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Alcohol and Substance Misuse

Once assessment and planning have been completed, including analysis of the collected data, the next step is implementing the strategies and interventions that will comprise the workplace health program.  The intervention descriptions below provide the public health evidence baseThe development, implementation, and evaluation of effective programs and policies in public health through application of principles of scientific reasoning, including systematic uses of data and information systems, and appropriate use of behavioral science theory and program planning models. for each intervention, details on interventions for alcohol and substance misuse, and links to examples and resources.

Before implementing any interventions, the evaluation plan should also be developed. Potential baseline, process, health outcome, and organizational change measures for these programs are listed under evaluation of alcohol and substance misuse programs.

Alcohol misuse

The National Institute on Alcohol Abuse and Alcoholism uses the following definitions of alcohol misuse:

  • Alcohol misuse describes alcohol consumption that puts individuals at increased risk for adverse health and social consequences. It is defined as excess daily consumption (more than 4 drinks per day for men or more than 3 drinks per day for women), or excess total consumption (more than 14 drinks per week for men or more than 7 drinks per week for women), or both1

The Centers for Disease Control and Prevention (CDC) Alcohol Team uses the following definitions of alcohol misuse:

  • Alcohol misuse
    • For women, more than 1 drink per day on average
    • For men, more than 2 drinks per day on average
  • Binge drinking
    • For women, 4 or more drinks during a single occasion
    • For men, 5 or more drinks during a single occasion
  • Excessive drinking includes heavy drinking, binge drinking or both
  • Alcohol misuse is a pattern of drinking that results in harm to one’s health, interpersonal relationships or ability to work
  • Alcohol dependence, also known as alcohol addiction and alcoholism, is a chronic disease and is associated with experiencing withdrawal symptoms, loss of control, or alcohol tolerance

Alcohol misuse can result in a number of adverse health and social consequences.

  • More than 700,000 Americans receive alcoholism treatment every day, but there is growing recognition that alcoholism (i.e., alcohol dependence or addition) represents only one end of the spectrum of “alcohol misuse”2
  • There are approximately 79,000 deaths attributable to excessive alcohol use each year in the United States3

Alcohol misuse is a risk factor for a number of adverse health outcomes including:

  • Unintentional injuries (e.g., motor vehicle accidents, falls)
  • Violence (e.g., homicide, suicide)
  • Liver disease
  • Diseases of the central nervous system (e.g., stroke, dementia)
  • Heart disease including coronary artery disease, atrial fibrillation (i.e., abnormal heart rhythm), high blood pressure, and congestive heart failure
  • Various cancers (e.g., breast, colorectal, and liver)
  • Risky sexual behaviors and adverse pregnancy outcomes

Many problem drinkers have medical or social problems attributable to alcohol (i.e., alcohol misuse or "excessive drinking") without typical signs of dependence, and other drinkers are at risk for future problems due to chronic alcohol consumption or frequent binges. Nondependent drinkers who misuse alcohol account for the majority of alcohol-related disability and death in the general population.4

Alcohol misuse is associated with high costs to employers including absenteeism, decreased productivity (due to poor work performance), turnover, accidents, and increased health care costs.

  • The cost of alcohol misuse in the United States was estimated to be $185 billion in 1998. About $16 billion of this amount was spent on medical care for alcohol-related complications (not including fetal alcohol syndrome [FAS]), $7.5 billion was spent on specialty alcohol treatment services, and $2.9 billion was spent on FAS treatment. The remaining costs ($134 billion) were due to lost productivity. Lost productivity due to alcohol-related deaths and disabilities impose a greater economic burden than do health care costs5
  • Over 15% of U.S. workers report being impaired by alcohol at work at least one time during the past year, and 9% of workers reported being hung-over at work6

The United States Preventive Services Task Force recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

Other substance misuse

Many substances, both illegal and legal, have the potential for misuse. Common examples include cocaine, ecstasy, heroin, inhalants, marijuana, methamphetamine, PCP/Phencyclidine, and prescription narcotics. Workplace approaches for employees with alcohol or substance misuse problems are similar.7

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Health-related programs for alcohol and substance misuse7-8

Employee programs refer to activities that include active employee involvement, such as classes, seminars or competitions. Employee programs are frequently provided on-site at the workplace.

Employee Assistance Programs (EAPs) can offer information and referral services for employees with alcohol or drug use problems

  • Several behaviors regarding job performance indicate a high likelihood that an employee has problematic alcohol or drug use:
    • A pattern of poor quality or poor quantity of work
    • Attendance problems
    • Problems related to interaction with clients or customers
    • Employees may self-identify that their misuse behaviors are causing problems
  • When these problems are identified the employee can be referred to the EAP for additional assessment
Support education programs through an EAP or health promotion program
  • Employees need education on recognizing signs and symptoms of misuse in themselves and others
  • Worksite health fairs, education campaigns and EAP brochures should include information on alcohol and substance misuse and specific information on obtaining confidential counseling and referral through EAP programs
  • Additionally, support can be provided through programs such as Alcoholics Anonymous or Al-Anon, and the availability of counseling, diagnosis and treatment services
Worksite health promotion such as physical activity or nutrition programs can reduce alcohol and drug misuse
  • Encouraging healthy behaviors is an appropriate adjunct to standard therapies for substance misuse. See the workplace implementation descriptions for physical activity, nutrition, and obesity

Tools and Resources (more)

