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Under the Influence? Drugs and the American Work Force III Effectiveness Of Workplace Interventions
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Under the Influence? Drugs and the American Work Force This page in the original is blank.
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Under the Influence? Drugs and the American Work Force 6 Detecting and Assessing Alcohol and Other Drug Use The response of many employers to the perceived problem of alcohol and other drug use has been to establish drug-testing programs, either voluntarily or in compliance with federal regulations. Drug-testing programs typically have two main purposes: (1) to determine drug use among a firm's employees or prospective employees and (2) to deter such use for reasons of safety, productivity, and health. Given the preponderance of drug-testing programs among the drug intervention programs of U.S. corporations, a substantial portion of this chapter is devoted to describing what these programs entail; committee members thought it was critical to provide the reader with a thorough description of the technological issues associated with commonly used analytical methods of urinalysis drug testing. The extent to which these programs have been shown to be effective in achieving these goals is the subject of Chapter 7. Both direct and indirect methods are used to detect alcohol and other drug use among the work force. Biochemical analysis and self-reports are the two most commonly used direct methods for assessing substance use. Each has limitations. Biochemical methods, primarily urinalysis, usually detect only recent use and generally cannot measure patterns or frequency of use. Although hair analysis can potentially trace longer-term patterns of use, data on the measurement properties of this analytical technique are still limited. Self-report methods can measure patterns and frequency of alcohol and other drug use but are limited by validity problems, primarily involving the failure of some respondents to disclose use.
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Under the Influence? Drugs and the American Work Force To avoid the limitations of the direct methods, the use of indirect methods for assessing drug use and identifying drug users has been rapidly growing. Indirect approaches typically involve measuring or observing behaviors or responses that are frequently associated with alcohol and other drug use and inferring use from what is observed. They too have significant limitations, but they can complement the information gleaned from biochemical analysis and self-reports. This chapter first provides a brief historical perspective on the evolution of what is currently the most common biochemical method for detecting applicant and employee alcohol and other drug use in corporate America. It then reviews the main procedural components of forensic drug-testing programs. That is followed by a description of the most widely used indirect methods for assessing alcohol and other drug use: personal profiles, and behavioral indicators. The chapter ends with the committee's conclusions and recommendations. EVOLUTION OF BIOCHEMICAL DRUG TESTING The analysis of urine specimens and other body fluids to determine if particular individuals have used various drugs is not new. Drug testing in forensic toxicology and some clinical hospital laboratories predates President Reagan's executive order of September 1986 by at least 15 years (Finkle, 1972; Hawks and Chiang, 1986). The results of urine testing and their use as evidence in legal contexts has been tacitly accepted in the United States for many years. Large-scale drug testing was originally stimulated by the Department of Defense's (DoD) need to monitor its armed forces during the Vietnam War era, and by the heroin ''epidemic" in the 1970s, which resulted in thousands of patients being treated with methadone (Federal Register, 1972) and were required to be drug free and monitored to confirm that they were not taking additional drugs. In late 1980 the testing industry further expanded as the Navy, following a series of incidents that highlighted the pervasive use of marijuana among their personnel, announced a policy of "zero tolerance" for illicit drugs (Cangianelli, 1989). Over a period of 2 years they designed and implemented a testing program that required contracted laboratories to analyze more than 2 million urine specimens each year in order to monitor and control illegal drug use in the Navy. By the time the naval program was in place, the other branches of the services had followed suit (Willette, 1986). Private industry then followed. By 1985, several major U.S. corporations included drug testing in applicant screening programs, and some selected employees with the stated motive of promoting occupational safety and employee assistance (Frings, 1986; Hanson, 1986). The technical, logistical, and laboratory operations requirements to support
