What to Do About Substance Abuse

Bob Poznanovich knows he has no one to blame but himself for his flameout as a highflying 30-something executive. Still, he wonders what might have been if his employer had treated him differently.

He was vice president for sales and marketing in the computer division, "making good money, hanging out with movers and shakers," he says. "When I went to parties, I saw bankers, lawyers, pro athletes and business leaders, and they were all using cocaine, the drug of choice at the time. … I started using it, too. Soon, I was spending $1,000 a day, getting high on the job with employees, even with customers. It took over my life."

Poznanovich’s bosses at Zenith—now LG Electronics—knew he was a substance abuser. Yet he lived that way for more than a year before he was fired. Later, an HR professional told him that managers at the company held almost 50 meetings where they debated how to handle their star addict. "They didn’t know what to do with me," he says. "Analysis became paralysis. They never talked to me until they decided to fire me."

Poznanovich, now executive director of business development for Hazelden, an addiction treatment center in Center City, Minn., says his employer’s reluctance to confront him was a mistake. "I was having a big impact on revenues, margin, other employees and stakeholders. I wasn’t showing up for work; I was late; I was distracted." Had managers warned him, "I would have run out and gotten help," he says. "My job and status as an executive was key to my self-image."

Persistent Problem

According to 2008 data from the federal Substance Abuse and Mental Health Services Administration, 10.2 percent of full-time employed adults and 11 percent of part-time working adults are substance-dependent. Of these approximately 14 million workers, about 85 percent are hooked on alcohol alone or on alcohol and drugs; 15 percent abuse drugs only. The percentages have stayed fairly steady since 2002. Marijuana remains the most popular drug; use of cocaine and ecstasy has dropped, but use of prescription painkillers is increasing rapidly.

Workers in industries such as food services, construction and accommodations are more likely to use drugs and alcohol; those in industries such as utilities, education and public administration are less likely. More men than women are substance abusers. These high-risk workers don’t include the millions more who use drugs or alcohol at home or work but who do not exhibit characteristics of dependence or addiction.

Convincing Business Case

Substance abusers are a debilitating drain on resources and productivity. They use more sick days, show up late more often and stay in jobs for shorter amounts of time. They’re three-and-a-half times more likely to cause accidents at work and in transit. Their health care costs are double their peers’.

Weaning even a few workers from addiction or abuse can positively impact a business. "If one looked at all the sources of savings, a return on investment of 10-to-1 for an alcohol or drug case would not be unreasonable," says Tom Amaral, president of EAP Technology Systems Inc., a Yreka, Calif.-based vendor of software and services to employee assistance programs. Those savings come from decreased health care claims, decreased absenteeism and increased productivity.

Success stories abound, yet attempts to identify, treat and support meaningful percentages of employees who have drug or alcohol problems continue to prove frustrating.

Beginning in the 1960s, when drug and alcohol dependence at work became a national concern, employers turned to employee assistance programs (EAPs). The programs tended to be internal operations staffed by counselors who often had been through recovery themselves and could offer confidential guidance.

Later, spurred by high-profile accidents and mistakes made by impaired workers, federal officials stepped in to protect the public. Today, employers in certain safety-sensitive industries operate under government mandates that require drug testing and the establishment of drug-free workplace policies and programs; these employers are more aggressive about identifying and firing or treating abusers. However, Edward Trieber, managing director of Harris, Rothenberg International, a regional EAP in New York, estimates that safety legislation covers fewer than one-fifth of employers.

First Line of Defense

EAPs have been embraced by business leaders for 25 years and still provide a first line of defense. Seventy-five percent of employers offered EAP coverage in 2009, up from 31 percent in 1985, according to the Employee Assistance Society of North America, in Arlington, Va. Most large and mid-size organizations provide EAPs for employees as well as their families. About 2,400 EAPs serve roughly 90 percent of North American workers.

Unlike other providers of mental health services, such as psychiatric hospitals or substance abuse clinics, EAPs partner with employers. Guided by an "EAP Core Technology" defined by the Arlington, Va.-based Employee Assistance Professionals Association, EAPs’ mission is to improve and maintain the productivity and healthy functioning of the workplace.

Six or seven large EAPs dominate about 80 percent of the market; among them are ComPsych Corp. in Chicago and Ceridian Corp. in Minneapolis. "We’ve seen ‘a Wal-Mart effect’ on what used to be small, professional-based EAPs," says Dave Sharar, managing director of Chestnut Global Partners, a regional EAP in Bloomington, Ill. Now, "all the largest employers are giving their business to mega-vendors who are offering health care coverage under one umbrella. The argument is that it is cheaper."