  • The Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-based Programs and Practices Model Programs for the Workplace (NREPP) [*] provides specific techniques and interventions that have been carefully implemented and evaluated and shown positive outcomes
  • Mental Health America’s Factsheet: Co-occurring Disorders: Fast Facts [*] provides facts, risk factors, and signs and symptoms of alcohol and substance abuse disorders
  • Mental Health America’s Factsheet: Co-occurring Disorders Alcohol and Drug Abuse, Addiction and Co-occurring Disorders [*] provides information designed to increase the understanding of substance abuse and co-occurring disorders such as depression

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Health-related policies for alcohol and substance misuse8-9

Workplace policies promote a corporate “culture of good healthThe creation of a working environment where employee health and safety is valued, supported and promoted through workplace health programs, policies, benefits, and environmental supports. Building a Culture of Health involves all levels of the organization and establishes the workplace health program as a routine part of business operations aligned with overall business goals. The results of this culture change include engaged and empowered employees, an impact on health care costs, and improved worker productivity..”

Alcohol- and drug-free workplace policies discourage substance misuse
  • Key principles to develop a well-defined alcohol- and drug-free workplace policy include:
    • Drug free policies are publicized and employees are clear that substance misuse is never permitted in the workplace
    • Workplace heath promotion programs include education on substance misuse 
    • EAP services include assessment, counseling, and referral for employees regarding substance misuse
In high performance job settings, workplace policies require alcohol and drug testing 
  • As part of workplaces' "rules of conduct" or "fitness for duty" regulations, supervisors are often empowered to discipline or remove an employee from the job on the suspicion of drinking. In these settings the protocol for testing and follow up should be well defined and clear to all employees
  • For example, alcohol testing is mandated for the transportation industry through Federal regulations. Alcohol testing is most commonly used in other workplace settings when cause is established, particularly in response to on-the-job accidents. In such cases, alcohol testing is critical in establishing possible culpability, especially if injuries have occurred. When alcohol tests are positive, case dispositions may vary according to company policy, ranging from dismissal to the offering of counseling or treatment under the auspices of an EAP
Policies for worksite health promotion such as physical activity or nutrition programs can reduce alcohol and drug misuse

Tools and Resources (more)

  • The Substance Abuse and Mental Health Services Administration (SAMHSA) Drug Free Workplace Kit: Develop a Policy website provides information on drug-free workplace laws and regulations, basic elements of an effective policy, and resources for developing a policy

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Health benefits for alcohol and substance misuse10-14

Employee health benefits are part of an overall compensation package and affect an employee’s willingness to seek preventive services and clinical care.

Provide coverage for screening and counseling to reduce alcohol misuse

  • The United States Preventive Services Task Force recommends screening and counseling in clinical settings for people who misuse alcohol (i.e., patients who drink in excess of NIAAA guidelines)
  • Brief counseling in clinical settings can reduce consumption among drinkers who misuse alcohol who do not meet the criteria for alcohol dependence. Each dollar invested in screening and brief counseling saves $4 in health care costs
  • Routine measurement of biochemical markers (i.e., screening) is not recommended in asymptomatic persons
  • Pregnant women should be advised to limit or cease drinking during pregnancy
  • All persons who use alcohol should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking alcohol
Provide coverage for screening for depression in clinical practices
  • Other mental health disorders frequently co-occur with alcohol and drug misuse problems. For people struggling with co-occurring mental health and substance misuse disorders, physical safety and overall health risk are greater; the impairment of life skills is greater; and the chances for successful treatment are much less
  • Mental health problems often predate substance misuse problems by 4-6 years; alcohol or other drugs may be used as a form of self-medication to alleviate the symptoms of the mental health disorder
  • In some cases, substance misuse precedes the development of mental health problems. For instance, anxiety and depression may be brought on as a response to stressors from broken relationships, lost employment, and other situations directly related to a drug-using lifestyle
  • A person with a substance misuse problem should be screened and treated as needed for depression and other mental health problems

Tools and Resources (more)

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Environmental support for alcohol and substance misuse

Environmental support provides a worksite physically designed to encourage good health.

Environmental support for worksite health promotion such as physical activity or nutrition programs can reduce alcohol and drug misuse

Tools and Resources

  • Leading by Example: Creating Healthy Communities through Corporate Engagement published in 2011 by the Partnership for Prevention features 19 businesses and business groups who are providing leadership and reaching out to improve the health and wellness of their communities providing many benefits to their organizations.
  • Leading by Example: The Value of Worksite Health Promotion to Small- and Medium-sized Employers published in 2011 by the Partnership for Prevention provides best practices and strategies for creating or enhancing a worksite health promotion program as well as worksite health program descriptions from almost 20 small employers
  • The Substance Abuse and Mental Health Services Administration's (SAMHSA) Drug Free Workplace Kit is designed to provide public and private employers with evidence-based information, resources, and tools for producing and maintaining drug-free workplace policies and programs
  • The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Communities That Care includes surveys, training for community activities, assessment and other tools to enhance community capacity to prevent alcohol and substance misuse and related problem behaviors
  • National Business Group on Health’s An Employer’s Guide to Behavioral Health Services [PDF - 761KB] provides a number of evidence-based actionable strategies and recommendations that will allow employers to create and implement a system of affordable, effective, and high-quality behavioral health services. This report was done in collaboration with the Substance Abuse and Mental Health Services Administration (SAMHSA)
  • National Business Group on Health’s Issue Brief (January-February 2003 vol 2, No 1.) Solutions to Workplace Substance Abuse: Prevention and Treatment Strategies [PDF - 301KB] identified effective strategies and costs for interventions, potential cost savings to employers, and other health outcomes

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