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Under the Influence? Drugs and the American Work Force these massive testing programs were wholly inadequate in the beginning. They rested primarily on cumbersome, inefficient, and nonspecific techniques, such as thin layer chromatography (TLC) and gas chromatography (GC). Many of the laboratories doing drug testing had little notion of what constituted legally adequate work, and experienced forensic analytical toxicologists were few. Performance testing surveys revealed serious inaccuracies in some laboratory results. These survey reports still haunt toxicologists and are quoted repeatedly by antagonists to today's employee drug-testing programs, although the data are now obsolete (Hanson et al., 1985; McBay, 1986; Boone, 1987). Throughout the 1970s the National Institute on Drug Abuse (NIDA), mainly through their Research Technology Branch, and the DoD sponsored projects to develop new techniques and analytical methods for the detection of illicit drugs and their metabolites in urine and other body fluids (Foltz et al., 1980). Immunoassays such as EMIT, an enzyme-based assay, and Abusescreen, a radio-labeled assay, came to fruition in 1981, and improved gas chromatography, and eventually mass spectrometry (GC/MS) became available. Variants of these techniques now form the core of almost all urine analysis methods for detecting evidence of illicit drug use. Against this long background and the example provided by the DoD, President Reagan issued an executive order in 1986 directing federal agencies to achieve a drug-free federal workplace, an action that was catalyzed by the report of the President's Commission on Organized Crime (1986). In July 1987 Congress expanded on the executive order by enacting a law that required urine testing for federal employees, including employees of federal contractors, and also required that technical and scientific guidelines and standards of practice be met by all laboratories testing urine specimens covered by the law. Scientists from NIDA and forensic toxicologists worked intensively to define a practical laboratory program that would permit testing human urine for five commonly used illicit drugs and their metabolites, with a minimum of error and a maximum of protection for employees. The results of their work were published as "Mandatory Guidelines for Federal Workplace Drug Testing Programs" in April 1988 (Federal Register, 1988). Just 3 months later, a National Laboratory Certification Program was implemented by NIDA, which required strict adherence to the guidelines and certification standards. Today there are almost 100 laboratories certified by HHS1 as competent to conduct forensic urine drug testing for, at a minimum, marijuana, cocaine, opiates, amphetamines, and phencyclidine and 1 Note that the 1992 ADAMHA Reorganization Act (P.L. 102-321) resulted in NIDA's National Laboratory Certification Program and related activities being transferred to the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services.
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Under the Influence? Drugs and the American Work Force their metabolites. The HHS-NIDA guidelines have since been revised and updated (Federal Register, 1993). In 1989 the Nuclear Regulatory Commission (NRC) established its own regulations, and following the Omnibus Transportation Act of 1991 the Department of Transportation (DOT) issued regulations that included testing for alcohol and permitted individual urine specimens to be split into two before submission to the laboratory. The DOT issued proposed rule making for their program in January 1993 (Federal Register, 1993). Professional organizations have shown an interest in certifying laboratories in which their members are employed. Most notably, the College of American Pathologists, which has a long history of monitoring, improving, educating, and regulating clinical laboratories, has established a program to which many laboratories subscribe. Their guidelines compare well with those of NIDA and differ only in detail (College of American Pathologists, 1990). Similarly, some states have enacted statutes and regulations specifically to control laboratories doing employee drug testing. These regulations vary greatly. Although the laboratory aspects of federal testing programs have become a model, and proposed new federal legislation may set minimum standards for all drug testing (The 1993 Drug Testing Quality Act—HR33), for the moment, a vast amount of testing is not done in NIDA-certified laboratories. These unregulated programs often include preemployment, random, for-cause, and penal testing. In a period of about 20 years, urine testing has moved from identifying a few individuals with major criminal or health problems to generalized programs that touch the lives of millions of citizens. It has given rise to a distinct and lucrative industry, with activities ranging from specimen collection to medical treatment, that was unimagined just 10 years ago. Tens of millions of urine specimens are analyzed every year in laboratories that vary from NIDA-certified operations to uncertified testing at workplaces, in amateur and professional sports, in doctor's offices, and in jails. One idea that motivates such widespread testing is the well-intentioned and generally popular goal of deterring the abuse of drugs among employed people and in other selected populations. There are, however, serious differences between the deterrence-oriented identify, catch, and punish philosophy and the less punitive identify, treat, and rehabilitate approach. These orientations often conflict and can seriously confound forensic toxicologists and medical review officers who are responsible for interpreting drug test results. At the end of 1989 NIDA's Division of Applied Research sponsored a consensus conference to assess technical, scientific, and procedural issues of employee drug testing after about 18 months of operations following the President's executive order. A report was published early in 1990 (Finkle et al., 1990) that expressed the views and recommendations of the conference
