Overview

The Network of Employers for Traffic Safety (NETS), through a Cooperative Agreement with the National Highway Traffic Safety Administration (NHTSA), has contracted Ensuring Solutions to Alcohol Problems at The George Washington University Medical Center, Department of Health Policy.  This summary provides a synopsis of the activities and findings from Year One of the project and activities planned for Year Two (beginning in January 2007). A more detailed description is presented in Ensuring Solution’s Year One Final Report to NETS and is available by request.

The purpose of Year One of this project was to:

• Review the literature on screening and brief intervention (SBI).

• Gather information from employers and vendors using a web-based assessment and telephone interview to identify current practices and products/services used to identify and manage alcohol misuse and dependence among workers and their families.

• Identify promising approaches and components of SBI that may be appropriate for workplace settings.

Highlights of Year One include:

• Prepared a review of the literature that presents the science supporting the effectiveness of SBI; the use of SBI as a clinical practice standard; SBI training and competency recommendations; government health services and foundations investment in developing SBI demonstration projects; and economic and clinical outcomes of SBI.

• Recruited over 500 employers and 200 vendors through various professional organizations and associations, business coalitions, and experts in the fields of health promotion, substance abuse, employee assistance, human resources, and screening and brief intervention from across the U.S. to participate in the web-based assessment of SBI practices and SBI products/services.

• Conducted in-depth follow-up telephone interviews with a subset of employers and vendors who participated in the assessment.

• Analyzed and summarized assessment and interview data.

• Based on review of the literature and assessment and interview data, conceptualized two SBI approaches for workplace settings to be further developed and refined in Year Two by employing product development workgroups.

• Prepared draft manuscript providing a comprehensive description of Year One activities and findings to be submitted for publication.

Brief Summary of the Literature

There is a substantial body of peer-reviewed literature that finds that screening and brief intervention are effective techniques in primary health care and hospital emergency care for detecting and treating people who misuse alcohol. Alcohol screening is defined as the use of a valid brief questionnaire about the context, frequency and amount of alcohol used by an individual. Alcohol screening provides a quick way to identify individuals whose drinking patterns indicate that they have an alcohol problem or are at risk for developing one. Examples of valid questionnaires are: AUDIT (Alcohol Use Disorder Identification Test), MAST (Michigan Alcohol Screening Test), and CAGE (4 question screener). Brief intervention can be defined as when a healthcare provider (such as a nurse or EAP counselor), using the results of a screening questionnaire that indicates an alcohol problem, expresses concerns about the individual’s drinking and advises the individual to cut down on his/her drinking. The healthcare provider helps the individual to develop an action plan to achieve this goal. Brief interventions are not designed to treat alcoholism, which requires greater expertise and more intensive care management.

Ensuring Solutions reviewed this extensive body of literature for a project with NHTSA, SAMHSA, CDC and other Federal agencies. Summarizing 30 years and more than 360 controlled clinical trials of alcohol treatments, William Miller identified SBI as the most effective alcohol treatment presently available (Miller & Hester, 2003). Yet, these well-studied techniques are not widely used in medical or in non-medical settings.  

The research literature and clinical practice standards of professional medical societies concur that SBI for alcohol problems leads to reduced alcohol consumption among excessive drinkers, and reductions in alcohol-related health outcomes, including mortality.  There are strong justifications for expanding alcohol SBI throughout the healthcare system and to workplace settings.

• SBI has been rigorously tested in a wide variety of healthcare settings, delivered by a range of providers, and produced consistently positive results in reductions in drinking and alcohol-related problems;

• SBI is integral to evidence-based clinical practice standards for treatment of substance use disorders promulgated by relevant professional medical societies, federal agencies, international health organizations and national health ministries of developed nations;

• Major commercial health insurers and business groups consider SBI a core feature of clinical practice guidelines used to determine medical necessity and reimbursement;

• The federal agencies responsible for public health and public safety recommend routine SBI;

• Seventeen medical professions recommend SBI training and the demonstration of clinical competency in SBI for professional education;

• Federal health services and major foundations are investing substantial resources in developing SBI demonstration programs to test the efficacy and effectiveness of these interventions;  and

• The ratio of cost to implement SBI to healthcare cost savings of SBI is positive and substantial.

• Clinical and workplace outcomes associated with SBI are favorable.

SBI could be offered to workers and their families through a number of company resources such as employee assistance programs (EAPs), health promotion and wellness programs, occupational health and safety clinics, health fairs, employer-sponsored health insurance plans, disease management, or disability/rehabilitation programs. Moreover, employer-, health plan-, and other websites (e.g., TUwww.alcoholscreening.orgUT and TUwww.drinkerscheckup.comUT) may be useful for delivering the alcohol screening component of SBI as well as providing objective feedback on drinking patterns and need for behavioral change. However, based on review of the literature, to the best of our knowledge, no assessment has been made of the effectiveness of SBI in the many non-medical settings where it could be offered to workers and their families. No analyses summarize how SBI, which was developed as a medical treatment, may need to be adapted to fit to non-medical settings.  