Competing with the big guys are regional players such as Chestnut and Harris, Rothenberg. A small number of facilities, such as New York City’s Mount Sinai Medical Center, run EAPs that either serve their employees exclusively or cover a few other companies’ employees as well to defray costs.

Responsibility for the EAP usually falls to HR. Depending on size and sophistication, it could be housed under a benefits specialist or a medical officer.

Employees with substance dependence issues can use their EAP on their own initiative or in response to a supervisor’s suggestion. If employees fail a random drug test or one ordered after a finding of reasonable suspicion, they can be required to contact the EAP as a condition of employment or for approval to return to work. They can seek treatment outside the EAP. Most just continue to work without addressing the problems.

Not Getting It Done

What impact are EAPs having on identifying and treating workers with substance dependence? The statistics tell an unsettling story. According to metrics from the national EAP Data Warehouse, EAPs receive on average 1.6 employee alcohol referrals and 0.5 drug referrals per 1,000 employees each year. That translates to about 18,000 alcohol and 5,600 drug referrals nationwide annually.

If you assume conservatively that EAPs are available to about 80 percent of the 14 million employees in need of treatment, that means EAPs are reaching only 0.02 percent of these workers.

Furthermore, most EAPs do a poor job of identifying alcohol and drug problems for employees who use EAPs for other reasons, says John C. Pompe, SPHR, manager of disability and behavioral health programs for Caterpillar Inc. "Unless someone calls the EAP specifically to request alcohol or drug treatment—and few do—substance abuse problems will go unnoticed,"

Fortunately, many workers find treatment through other avenues. For example, a federal study revealed that in 2008, 341,130 full-time employees received treatment for substance abuse. Of those, 52.7 percent were referred by courts or criminal justice systems and 26.3 percent were self-referred. Only 2.2 percent entered treatment via employers or EAPs.

Why Employers Look Away

Even with screening and zero-tolerance policies, the incidence of substance abuse in the workforce has remained steady at about 10 percent for the last decade. Why are employers accepting so little progress? Why are they settling for safety risks, productivity losses and skyrocketing health care costs? Here are some reasons:

Unwanted publicity. Giving more attention and resources to identify, treat and help addicted employees return to the workforce could damage an employer’s corporate image.

Financial commitment. Combating substance abuse can be costly—and outcomes modest. Some employers say it is better to live with losses from alcohol and drugs and to direct resources instead toward mitigating other diseases such as obesity and diabetes.

Opportunity costs. Training supervisors in performance management—so they can, for example, confront workers when needed—takes commitment of resources. Even when EAPs bundle training on evaluation and progressive discipline techniques into their contracts at no additional cost, few employers use the features. "We badger our clients to do the training," Sharar says. "Only 30 percent to 40 percent agree."

Repeat offenders. The same person often must be treated multiple times, says Dr. Jeff Levin-Scherz, a senior consultant for Towers Watson in Boston. And, employers decry the seeming waste of resources on repeat offenders, despite the fact that multiple treatments are just as frequent in other chronic diseases they support without complaint, says Dr. Brent Pawlecki, Pitney Bowes’ corporate medical director.

Societal problem. Citing the impetus to legalize marijuana and the pervasiveness of alcohol, some U.S. employers conclude that trying to deal with dependency is futile.

Not a disease. Despite research to the contrary, employers say that defining substance abuse as a disease is politically correct but inaccurate. Substance abusers, they say, are not sick; they’re making choices.

Counter to company culture. Supervisors and colleagues abhor telling on others and see it as "ratting them out."

Legal constraints. Employers are confused about their responsibilities under the Americans with Disabilities Act and fearful of costly discrimination cases. The act makes it illegal for employers to discriminate against recovering alcoholics and drug users.

Sad Truths

Why do EAPs have so little to show for their commitment to work with employers, combat substance abuse and increase productivity?

Cost vs. value. The employer negotiates services based on per-employee fees ranging from $12 to $30. The cost, in comparison to expenditures on health insurance, remains minimal. Under this "capitation" model, however, the more an EAP does—and drug and alcohol abuse cases require more—the less it profits. The incentive, then, is to do as little as possible while making it appear to employers that the EAP does more.

EAPs "restrict access, cherry-pick the low-maintenance cases and avoid the high-maintenance ones," says Dan Hughes, director of the employee assistance program at Mount Sinai Medical Center and head of the research subcommittee for the Employee Assistance Professionals Association. "Everyone in the field knows that’s the case."

Altered emphasis. To compete, EAPs have added less-costly services to attract more employees. They surround the drug and alcohol portfolio with wellness, marital, family, financial, legal and emotional counseling, plus provide stress reduction and find pet sitters, baby sitters and tutors. The EAP Data Warehouse reports that only 3.4 percent of employees covered by EAPs contact them for mental health issues. In this way, EAPs have gotten away from their core function, Pompe explains.