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Under the Influence? Drugs and the American Work Force participants, that included politicians, government officials, representatives of business, industry and labor, as well as laboratory scientists and physicians. Their recommendations for improvements in the guidelines for testing as well as concerns related to laboratory certification and other important aspects have not been implemented nearly 4 years later, although few minor recommendations have been included in the revised HHS-NIDA guidelines (Federal Register, 1993). This type of inaction is particularly unfortunate and has recently been paralleled with another important report (Rollins, 1992), which evaluated the efficacy of on-site testing (still not released by NIDA). BIOCHEMICAL METHODS FOR DETECTING DRUG USE Forensic urine drug testing begins with specimen collection from the donor, proceeds to laboratory analysis, and then, in properly run programs, culminates in the interpretation of reported results by a medical review officer. These three components of the test are interdependent and essential to the integrity of the process and the validity of the laboratory results. The laboratory, however, is the only actor in this sequence that is subject to certification and regulation under the federal guidelines. Since actions based on drug tests may often be contested legally, the testing process must have sufficient integrity to establish the validity of test results. Showing such integrity requires detailed attention to prescribed procedures, quality control, and documentation. Specimen Collection When a specimen is collected for clinical purposes, there is no suspicion that the donor altered the specimen or attempted to subvert the analysis. It is generally part of a medical evaluation, the donor has health incentives to cooperate, and there is no legal attention to the test results. The same is not true for employee testing, which may involve use of illegal drugs and possible loss of employment. Thus, special procedures must be used to ensure that a specimen reaching the laboratory can be clearly identified as coming from a particular donor's urinary bladder, at a particular time and place, and that the specimen is unadulterated and has not been tampered with between collection and submission to the laboratory. These procedures have been described by Caplan and Dubey (1992). They begin with specimen collection under either direct or indirect observation. Direct observation means that the collector observes the urination and can attest to the fact that the specimen came directly from the donor into the collection container. This is not a common practice in typical employee-testing programs. In the indirect collection process, the actual voiding of
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Under the Influence? Drugs and the American Work Force urine is not witnessed, but safeguards are taken to ensure specimen integrity. Common measures include ensuring no access to water taps, placing a bluing agent in the toilet bowl, and measuring of the urine specimen temperature immediately after collection to detect any dilution or specimen substitution. In collections by either procedure after the urine is voided, a tamperproof seal is placed over the collection bottle for transportation by courier to the laboratory. In addition, security seals are generally preprinted with unique identification numbers, and the specimen donor is required to date and initial the seal after it is placed on the collection container. The specimen is accompanied to the laboratory by a completed chain-of-custody form. This form not only requests the particular analysis but it also documents the date, time, and process of collection and provides the link between the specimen and the donor. A new government-approved form designed by DOT with the advice of scientists in the field and based on the past 5 years experience is likely to become the standard by the end of 1993 (D. Smith, personal communication, 1992). A minor industry has developed to provide specimen collection services. Managing urine collection systems is not a trivial task. Simply keeping track of specimens poses difficulties when, as is frequently the case, collection sites send samples to several different laboratories and serve several different employers. While there is some uniformity in the federal system, in the private sector employers use different chain-of-custody forms, collection kits, seals, and courier services. Neither the companies who provide collection services, urine collectors, nor the sites at which they work are in any way regulated. It is generally the responsibility of employers and laboratories to select experienced and trustworthy collectors. Tactics often used in attempts to confound urine analyses include dilution of the urine, substitution of drug-free urine, and the addition of substances that may render the urine unsuitable for analysis. Typical adulterants are salt, bleach, detergents, vinegar, bicarbonate, hand soap, vitamin C, ammonia, peroxide, and phosphate (Warner, 1989; Pearson et al., 1989). Recording specimen temperature at the time of collection is a useful check against possible urine substitution or dilution with cold water. Specific gravity and concentration of creatinine (a component of urine) may also indicate dilution, but recent studies strongly suggest they are of limited value for this purpose (Needleman et al., 1992; Peat, personal communication, 1992). The likely use of acidic or alkaline adulterants is suggested by massively altered urine pH. Temperature, specific gravity, and pH are easily measured. When the urine collection procedure is indirect (not observed), then determination of creatinine at the laboratory may be a useful determinant that the submitted specimen is actually human urine. None of these tests is specific for
