Case management and supported employment: a good fit.

Individuals with severe disabilities have often been denied the full range of vocational opportunities. Because of discrimination and oppression, and false beliefs regarding their skills, capacities, capabilities, and interests, individuals with disabilities have often been relegated to nonwork activities or sheltered work opportunities. Passage of legislation, such as the Developmental Disabilities Assistance and Bill of Rights Act of 1984 and Title VI, Part C of the Rehabilitation Act Amendments of 1986, in combination with systems change grants funded through Title III of the Rehabilitation Act, provided the basis for the initiation of a series of federal- and state-funded demonstration projects designed to provide opportunities and supports for individuals with severe or significant disabilities to work at competitive sites in the community. This model of vocational services, called supported employment, while initially conceived as a vocational program for individuals with mental retardation, has been modified to successfully provide services to individuals with mental illness, acquired brain injury, autism, cerebral palsy, physical disabilities, and other disabilities. A key to the success of these programs is the complementary working relationship between the case manager and the job coach. While there may be some overlap in what each brings to the person with a disability, each professional plays distinctive and critical roles in the carrying out of supported employment.

When people with pre-existing disabilities age in place: implications for social work practice.

We focus on a population of people with disabilities who are "aging in place," that is, individuals aging with pre-existing physical disabilities. We distinguish between those who experience prolonged aging and others who experience accelerated aging. A brief overview of people aging with disabilities and selected background information on the increasing linkages between the aging and disability communities is provided. Four case examples illustrate the practice implications faced by social workers in partnering with people with pre-existing disabilities and in being sensitive to their desires concerning aging in place.

Personal assistance services and case management.

Case managers can serve a vital role in the coordination and support of consumer-driven personal assistance services (PAS) for people with disabilities. Personal assistants provide services such as assistance with mobility needs, transferring in and out of a bed or wheelchair, bathing, dressing, grooming, toileting, preparing meals, check writing, and communication interpretation. Maximum independence and autonomy are often achieved when disabled people manage the services that they need. By focusing case management on doing what the individual directs, the case manager can enhance independence, autonomy, and accommodation. In response to needs identified by its members, the Paralyzed Veterans of America (PVA) began to develop a comprehensive PAS training program for institutions, agencies, families, and individuals. The Independent Living Training Program is based on an approach to PAS that incorporates a case management model that supports the principles of consumer empowerment and self-determination.

Subjective and cardiovascular effects of intravenous nicotine in smokers and non-smokers.

The present study assessed the subjective and cardiovascular effects of intravenous nicotine in smokers and nonsmokers. Nonsmokers (n = 5) and smokers (n = 5) were administered a single dose of nicotine (0.75 or 1.5 mg) or saline on each of 3 days. The nicotine doses were given in ascending order in a double-blind fashion. Although smokers and nonsmokers manifested significant increases in systolic and diastolic blood pressure and heart rate 1 min after administration of all active test doses, the difference between peak heart rate and that measured at later times was greater in nonsmokers than in smokers. Nonsmokers and smokers also differed in subjective self-reports. In response to items on visual analogue scales indicative of positive effects (e.g., "good effects," "like drug," "use again," and "feel energetic"), smokers but not nonsmokers reported high scores (> 40) after nicotine injection. In addition, responses on the MBG and LSD subscales of the Addiction Research Center Inventory indicated that smokers experienced positive subjective effects after the test doses, whereas nonsmokers experienced disorientation. The fact that intravenous nicotine was not associated with positive subjective effects in nonsmokers indicates that repeated exposure is required to establish positive reinforcing effects of nicotine.

Illicit drug use by persons with disabilities: insights from the National Household Survey on Drug Abuse.