EAPs with laundry lists of services dominate the market and de-professionalize the field, Hughes says. "EAPs are being sold on wellness and coaching. They’re supposed to follow a professional services model—help the employer solve complex, difficult problems that are linked with a number of mental health issues," he adds.

Networks without EAP grounding. The majority of EAPs rely on external networks of certified psychological or drug counselors or social workers who receive referrals from a central phone intake unit. Most are not attuned to the EAP mission. "You need someone who is intimately involved with the work organization," says William Sonnenstuhl, an associate professor at Cornell University’s R. Brinkley Smithers Institute for Alcohol-Related Workplace Studies in New York.

For example, clinicians are not necessarily trained "in the focus on productivity as it relates to mental and behavioral health," Hughes says. "They don’t have a firm grounding in the core technology—the constructive confrontation and the role the employer plays in the treatment." In constructive confrontation, a supervisor meets with the employee and ties the employee’s workplace behavior to consequences such as job loss.

Dead-end treatment. The typical EAP contract offers mental health referrals for one to six sessions with a clinician. From the employee’s perspective, it’s free and confidential; there are no payments, no deductibles. The company pays the capitation fee. The clinician, in theory, determines the next referral and the specific provider. If continuing treatment is advisable and the employee has insurance, the insurer enters the picture. But that rarely happens. Most cases end with the free sessions. Clinicians refer out less than 10 percent of the time, Sharar says. Even when they do make a referral, the client often fails to follow through, guaranteeing that in more than 90 percent of the drug and alcohol cases that actually reach the EAP, neither the employer nor the insurer will know the person has a dependency problem.

The scenario changes when the employer knows the employee is seeking help and is asked to assist and support rehab and re-entry. Consider the difference in results: "You’re looking at a 13 percent to 15 percent cure rate without employer involvement," Sonnenstuhl says. "The success rate is 75 percent to 80 percent when the employer plays a role." But that rarely occurs. At ComPsych—the country’s largest EAP, serving 13.2 million employees and their families—only 300 to 400 employees authorize the EAP to share treatment details with employers each month, says Clinical Director Ewa Antonowicz.

Uneven intake. Though employees who contact EAPs for reasons other than drug or alcohol abuse may have underlying substance dependency problems, most go undetected. "EAPs do a very poor job of case-finding for alcohol and drug problems," says Eric Goplerud, a research professor at The George Washington University. "Unless someone calls the EAP specifically to request alcohol or drug treatment, in most instances substance abuse problems go unnoticed." Goplerud directs a research and communication initiative to fight alcoholism.

Poor follow-through. EAPs lack case management, Pompe says. Most risk of relapse occurs within the first 120 days in recovery, yet there is often no follow-up during that period, Sharar notes.

Best-practice EAPs monitor cases for up to a year, says Mandie Conforti, a senior consultant at Towers Watson in Chicago.

Harris, Rothenberg counselors usually call employees monthly, asking, "Did you go to counseling?" says Beatrice Harris, managing director.

Hyped metrics. To justify their fees, some EAPs flood employers with reports highlighting the number of employee contacts per month or per quarter. Often, instead of tracking cases, EAPs report each employee communication; numbers become inflated when one person makes many inquiries. Furthermore, services that attract inquiries may be low-maintenance, yet all inquiries get lumped together.

The Skinny on Substance Abusers

And what of the workers who need help? Why don’t they take advantage of EAPs? Two main reasons: denial and confidentiality concerns.

Many substance abusers are in denial and refuse to seek help voluntarily. They reject the idea that they have problems or that their addiction is visible. Addicts "try to hide what we do from people at work or home who would care," says Mark Weingart, a recovering addict and financial industry trader in San Francisco.

Other substance abusers don’t trust in confidentiality from EAPs, insurers or in-house counselors, despite assurances. At ComPsych, "We’ve never had a case where we leaked it. We won’t communicate with the employer unless a release is signed. And the employee can revoke it," Antonowicz says.

Still, Terry Shapiro, executive director of the Hazelden Sober Residence in Chicago, says his clients are sensitive to the stigma of being labeled an addict or alcoholic and fear retaliation. "Most bypass the EAP and seek help on their own. They fear the shame of letting their employer know." Only about one-third of those covered by insurance for treatment submit claims.

What HR Professionals Can Do

Unless they are well-trained, supervisors often let substance abusers fly under the radar until they’re forced to act after a failed drug test, accident or embarrassing incident. In addition, EAP managers and clinicians have scant motivation to pay attention to high-maintenance substance abuse cases for the reasons mentioned earlier. Therefore, HR leaders have important roles to play in choosing and monitoring EAPs—and they can’t pass the buck when EAPs perform poorly. "EAPs are tools of HR," Pompe explains. "When the job doesn’t get done, it’s too easy for HR to blame the EAP."