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Under the Influence? Drugs and the American Work Force adulteration or particular diseases, however, and the general health status of the donor may also affect the values. At present the specimen submitted to the laboratory for analysis is invariably urine. Although more difficult to analyze, blood or plasma can be more informative and useful for forensic and clinical interpretations; however, the routine use of venopuncture to obtain blood specimens is not likely to be acceptable by either donors or the law. In special circumstances, such as testing for drug-induced impairment following a vehicular or industrial accident, blood testing is commonly seen as appropriate and often occurs. Deep lung air exhaled into a breath-testing device to assess blood alcohol concentration is now the specimen of choice in drinking-driving law enforcement programs (Dubowski, 1992). The National Highway and Transportation Safety Administration has approved a variety of portable and larger instruments for breath testing, which will undoubtedly be used as a convenient way to test for alcohol under the new DOT regulations. Saliva is another possible specimen. Saliva has been used to test for some therapeutic drugs and their metabolites, and there is evidence that certain illicit drugs are also detectable through saliva tests (Schramm et al., 1992). Practical difficulties, which include collecting an adequate volume of defined saliva, problems posed by the mixing of parotid saliva with common mixed mouth secretions, and the analytical sensitivity required have limited, perhaps unduly, research on saliva tests, and so little is known about the pharmacokinetics or biodispositional properties of those markers of illicit drugs that can be found in saliva. In contrast, the use of head hair as a specimen to determine illegal drug use is under intensive study. Since Baumgartner (Baumgartner, 1984, 1989) used an immunoassay technique to detect the most commonly used illicit drugs and their metabolites in hair, the analytical toxicology of hair has been the subject of symposia, position papers, and extensive research in both the United States and Europe (Sunshine, 1992; Moeller, 1992). Hair can be and is analyzed in specific forensic cases but has not yet found favor in employee drug-testing programs. Although the question of whether hair analysis reliably and accurately detects drug use is being extensively studied, there is at present no body of reference data like that which exists for urine that would allow hair to become a routinely examined specimen. A consensus conference held under the auspices of the Society of Forensic Toxicologists with NIDA support concluded that the use of hair analysis for employee and preemployment drug testing is premature given current information on hair analysis for illicit drugs (National Institute on Drug Abuse, 1990; Keegan, 1991; U.S. Food and Drug Administration, 1990). Technical issues relating to analytical accuracy, precision, sensitivity, and specificity are as yet unresolved and the threshold concentrations that are needed to define potentially false-positive or false-negative results for
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Under the Influence? Drugs and the American Work Force either screening or confirmation procedures have not been established. One important point to note is that no reference material is available with which to standardize analytical methods. In addition, the quantities of drugs and metabolites incorporated into hair, especially cannabinoids, may be below the detection limits of routine confirmatory (GC/MS) procedures. Issues relating to the external contamination of hair, washing or other aspects of sample preparation, and minimum sample sizes for analysis are all unresolved. The pharmacology and toxicology of drugs in hair is also poorly understood at present. Among the matters we should know more about are the relationship between the dose of the drug and the concentration of the drug or its metabolites in hair over time, the minimum dose required to produce a positive analytical result, the time interval between drug use and the appearance or detection of the drug in the hair shaft, and the implications of individual variation by race, age, sex, and hair characteristics. There is however, research under way on all of these topics, and much has been published in the last 2 years, suggesting that answers to questions that must be resolved may soon be available, and that head hair will in fact be a useful specimen for the detection of illegal drug use (Sunshine, 1992). Perhaps in 1994 a follow-up consensus conference to the Society of Forensic Toxicologists Symposium would be in order to reassess current knowledge. However, even if current questions regarding hair analysis are clearly answered, the results could not address the issue of intoxication at the time of collection nor could they determine whether the individual's use of the drug resulted in intoxication at the time of consumption. Furthermore, hair analysis results may provide accurate information concerning whether past drug use occurred, but not in relation to where it occurred (e.g., on the job or off the job). Laboratory Methods As already stated, NIDA requires urine analysis for only five drug classes: marijuana (cannabinoids), cocaine (benzoylecgonine), opiates (morphine and codeine), amphetamine and methamphetamine, and phencyclidine. A complete analysis for these substances (analytes) is a multistep procedure that is carried out serially, from specimen receipt and verification to authenticated final report. Two of the three steps are analytical methods. The initial or screening test is designed to efficiently identify those urine specimens that are negative—that is, no drugs or metabolites are detected at concentrations above established cutoff values. Those specimens that test positive initially are subject to a confirmatory test which specifically identifies the drug, metabolite, or both, and assays the concentration. In all laboratories that are part of government-regulated programs, this two-stage procedure must