Although the literature review did not uncover evidence that current SBI models in primary health and specialty behavioral healthcare have been widely adopted or successfully adapted and rigorously evaluated in non-medical/work-related settings, there is evidence to suggest that health promotion programs and EAPs are feasible and promising vehicles for delivering SBI to workers and their families.  For example, the Wellness Outreach Program (developed by Max Heirich) is a CSAP Model Program which tested the efficacy of embedding alcohol moderation content within a general health and cardiovascular screening program in which employees were offered cardiovascular and general health risk assessment (HRA) which included assessment of alcohol risk, with immediate feedback at the end of the screening (Heirich and Sieck, 2000).  Findings of the study showed that at-risk drinkers who received alcohol screening and wellness counseling infused with alcohol-focused information lowered their drinking to safe levels compared to at-risk drinkers who only received screening. Furthermore, while research on outcomes for employees utilizing EAP services is limited, available data suggests EAPs are effective in reducing employees’ alcohol problems (Googins, 1990). Research by Walsh and colleagues (1991) compared the outcomes of employees who were referred to an EAP for alcohol problems. Employees were assigned to either inpatient treatment followed by Alcoholics Anonymous (AA), AA alone, or a treatment plan developed by the employee and EAP staff. After two years, all three groups showed significant improvement in job measures with no significant differences across the three modalities.  

A review of professional training resources, suggests that although current SBI training programs and guides for practitioners (such as those below) have been developed primarily for medical settings, initial review of program content suggests that adaptation for non-medical, work-related settings is feasible.

• Richard Saitz and Boston Medical Center’s Alcohol Clinical Training (ACT).

• NIAAA’s Helping Patients Who Drink Too Much: A Clinician’s Guide.

• World Health Organization’s AUDIT: Guidelines for Use in Primary Care and Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care.

• William Miller’s Treatment Improvement Protocol (TIPS): Enhancing Motivation for Change in Substance Abuse.

The literature review did not uncover any unique challenges or roadblocks that may need to be addressed to facilitate widespread use of SBI in the workplace, specifically. However, we know from the medical literature that reimbursement issues, staffing and time constraints, training resources, and workplace culture are key issues that are likely to be relevant in work-related venues too. Future research to develop and implement workplace SBI models should include efforts to gather such information.

Brief Summary of the Major Findings

Participation

Of the more than 500 employers and 200 vendors who accessed the web-based assessment, 265 employers and 71 vendors completed the assessment in full. Small, medium, and large employers located across the U.S. in various industries participated. Employers and vendors who reported offering SBI on the assessment were contacted for a follow-up telephone interview to gather more in-depth information.

Assessment of Employer SBI Practices

• 90% of employers reported being “very” or “moderately” concerned about employee alcohol misuse.

• 81% of employers disseminated information to employees about alcohol misuse and treatment options (primarily through HR, EAP, and supervisors).

• 61% of employers were interested in receiving more information on developing an SBI program.

• Only 29% of employers conducted alcohol screening (primarily through EAP, HR, occupational health, and educational outreach programs; by someone other than a supervisor/manager).

• Many employers reported using bioassay testing.

• Of the employers that screened, 60% provided BI (primarily through EAP).

• Of employers that screened, 91% reported that the identification of alcohol misuse was done by supervisor observation of job performance.

• Almost all employers that conducted SBI had a Drug-Free Workplace Policy in place.

• Among the sub-sample of 20 employers who agreed to be contacted for a follow-up interview, only 8 confirmed the use of a standard screening tool (primarily the AUDIT, CAGE, or MAST). The remaining 12 equated alcohol screening to any form of screening (e.g., supervisor signs and symptoms recognition) or testing (e.g., urine, saliva, breath).

• Although 13 of the sub-sample of 20 reported using BI (typically some combination of BI techniques such as motivational interviewing, cognitive behavioral, skill building, etc.; with 4 to 12 sessions per employee per year) only 6 could be confirmed. The remaining 7 equated BI with “intervening” in any way (e.g., supervisor makes a referral to EAP).

• Employers did not offer evidence of the effectiveness of their SBI program and weren’t aware of evaluation studies specifically on their SBI program. However, those in EAP-related positions were aware of studies on EAP utilization (e.g., rates of presenting problems).

Assessment of Vendor SBI Practices

• 73% of vendors indicated that alcohol screening is included in products/services offered to employers (primarily through EAP, worklife/wellness and education programs, and web-based self-assessment).

• Most vendors recommended standardized screening tools (AUDIT, CAGE, MAST).

• 66% of vendors offered BI products/services (primarily through EAP, web-based education programs, worklife/wellness programs).