Don't Fear Litigation HR professionals often cite the Americans with Disabilities Act or other perceived legal threats as reasons for not intervening. "Substance dependence is a disability, but that doesn't mean you have to keep someone or can't discipline them. The person has to be able to perform," says Charles J. Lattarulo, clinical director at Harris, Rothenberg International, a regional employee assistance program. Under the act, employers cannot fire, refuse to hire or refuse to promote someone solely because he has a history of substance abuse or enrolls in rehabilitation. Here’s how HR professionals can have impact:

Practice tough love. "If somebody has a problem and it’s affecting their work, it becomes pretty apparent," Weingart says. But employers have a tough time facing unpleasant situations.

Don’t overlook HR responsibilities. HR professionals’ interest in making strategic contributions to their companies has consequences, says Sonnenstuhl. Previously, HR professionals "focused on training and helping workers and supervisors. All this stuff is getting short shrift these days."

Make performance evaluation a priority. Supervisors must be trained to monitor performance daily and to become skilled in identifying problems, Sonnenstuhl says. "Train them to give progressive discipline so at-risk workers have a chance to get help. Today, it’s summary discipline. The message is: ‘Test this guy; if he’s positive, fire him.’ "

Harris, Rothenberg includes manager training costs in its fees. The training focuses on how to identify behaviors that may be typical of addicts, how to document such behavior and how to confront people. Managers express relief "when they learn there’s a way to deal with their situations," says Harris.

Foster constructive confrontation. Work with supervisors to increase referrals. "I’ve never found a company that confronted an employee where the employee didn’t agree to help," says Poznanovich. "I’ve never seen an employee choose alcohol or drugs over his job."

Adds Weingart: "Until you suffer enough consequences, you’re never going to stop. Why would I stop if life wasn’t so bad? Sometimes, doing something that’s perceived as negative for an addict or an alcoholic is exactly what they need."

Test. There’s no escape for employees who fail drug tests at the large regional energy company with 16,000 full-time employees where Edward Kavanaugh serves as senior HR specialist. If an employee tests positive, Kavanaugh talks with his or her supervisor and an HR business partner. Then, the HR business partner, the supervisor and sometimes a union representative meet with the employee to discuss violation of the drug-free workplace policy. The worker faces automatic suspension without pay for 30 days. For alcohol, the suspension is 24 hours. The person has 48 hours to contact the EAP and can’t return to work until he or she is released by the EAP.

"Employees are our asset," Kavanaugh says. "We get them help because substance dependence is a known illness." But there are limits to the commitment; Kavanaugh says the company isn’t interested in being an enabler. "In most situations, it’s one bite of the apple," he explains. "After that, you’re out."

At Mount Sinai Medical Center, a nurse who tests positive is confronted immediately and removed from the workplace. "She’s entitled to get appropriate care and then apply for reinstatement," Hughes says. "The job is the most compelling lever we have in treatment. To rejoin the staff, she must sign a ‘last-chance agreement,’ agreeing that if she commits another violation she is automatically terminated." With their licenses and their jobs on the line, he says, more than 75 percent of nurses do well when they return.

Let experts do their jobs. Remind supervisors never to make diagnoses; only mental health professionals are competent to do so. Judge and document conduct and performance; leave the reasons why to experts.

"I discourage people from telling the supervisor what their problems are," Pompe says. "Supervisors shouldn’t want to know because it compromises their ability to supervise. If they have to take a negative action, the person can claim you knew and discriminated against him."

Select EAPs carefully.  Employers should look for best practices and look behind utilization statistics in marketing pitches. Beware of buying based on price. Ask questions, do a site visit, talk to clients. Find out how easy it is to reach counselors; check how they publicize their presence. Are intake staff and counselors certified? Are they trained in EAP technologies?

Demand meaningful metrics. Currently, few EAPs produce metrics that offer a clear picture of how well they find and handle substance abuse cases. Require metrics that will enable you to monitor performance.

Well-crafted programs can be remarkably effective, but you’ve got to be committed, Sonnenstuhl says. "If you make your EAP accountable and commit to constructive confrontation, you can clean up your drinking and drug culture and invigorate your organization."

Go at it full-bore. "Don’t fool yourself by thinking a window-dressing approach will cut it," Pompe concludes. "If you want to have an impact, you need a comprehensive strategy."

The author, a contributing editor of HR Magazine, is a lawyer and a professor of management studies at Marist College in Poughkeepsie, N.Y.

Discuss your experiences regarding employee drug testing, drug treatment and medical marijuana issues with your peers. Share your experiences, expertise and best practices.