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Under the Influence? Drugs and the American Work Force be followed. The screening method, under NIDA guidelines, must be based on an immunoassay, and the confirmation method must be an acceptable form of gas chromatography-mass spectrometry (GC/MS). Although there are many immunoassay techniques, the demands of high volume (often thousands of specimens each day), efficiency, quality control, and laboratory management limit the techniques in practice to enzyme immunoassay (EMIT), fluorescence polarization immunoassay (FPIA), and radio immunoassay (RIA). For reasons of cost, efficiency, and adaptability to automated chemistry analyzers, most NIDA-certified laboratories use EMIT as the initial screening method. The only large-scale forensic drug-testing laboratories using RIA are those supporting DoD programs. FPIA is an excellent method, but largely because of cost it has found favor principally as a second-stage screening method for specimens that test positive for amphetamines by EMIT. FPIA reagents are more specific for amphetamines than the EMIT reagents and therefore screen out specimens that otherwise might needlessly go to the confirmation stage. These screening tests are necessarily designed to be highly sensitive to the analytes but not specific in their response, which means that at the screening stage some false-positive results can be expected. Thus, positive screening results alone do not necessarily imply the presence of a tested-for drug or its metabolite, and positive screening results cannot support a final report, nor can different immunoassays be used as screening and confirmation in tandem. The confirmation test must be based on a different chemical principle. This approach to forensic, analytical toxicology accords with the recommended guidelines and standards of the best-informed professional societies (American Academy of Forensic Sciences, Society of Forensic Toxicologists, 1991). Despite what careful science demands, there are unregulated drug-testing programs that do not employ confirmation testing, including testing within the penal system for compliance with parole conditions and probation and for prisoner evaluation; testing for compliance in methadone maintenance programs; and some workplace programs that use on-site "laboratories." Relying on screening test results is an unacceptable practice that is particularly serious in contexts in which personal liberty is at stake. The FDA requires manufacturers of immunoassay test kits to include a statement in the kit: "The assay provides only a preliminary test result. A specific alternative method must be used to obtain a confirmed analytical result. Gas chromatography/mass spectrometry (GC/MS) is the preferred confirmatory method." This clear and carefully worded statement is ignored in some programs (Rollins, 1992; Finkle et al., 1990). When used by an appropriately trained and skilled laboratory technician, GC/MS is the best method for confirming positive screening tests results (Hoyt et al., 1987; Foltz et al., 1980). Although the types of GC/MS
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Under the Influence? Drugs and the American Work Force TREATMENT Great strides have been made in the development of effective treatments for abuse of alcohol and other drugs. There remain, however, major problems in public perceptions of treatment efficacy. Even among members of the medical profession, the idea that addiction is untreatable because virtually all addicts relapse is common. Thus physicians are often reluctant to refer patients for treatment because they believe that the results will inevitably be poor. There is also a strong tendency to think of total and permanent abstinence from alcohol and other drug use as the only sign of successful treatment when diminution in alcohol and other drug use may itself be a valuable outcome. Alcohol and other drug use disorders are a complex group of chronic conditions that vary not only according to the substance or substances abused, but also according to individual factors such as psychiatric comorbidity, heredity, gender, race, ethnicity, education, and occupation. Different types of patients require different treatment modalities. Overall, the treatment for alcohol and other drug use disorders produces about as much improvement as the treatment of other chronic medical disorders. One fundamental cause of the mistaken perception that treatment for these disorders is ineffective is the tendency to view them as acute problems controllable by will power. Yet from the medical perspective, alcohol and other drug abuse and dependence are chronic disorders much like arthritis or diabetes. They develop gradually and they have a course characterized by remissions and relapses, although there is often overall progression over time. Treatments reliably produce relief of symptoms and improvements in function, but not cures. The efficacy of treatment for alcohol and other drug use disorders has been reviewed in a recent Institute of Medicine report (Gerstein and Harwood, 1990) and in other recent publications (McLellan et al., 1992), and so is not reviewed here. The work site has important linkages to treatment, with employees directly accessing treatment through EAPs, when they exist, or indirectly, via third-party payment. The workplace is an important element in the treatment arena because of the third-party benefits it may provide, the constraints it may place on payment for treatment, and the role it may play in treatment entry and treatment participation, employment maintenance, and relapse prevention. Entering Treatment Self-Referral Self-referral to treatment is difficult to define because it has not been operationalized and examined scientifically. Even the notion of self-referral
