By Ray Baker, MD

The Problem
Alcohol and other drug problems afflict 10 per cent of the working population, negatively affecting attendance, performance, behaviour and safety.  While facing significant liability and employee privacy constraints, employers must accommodate persons with disabilities including substance dependence.  Random drug testing, widely used across the US since 1984, has proven dramatically unsuccessful in curtailing drug use or improving workplace health and safety.

The Solution
Some Western Canadian corporations are using effective methods to achieve efficient resolution of workplace problems in personnel with substance use disorders. The process I will describe is fair and effective, creating a situation by which we end up with healthier and safer workplaces with improved morale. In this process, employees with addictions experience by far the highest rates of successful recovery.

Workplace Policy
An essential cornerstone of this approach is a workplace policy on substance use that includes all identified stakeholders during its development. All personnel are informed of the policy and disability management personnel, occupational health professionals, Employee Family Assistance Programs, and insurers are brought on board. Policy rollout includes supervisor training on how to identify and constructively intervene with employees demonstrating behaviours possibly due to substance use.

Assessment and Treatment
Employers are not expected to diagnose or make treatment decisions for employees’ medical disorders.  But workplace supervisory interventions must result in high-quality occupational addiction medicine evaluation resulting in proper diagnosis and treatment, and ultimately safe, sustainable return to work with safeguards in place in the event of relapse.  Contingency management (“do your best to get well or get gone”) links benefits such as disability insurance payments and return to work with compliance with undergoing medical assessment as well as adherence to treatment recommendations.

Effectiveness outcome research studies comparing treatment modalities for addictions have shown that the specific modalities applied at the treatment centre are less important in predicting success than treatment program graduates’ adherence to their relapse prevention activities following initial treatment.  Recovery from addiction, like recovery from other serious chronic diseases, is not an acute event but a process that must be maintained over months and years, with some risk of relapse continuing long after the person has returned to work.  So how can we safely return workers with addictions to safety-sensitive or highly-responsible positions?

Medical Monitoring
The purpose of medical monitoring is to verify participants’ adherence to their long-term individualized treatment plans and to notify an oversight body or employer immediately in the case of relapse or serious non-compliance.  It consists of face-to-face and telephone meetings, randomly scheduled biological sample collection for testing, liaison with treating professionals, PharmaNet reviews, and verification of mutual support group involvement.

Although contingency management using high quality medical monitoring results in the highest rates of successful sustained remission¹, medical monitoring is not therapy and the monitor must not have a therapeutic relationship with the participant. Since the monitor serves the needs of a third party, they would place themselves in a position of conflict of interest if they were to provide medical or counselling therapy to the participant

The risk of relapse diminishes with duration of abstinent remission.² The duration of monitoring ranges from one to many years depending upon stage and severity of the addictive disorder as well as the documented stability of the participant during monitoring.

Summary
Substance use disorders are a common source of workplace problems, from a mentally unhealthy or unproductive work unit to a source of potentially disastrous safety hazard and employer liability.

Random drug testing, although certainly an important component of the effective management of workers with addictions, it is by itself not the solution.

The solution lies in combining a carefully developed substance use policy with contingency management, requiring high quality diagnostic assessment, treatment and medical monitoring of long-term relapse prevention activities. The result is a win/win process: employers experience improved workplace health, safety and productivity and previously addicted employees achieve the highest rates of stable remission and healthier, happier lives.

Ray Baker is a speaker at the 2014 HRMA Conference + Tradeshow. His panel Testing the Limits: Drugs & Alcohol in the Workplace is on Tuesday, April 15. For more information, please visit bchrma.org/conf2014.

After recovering from burnout and a serious alcohol problem, Ray, until then a small town GP/Occupational Medicine physician, trained and specialized in Occupational Addiction Medicine. He has now evaluated several thousand individuals with addictive disorders often complicated by chronic pain, psychiatric symptoms and other complex problems.

[1] McLellan T, Skipper G, Campbell M, DuPont R Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States British Medical Journal. 2008; 337
[2] NIDA, Principles of Drug Addiction Treatment: A Research Based Guide (3^rd Ed), 2012, http://www.drugabuse.gov/sites/default/files/podat_1.pdf