OBJECTIVES: This study sought to evaluate the association of drug use with disability in a representative sample of the US household population. METHODS: The use of illicit drugs and alcohol reported by respondents in the 1991 National Household Survey on Drug Abuse who identified themselves as "disabled, unable to work" was compared with respondents without disabilities. RESULTS: Among younger adults (18-24 years), persons with disabilities were more likely than those without disabilities to report that they had used heroin (adjusted odds ratio [OR] = 6.89; 95% confidence interval [CI] = 1.35, 35.1) or crack cocaine (OR = 6.38; 95% CI = 1.05, 38.6). Among older adults (35 years and older), persons with disabilities were more likely to report the use of sedatives (OR = 2.46; 95% CI = 1.21, 4.94) or tranquilizers (OR = 2.18: 95% CI = 1.08; 4.42) not medically prescribed. CONCLUSIONS: These results suggest that use of illicit drugs is a potentially serious problem among persons with disabilities and requires both research and clinical attention.

Peptide T and glucose metabolism in AIDS dementia complex.

AIDS dementia complex (ADC) is the most common presenting neurologic manifestation of human immunodeficiency virus (HIV)-1 infection. We report FDG-PET studies in a 39-year-old man who had ADC and completed a 12-wk treatment protocol with 1.2 mg/day of intranasal peptide T, one before and one after 12 wk of treatment with peptide T. Peptide T is an octapeptide under investigation for treatment of ADC patients. Values of rCMRglc were converted to Z scores using the mean and standard deviation of values of rCMRglc in three HIV-seronegative matched controls, each of which was studied twice, at the beginning and end of a 12-wk interval. Thirty-five of 60 regions assayed showed Z scores with absolute values > or = 3 (considered abnormal) in the baseline study. Regions with high absolute values of Z scores were located in subcortical areas and in the limbic system, and to a lesser degree in the frontal, temporal and parietal lobes. Thirty-four of these 35 regions showed remission (decrease in the absolute values of Z scores) after treatment. Only one region showed no improvement in the second study. Three regions with absolute values of Z scores < 3 in the baseline study manifested Z scores with magnitudes > or = 3 in the second study. These preliminary observations suggest that functional neuroimaging techniques provide a useful tool in the evaluation of the response to treatment in ADC patients.

Buprenorphine reduces cerebral glucose metabolism in polydrug abusers.

Buprenorphine is a mixed opioid agonist-antagonist, which acts as a partial mu agonist and a kappa antagonist. The present study evaluated the acute effects of buprenorphine on cerebral glucose metabolism (CMRglc) in six human substance abusers using a double-blind, placebo-controlled, counterbalanced, crossover design. Each subject participated in two positron emission tomographic (PET) studies, 1 week apart, following the injection of buprenorphine (1 mg, intramuscularly) and placebo. Buprenorphine significantly reduced CMRglc and the regional cerebral metabolic rate for glucose (rCMRglc) by up to 32% in all but three of 22 bilateral and in 4 midline regions (p < .05). No region showed an increase in rCMRglc. Buprenorphine also produced miosis, respiratory depression, and subjective ratings of euphoria and sedation in comparison to placebo (p < .05). These observations extend previous findings of reduced CMRglc following acute treatment with morphine and other nonopioid euphorigenic drugs.

Issues in the treatment of mentally retarded patients in the community mental health system.

Developmental disability, particularly mental retardation, both affects a person's cognitive functioning and places that person on an alternative track of development which, when combined with social, political and economic pressures, places the developmentally disabled person at increased risk for mental illness. The presenting symptoms of mental illness will be modified by the mentally retarded person's cognitive impairment, personality development, and massively different life experience, as will the nature of his interactions with helping agencies. Evaluation, diagnosis and treatment must evolve from an alliance with the mentally retarded persons, not with caretaking agencies, and must be modified to take into account the retarded person's powerlessness. The therapist must be prepared to act as both advocate and bridge-builder for the patient, with the patient's increasing participation. The therapist must be prepared to steer between the Scylla of ignorance about the diagnosis and treatment of mental illness in the mentally retarded and the Charybdis of financial disincentives for human service agencies to collaborate in their care. The advantages of inter-agency cooperation in the treatment of dually-diagnosed individuals is described and illustrated.