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Under the Influence? Drugs and the American Work Force is questionable since many hidden pressures are exerted on individuals. Thus a client may enter therapy only to escape coercion from a supervisor or pressure from family and friends. One study found that the impetus for self-referral emerged from a social network, and the decision to self-refer resulted from a complex network of formal and informal controls. In some cases, supervisors urged the employees because of poor work performance; in others, coworkers were involved (Trice and Sonnenstuhl, 1988). Supervisor Referral As discussed with regard to EAPs, constructive confrontation is one of the mechanisms thought to arouse readiness for treatment in employees. This strategy uses deteriorating job performance to identify alcohol-and other drug-abusing employees. Organizational and occupational policies direct supervisors to confront suspected employees with impaired performance, to emphasize the negative consequences of its continuation, and to offer support for an EAP assessment. Constructive confrontation proceeds in steps. First, performance problems are discussed with the employee, and the individual is urged to seek help. If improvement does not follow these informal discussions, more formal disciplinary procedures are invoked. The constructive part of the informal discussion (1) expresses concern for the employee's welfare, (2) emphasizes that group membership may be maintained if conformity is restored, and (3) suggests that alternative routes are available to regain satisfactory performance. Constructive confrontation has been shown to be successful in improving work performance when used as intended. When the components of constructive confrontation were measured, it was found that concrete offers of help and persistence led employees to accept treatment, but the confrontational element could lead to refusing help and leaving the company. The combined results suggest that the balanced use of both constructive and confrontational elements produced positive outcomes with problem drinkers, whereas the use of confrontational elements alone tended to produce negative results (Trice and Sonnenstuhl, 1988). In contrast to the positive results produced by constructive confrontation, formal discipline produced unfavorable outcomes. Hence, written warnings, suspensions, and discharges were negatively associated with work performance following intervention. A combination of constructive confrontation and treatment outside the company generated greater performance improvements than either of these two alone (Trice and Sonnenstuhl, 1988). Advantage of Early Detection and Referral Although there are productivity-based arguments for efforts to detect alcohol and other drug use in the workplace, a clinician might focus solely
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Under the Influence? Drugs and the American Work Force on the potential benefits to the patient. The available outcome studies suggest that better outcomes are associated with earlier treatment (Institute of Medicine, 1989), and factors such as employer pressure toward continuation in treatment can favorably influence prognoses. Addiction is a complex disorder that responds to treatment at any point along the line in its progression. The notion that one must "hit bottom" before recovery no longer seems accurate (Runge, 1990). Treatment of alcoholism is more effective in the early stages of the addictive process, when the clients are socially stable and have not yet developed adverse medical or social consequences (Heather, 1989). However, the effectiveness of early intervention in altering the course of the disease is still debatable, and critics have voiced concern over labeling and creating self-fulfilling prophesies. Although it is premature to judge the value of early intervention, there is reason to believe it is beneficial (Heather, 1989). A few studies have recruited drinkers who either were not seeking treatment or had been heavy drinkers for a relatively short period of time in an attempt to evaluate the effectiveness of early intervention. Skutle and Berg (1987) investigated early intervention in problem drinkers, and evaluated four behavioral treatment methods in an outpatient setting with clients who had been problem drinkers for less than 10 years and had no prior treatment, tolerance, dependence, liver damage, or medical illness. All treatment groups were comparable at admission and showed a similar decrease in drinking behavior after treatment. After the initial decrease, the level of consumption remained lower during the 3-, 6-, and 12-month follow-up periods. Other life problems also decreased. Hence, minimal intervention (4 to 16 hours) can be recommended for early problem drinkers with relatively low consumption at intake. Clients with higher consumption appeared to profit less. In the Malmo Project in Sweden (see Babor et al., 1986), Kristensen identified 585 heavy drinkers through elevated serum gamma glutamyl transferase (GGT) and intervened in half of the group by giving them a thorough evaluation and follow-up until their GGT returned to normal. A control group was sent a letter that their GGT was elevated, advised to restrict intakes, and told to repeat the GGT in 2 years. The GGT values of both groups decreased significantly; however, the control group had more sick days, more hospitalization, and twice as many deaths. Hence, simple early intervention based on regular feedback had a significant effect on drinking habits and physical health. The Edinburgh Royal Infirmary Project in Scotland (see Babor et al., 1986) investigated the effects of brief intervention in problem drinkers identified in a general hospital as having a current problem. The intervention group had 30-50 minutes of counseling and received a booklet with advice about reducing drinking. The control group received nothing. After 1 year, only
