healthcare professionals should be encouraged to prioritise work as a clinical outcome of care, especially if work is likely to have therapeutic benefits. Some clinicians, in our experience, need support to challenge their beliefs that some long-term health conditions are untreatable and that recovery and return to work is unlikely.