3.6.3.60 Guidelines to Table 6 - Functioning related to Alcohol, Drug and Other Substance Use

Summary

Table 6 is used to assess the functional impairment of a condition resulting from excessive use of alcohol, drugs or other harmful substances (such as, glue or petrol) or the misuse of prescription drugs.

Table 6 applies only to people who have current, continuing alcohol, drug or other harmful substance use disorders and those in active treatment.

The identifying feature of a substance use disorder is a cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems and/or risks.

Conditions causing impairment commonly assessed using Table 6

These include but are not limited to:

• alcohol use disorder
• various illicit drug use disorders
• various inhalant use disorders, and
• various prescription drug use disorders.

Diagnosis & evidence

The diagnosis of the condition causing impairment must be made by an appropriately qualified medical practitioner and supported by corroborating medical evidence. This includes a GP or other medical specialist, such as an addiction medicine specialist or psychiatrist with experience in diagnosis of substance use disorders.

People who suffer from long-term impairment that has resulted from previous alcohol, drug or other substance use but who no longer have an active substance use disorder and are no longer receiving active treatment must be assessed under the other relevant tables and not Table 6. For example, if the person has a resulting brain injury, they must be assessed under Table 7 - Brain Function. Similarly, if a person has resulting chronic liver disease they should be assessed using either Table 10 - Digestive and Reproductive Function and/or Table 1 – Functions requiring Physical Exertion and Stamina, depending on the functional impairment resulting from the chronic liver disease.

A PERSON'S SELF-REPORTED SYMPTOMS MUST NOT BE SOLELY RELIED UPON in determining functional impacts of the person's condition (impairment). There must be corroborating medical evidence of the person's impairment.

In addition, information provided by carers or those who provide support to a person must only be used as corroborating evidence of the level of impairment where consistent with medical evidence, and is not to be used for the purposes of diagnosis or assessing treatment.

Examples of corroborating evidence for the purposes of Table 6 include, but are not limited to:

• a report from the person’s treating doctor
• supporting letters, reports or assessments relating to the person’s substance use disorder (such as, a drug and alcohol counsellor or rehabilitation facility)
• a report from a medical specialist (such as, a GP, addiction medicine specialist or psychiatrist with experience in diagnosis or treatment of substance use disorders) confirming diagnosis of substance use disorder and resulting impairment of other body systems or functions
• a report from an allied health practitioner (such as, a psychologist) confirming the person’s functional impairment
• results of investigations (such as, liver function tests, alcohol and substance use assessment scales)
• interviews with the person and those who provide care or support to the person
• reports or other records of participation in treatment programs
• work or training attendance records.

Interpretation & application of relevant terms

Excessive use - means problematic use that results in damage to a person's mental or physical health.

‘Harmful substances’ refers to substances which, on taking them, result in damage to a person's mental or physical health or carry other significant health risks, such as overdose or seizures (for example, glue or petrol sniffing).

‘Misuse of prescription drugs’ means in a manner other than prescribed by a medical practitioner, and as a result of that misuse they have developed a functional impairment.

‘Long term’ refers to impairments that have resulted from previous substance use and are not likely to significantly improve over the next 2 years, such as chronic liver disease, brain damage and cardiovascular conditions.

Determining the level of functional impact - rules

When establishing whether a person’s impairment causes no or minimal (0 points), mild (5 points), moderate (10 points), severe (20 points) or extreme (30 points) functional impact, each descriptor and all its paragraphs for an impairment rating level in the Table must be read as a whole.

The structure of the Tables requires that, in assessing the level of functional impact, a comparison must be made of all the descriptors for each level of impairment. This does not necessarily mean all descriptors must be met, but all must be considered to determine which descriptors apply to the person’s impairment.

The descriptors in each Table follow an incremental hierarchy, which is expressed among other things, by the use of terms indicating increasing levels of difficulty in performing certain activities. These levels are expressed as: no or minimal difficulty, occasional difficulty, moderate difficulty, severe difficulty, and, extreme difficulty or unable to. Some Tables also represent an increase in frequency of symptoms, which is reflective of the impairment rating level.

When determining a person's limitations in relation to conducting 'work tasks', consideration must be given to a person's ability to undertake the task, regardless of whether or not it is part of work they do or have done previously. 'Work' is taken to refer to any work that exists in Australia, even if not within the person’s locally accessible labour market.

An assessment starts by considering the descriptors for 0 points, and if a person has more than 'no or minimal functional impact', the descriptors for 5 points are then considered, and so on for the descriptors for higher impairment levels. When it is determined that the person meets all the required descriptors for a certain impairment rating level, but does not meet all the required descriptors for the next impairment rating level, the appropriate impairment rating applicable to the person's circumstances will be the rating at which all the required descriptors are met.

However, one of several descriptors may be sufficient for that rating when the word 'or' links the descriptors. In other cases, a prescribed number of descriptors may be required for that rating to apply (for example, ‘the person has moderate difficulty carrying out at least 4 of the following’).

Note 1: Individual descriptors or their parts must not be applied in isolation from one another.

In determining whether the required descriptors for a specific impairment level are met or not, ALL the descriptors for that level must be considered and applied as set out in the descriptor. NO descriptors or their parts are to be disregarded.

Note 2: The descriptors must be applied sequentially to allocate an impairment rating - the incremental hierarchy of descriptors MUST NOT be ignored. As mentioned above, the assessment process involves applying the 0-point descriptors first and continuing to apply the descriptors for higher impairment levels, until all the required descriptors for a certain impairment rating level are met.

Note 3: If the person's impairment does not meet all required descriptors for a certain impairment level, the person's impairment cannot be rated at that level or at any higher level.