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Under the Influence? Drugs and the American Work Force 35 percent of the intervention group had alcohol problems compared with 62 percent of the control group. Thus, there is evidence that both early interventions in problem drinking and inexpensive interventions of a minimal sort can have substantial positive effects. Treatment Follow-up and Work Site Reentry Plan for After-Care Although the initial phase of alcohol and other drug treatment is designed to teach clients abstinence skills, the maintenance of these skills and their generalization to new situations and environments is a continuing issue (McCrady et al., 1985). Hence, after-care oriented toward the maintenance of abstinence and therapeutic gains is an important component of treatment. Indeed, it may well be the active ingredient in the achievement of long-term sobriety. The term after-care has assumed a number of different meanings and encompasses a variety of intervention strategies. After-care treatments vary in modality (individual, family/couples/groups), organization, time parameters, therapeutic orientation, purpose, and attendance expectations, but as a concept after-care has two important components. First, it involves therapeutic activities designed to maintain gains achieved in the initial phases of treatment rather than procedures that attempt to develop new skills. Second, it can be an important complement to many different forms of initial treatment. After-care may follow outreach activities, emergency treatment, inpatient treatment, intermediate care, or outpatient treatment. Although after-care is a critical part of treatment, there are few studies that evaluate its effectiveness (Ito and Donovan, 1986). Effectiveness of After-Care Ito and Donovan (1986) reviewed studies of the effectiveness of after-care on treatment outcomes. They concluded that it contributes significantly to positive outcomes in alcoholic clients and that it does so independently of patient prognostic variables (residential stability, interpersonal relationships, social activity, health, employment, and drinking status). After-care is also important to the early detection of and intervention in relapse. Its effectiveness appears to lie not so much in preventing slips but rather in preventing minor slips, that are almost inevitable, from developing into full-blown relapses. Patients in after-care may obtain help in dealing with the stresses that lead to slips and with the stresses that slips create. However, in order for this to occur, the clients' slips must come to the attention of after-care workers. Hence, it is important for a program to
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Under the Influence? Drugs and the American Work Force provide a clear expectation that slips will be acknowledged immediately so that appropriate interventions can be made. Common sense indicates that attendance at after-care is crucial to long-term outcomes; however, its effects have been difficult to evaluate scientifically. Foote and Erfurt (1988) reviewed a number of studies that investigated the effectiveness of after-care and found mixed results. Some studies report no relationship between outcome and follow-up attendance, whereas others found a positive relationship. However, all of the studies had serious shortcomings in their designs. Follow-up periods were short; there was selection bias in those who attended after-care; and often there was an absence of collateral information. Thus Foote and Erfurt concluded that most after-care studies were relatively uninformative about the power of after-care to improve recovery rates. Ito and Donovan (1986) found three major predictors of after-care attendance: (1) the autonomy perceived by the patient during inpatient treatment, (2) the distance traveled to after-care, and (3) the cognitive functioning of the patient. They report that after-care attendance can be increased by telephone calls, orientation lectures, and behavioral contract scheduling. Foote and Erfurt also discussed the need for a nontraditional proactive approach to after-care in which the provider reaches out to the client. In this approach, the provider seeks out the patient until the problem is solved—yet this seldom happens. Indeed, Foote and Erfurt found that little attention was paid to the process of getting patients to participate in after-care. Patients were often "encouraged" to attend after-care; however, stronger intervention than encouragement is needed. One of the major problems may be that after-care is not given in the best settings. The authors argue that it should be located at the work site because of the work organization's financial interest and its ability to monitor employees. They also feel that the use of the relapse prevention model at the work site deserves attention. However, there are few guidelines pertaining to EAP follow-up activities and a dearth of studies concerning the effectiveness of EAP follow-up. Although it is clear that EAPs and work sites should pay more attention to follow-up and after-care, additional research is needed to determine the best, most cost-effective ways to do this (Foote and Erfurt, 1988). EAPs have placed their energies in case finding, intake, and referral; most have devoted little time to relapse prevention. Follow-up for many is either nonexistent or limited to the duration of treatment and one or two visits after return to work. Hence, EAPs may not be preventing relapses as much as they are teaching clients how to use the treatment system more frequently and effectively. Currently, most EAPs have neither the time nor the staff to deal with follow-up and relapse prevention since the model focuses so heavily on case discovery and initial treatment. Yet since EAPs have a close relationship with the work site, they are in an excellent position
