Adapting addiction treatment

It is well known that patients with substance use disorders (SUD) and general learning disabilities experience barriers to treatment, have more relapse to substance use during treatment, and drop out of addiction treatment on a larger scale than patients without learning disabilities. However, our studies show that most of these patients go through years of treatment and contact with public support systems without being assessed or diagnosed with learning disabilities.

A 2019 review paper on intellectual disabilities and substance use by van Duijvenbode and VanDerNagel in European Addiction Research is quite direct, criticising addiction medicine for ignoring a whole population of patients: 'This article is meant to address the elephant in the room and wake up the sleeping dogs. That is, this article has addressed the topic that has been ignored by addiction medicine (i.e., SU[D] in individuals with mild to borderline intellectual disability).' Our research from Norwegian addiction facilities supports their statement.

In our study (published in 2018 in the Journal of Mental Health Research in Intellectual Disabilities: see tinyurl.com/wgxxnye) of 94 in-patients with SUD, about 30 per cent fulfilled the criteria for intellectual or borderline intellectual disabilities. Only one participant was identified with a developmental disorder by the treating institution. None were identified with learning disabilities prior to treatment. The individuals with intellectual or borderline intellectual disability in our study had lower education, more previous contact with public support systems, and more self-reported childhood learning difficulties than patients without learning disabilities. There were no statistically significant differences between the groups concerning substance-related factors, except for substance-use relapse during treatment.

Our research shows that neither child welfare services, schools, nor psychiatric services had identified the learning disability during childhood, and that they continue to go unrecognized for their learning difficulties through addiction treatment. If we are to adapt treatment to the intellectual disability, we first need to identify it. In a 2018 paper in the Nordic Journal of Psychiatry, we validated the Hayes Ability Screening Index (HASI), and can recommend it as a quick measurement to identify who should further receive a full assessment for learning disabilities.

With this new knowledge available, we should no longer allow ourselves to be sleeping dogs, but try our very best to adapt addiction treatment to the needs of individuals with general learning disabilities. However, studies on treatment effects often omit individuals with learning disabilities, and we therefore know little about effective interventions. Until we have solid, evidence-based methods for this population, addiction medicine can profit from adapting techniques such as shorter sessions, repeating learning material, involving caregivers in treatment and the use of visual support material in treatment.

Kirsten Braatveit
Clinical psychologist/PhD
Blue Cross, Haugaland A-senter
Helse Fonna HF, Department of Research and Innovation
Norway