Determination of the descriptor that best fits the person's impairment level must be based on the available medical evidence including the person's medical history, investigation results and clinical findings. A person's self-reported symptoms must not solely be relied on. An impairment rating must not be applied unless the person's self-reported functional impacts are consistent with and supported by the medical evidence available.

In determining the level of functional impact, care should be taken to distinguish between activities that the person does not do as opposed to activities that they have difficulty performing because of their impairment.

An activity listed under a descriptor cannot be taken as being able to be performed if it can only be performed once or rarely - the person needs to be able to usually perform such activity whenever they would normally attempt it or be required to perform it. Where an activity is usually required to be performed repetitively, a person who can only perform such activity once and is then unable to perform the activity again when required will be taken to be unable to perform this activity. Equally, where an activity is normally undertaken infrequently (for example, only once per day or once per week), a person who can perform that activity once per day or once per week, is not unable to perform the activity merely because they are unable to perform the activity repetitively or with greater frequency than would normally be required.

When determining which impairment rating applies to a person the rating that best describes the person's abilities or difficulties must be applied. In applying the descriptors in Table 6, each descriptor sets out how the points within it are to apply.

For example, the 5-point descriptor states at least one of' the descriptors must apply. The 10, 20 and 30-point descriptors state at least 3 of the descriptors must apply.

Where a Table refers to a person being unable to perform certain tasks, the term 'unable' is not intended to mean that the task is unable to be performed without some symptoms. When a person experiences some symptoms when performing an activity this does not mean the person is 'unable' to perform the task. The assessment of the symptoms experienced in performing the activity is relevant where they are severe enough for the person to not be physically able to perform the activity on a repetitive or habitual basis, and not once or rarely.

High levels of consumption will increase health risks, but the use of alcohol, drugs or other harmful substances itself does not necessarily indicate functional impairment. A person who consumes a high level of alcohol may not have developed any medical complications or experienced significant problems in how they function. Each person should be assessed on an individual basis, as the level of impairment cannot be predicted from the reported level of alcohol, drug or other harmful substance use alone. It should not be assumed, for example, that a person on a methadone program is severely functionally impaired and has no work capacity.

If reasonable treatment has not been undertaken, it must be considered whether the person has a medical or other compelling reason for not doing so. For example, due to their condition, the person may have insufficient insight and ability to make sound judgements and this may then affect their compliance with and ability to see the benefit of recommended treatment. They may also have cognitive impairments from long term substance use affecting their judgement and insight. As such, a person's impairment could be considered stabilised for DSP purposes as they are unlikely to experience significant functional improvement within 2 years.

However, in cases where the person is considered to have sufficient insight and judgement, and their decision not to undertake reasonable treatment is not due to a medical or other compelling reason, the condition cannot be regarded as reasonably treated and stabilised.

When assessing episodic or fluctuating impairments and conditions, a rating must be assigned which reflects the overall functional impact of those impairments, taking into account the severity, duration and frequency of the episodes or fluctuations as appropriate (see 3.6.3.08 ‘Assessing impairments caused by episodic or fluctuating medical conditions’). The signs and symptoms of substance use disorders may vary over time and the person’s presentation on the day of the assessment should not be solely relied upon.

Impairment Ratings for Table 6

0-point impairment rating level

The 0-point descriptor requires that the person have NO OR MINIMAL functional impact from alcohol, drugs or other harmful substance use.

For this rating to be assigned, the person can carry out all activities in descriptor (1).

5-point impairment rating level

The 5-point descriptor requires that there is a MILD functional impact from alcohol, drugs or other harmful substance use.

For this rating to be assigned, the person MUST meet at least 1 of the descriptors at (1)(a), (b) or (c). Additionally, if point (c) were to apply, a person would be expected to be able to sustain employment or training activities without excessive absences (such as, no more than approximately 30 days total absence across a 6-month period (26 weeks)).

10-point impairment rating level

The 10-point descriptor requires that there is a MODERATE functional impact from alcohol, drugs or other harmful substance use.

For this rating to be assigned, the person MUST meet at least 3 of the descriptors at (1)(a), (b), (c), (d) or (e).

20-point impairment rating level

The 20-point descriptor requires that there is SEVERE functional impact from alcohol, drugs or other harmful substance use.

For this rating to be assigned, the person MUST meet at least 3 of the descriptors at (1)(a), (b), (c), (d), or (e).

30-point impairment rating level

The 30-point descriptor requires that there is an EXTREME functional impact from alcohol, drugs or other harmful substance use.

For this rating to be assigned, the person MUST meet at least 3 of the descriptors at (1)(a), (b), (c), or (d).

Avoiding double counting

Regardless of the number of substances the person is dependent on, only one rating is to be assigned under Table 6 to reflect the overall functional impairment.

Double counting of impairments must be avoided (see 3.6.3.06 ‘Rating multiple conditions with common impairments & double counting’).

Examples of Table 6 assessment

If a person has sustained irreparable damage and/or is unable to withdraw from the substance without further serious health complications (for example, withdrawal seizures) then it may be appropriate to assess them while still using the substance on the table which most appropriately captures the impairment.

Impairments that should not be assessed using Table 6

Long term impairments that result from previous alcohol, drug or other substance use, can include:

• neurological or cognitive impairment
• cirrhosis or other chronic liver disease
• cardiomyopathy
• neuropathy
• pancreatitis or other complications of end organ damage.

To avoid double counting, these resulting conditions should be assessed under the appropriate table according to the area of functional impact.

Act reference: Social Security (Tables for the Assessment of Work-related Impairment for Disability Support Pension) Determination 2023 Table 6 - Functioning related to Alcohol, Drug and Other Substance Use