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Under the Influence? Drugs and the American Work Force to provide meaningful follow-up. Foote and Erfurt concluded that EAPs and work sites should pay more attention to follow-up and after-care, a conclusion the committee endorses. In summary, much of the thrust of the EAP effort has been on the detection of new cases as opposed to the follow-up of those who have received treatment. Given the marked propensity for relapse and the EAP's important link with the work site, much more emphasis should be placed on follow-up. Thus recovery should be viewed as a process rather than an event with workplaces, EAPs, and treatment providers all playing important roles in aiding clients' recoveries over the long term. CONCLUSIONS AND RECOMMENDATIONS • Recovery from alcoholism and other drug use disorders is a process that can take months or years of continuing care. The continuing abuse of alcohol or other drugs is a chronic disorder, and the evidence suggests that the ameliorative effects of brief treatments without follow-up are seldom sustained over the long run. Employee assistance programs (EAPs) are well situated to oversee that follow-up, which is essential to a long-term recovery. Recommendation: Because of high dropout rates in substance abuse treatment programs, EAPs should monitor treatment participation and provide for long-term follow-up. • EAPs are not generic across work sites. EAPs should and do vary across work sites and over time. Thus, it is misguided to ask whether the generic EAP is an effective program. Recommendation: EAPs should be evaluated in terms of the amount and quality (including process evaluation) of the services they provide and not just by patient count. Researchers should seek to understand how EAPs contribute to a range of different outcomes in a range of different settings. This requires more high-quality critical case studies of EAPs, perhaps with some common criteria of programmatic effectiveness. Care must be taken to secure adequate control groups, and, rather than attempting to evaluate the overall effectiveness of supposedly static programs, attention should be paid to the effects of particular EAP services and their dynamic nature. • Given the measurement limitations of drug test results in assessing drug abuse or dependence (see Chapter 6), not all individuals testing positive require or are likely to benefit from treatment, counseling, or other
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Under the Influence? Drugs and the American Work Force administrative actions that might be triggered by a positive drug test result. Blanket rules referring all positive-testing employees to treatment can be costly to employers without providing commensurate benefits to them or their employees. Care is required to determine the appropriate course of action in the event of a positive test. Recommendation: Persons reviewing test results should be required to demonstrate expertise with respect to toxicology, pharmacology, and occupational medicine. Standards should be set and continuing education and certification should be required. Such individuals should be involved in the interpretation of the results of drug-testing programs, and in the case of positive postemployment tests, should assist other professional staff in interpreting the seriousness of revealed drug use and provide guidance in determining the best course of action for coping with any drug problems (e.g., evaluation referral to proper medical specialist if needed). REFERENCES Amaral, T.M., and S.H. Cross 1988 Cost-Benefits of Supervisory Referrals. Paper presented at the 17th ALMACA Annual Conference, Los Angeles, Calif. Babor, T.F., E.B. Ritson, and R.J. Hodgson 1986 Alcohol related problems in the primary health care setting: a review of early intervention strategies. British Journal of Addiction 81:23-46. Bacon, S.D. 1973 The process of addiction to alcohol: social aspects. Quarterly Journal of Studies on Alcohol 34:1-27. Beattie, M.C., R. Longabaugh, and J. Fava 1992 Assessment of alcohol-related workplace activities: development and testing of your workplace. Journal of Studies on Alcohol 53:469-475. Bertera, R.L. 1990 The effects of workplace health promotion on absenteeism and employment costs in a large industrial population. American Journal of Public Health 80:1101-1105. Beyer, J.M., and H.M. Trice 1978 Implementing Change: Alcoholism Policies in Federal Work Organizations. New York: The Free Press. Blum, T.C., and P.M. Roman 1989 Employee assistance programs and human resource management. Research in Personnel and Human Resource Management 7:259-312. 1992 A description of clients using employee assistance programs. Alcohol Health and Research World 16:(2)120-128. Blum, T.C., P. Roman, and N. Bennett 1988 A Longitudinal Analysis of Internal EAPs. Paper presented at the annual meetings of the Association of Labor-Management Administrators and Consultants on Alcoholism, Los Angeles, Calif..
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