• 86% of vendors were interested in receiving more information on developing an SBI program.

• Among the diverse sub-sample of 9 vendors who agreed to be contacted for a follow-up interview, 8 used a standardized screening tool, often in conjunction with a clinical interview or other psychosocial, mental health, or drug use assessment; 8 offered BI, and 8 provided referral to treatment.

• Vendors (like employers) supported supervisor training in the identification of alcohol misuse through awareness building, signs and symptoms recognition, and referral process to EAP or health plan but not in the routine use of alcohol screening tools or BI.

• Most vendors had no knowledge of evaluation studies on SBI practices, specifically. However, in some cases, EAP utilization reports were generated and surveys administered by the vendor (e.g., satisfaction survey) but results were not available or specific to SBI.

Conceptualization of Two SBI Approaches for the Workplace

Two promising approaches to conducting SBI in work-related venues emerged from the synthesis of the web assessment data and the rich qualitative data collected in the interviews. The first is a “Post Bioassay/EAP” approach and the second is an “Occupational Health & Wellness/EAP” approach. Although these approaches have been conceptualized and presented here as two different and unique approaches, there is considerable overlap in program components and they can be tailored for an individual employer.

“Post Bioassay/EAP” Approach. The “Post Bioassay/EAP” approach reflects a subset of employers who primarily use an alcohol and drug testing program to identify alcohol misuse in the workplace in such cases as reasonable suspicion, fit for duty, random, and on-going follow-up testing. A positive test results is the trigger for engaging employees in SBI. Employees are referred to the internal or external EAP. The other inherent trigger is self-referral to EAP. This approach relies heavily on supervisors’ awareness of substance use issues, ability to identify signs and symptoms of alcohol misuse, knowledge of and ability to follow organizational policies (e.g., DFWP policy) and protocols around alcohol-related incidents (e.g., how to confront an employee, document the events of the encounter) and ability to conduct supervisory performance evaluations, initiate constructive confrontation, and provide referrals (e.g., mandatory referrals to EAP). Signs and symptoms recognition and constructive confrontation training for supervisors and others in leadership/management positions and SBI training for EAP counselors are essential. EAP counselors must be able to conduct alcohol screening and initiate brief intervention (immediately, if possible). Staff should be trained to conduct administrative and clinical follow-up to continue engagement in SBI process. In addition to providing SBI, EAP counselors can provide referrals for more in-depth assessment and treatment (e.g., diagnostic assessment of alcohol dependence, referral to inpatient or outpatient treatment center) in cases where more treatment is needed beyond brief intervention. The expected outcomes of this approach include (among others) increased identification of alcohol misuse, increased worker productivity, decreased number of workers with alcohol problems, and decrease in benefit use over time. 

“Occupational Health & Wellness/EAP” Approach. The “Occupational Health & Wellness/EAP” approach reflects a different subset of employers who primarily use occupational health and safety clinics and health promotion/wellness programs, including routine health risk assessments (HRAs) and 24-hour automated telephonic or web-based screening to identify alcohol misuse and assess risks associated with drinking behavior. The results of the HRA and automated screening are the catalyst for engaging employees in SBI. SBI is delivered by occupational health and safety staff (e.g., nurses or physicians), health promotion/wellness staff, or by EAP counselor (internal or external). Self-referral is inherent in this approach. Nurses, physicians, health promotion practitioners, and EAP counselors can receive self-referrals, supervisor referrals, or referrals from automated screening. The occupational health and wellness staff are in a unique position to immediately engage workers in SBI at the time (or shortly after) an HRA is administered. This approach relies heavily on the staff’s ability to effectively conduct alcohol screening and brief intervention, awareness of substance use issues, knowledge of signs and symptoms of alcohol use, knowledge of a wide variety of substance abuse treatment resources, and ability to properly refer employees or encourage self-referral to a treatment provider if more intensive treatment is needed. SBI training for occupational health and wellness staff and EAP counselors is essential. Staff should also be trained to conduct administrative and clinical follow-up. Signs and symptoms recognition and constructive confrontation training for supervisors and others in leadership/management positions is also essential. This approach relies on supervisors’ awareness of substance use issues, ability to identify signs and symptoms of alcohol misuse, knowledge of and ability to follow organizational policies (e.g., DFWP policy) and protocols around alcohol-related incidents (e.g., how to confront an employee, document the events of the encounter) and ability to conduct supervisory performance evaluations, initiate constructive confrontation, and referrals, including mandatory referrals or encouraging self-referral to occupational health and safety staff or EAP. In addition to providing SBI, occupational health and wellness staff and EAP counselors may provide referrals for more in-depth assessment and treatment (e.g., diagnostic assessment of alcohol dependence, referral to inpatient or outpatient treatment center) in cases where more treatment is needed beyond brief intervention. The expected outcomes of this approach include (among others) increased identification of alcohol misuse, increased worker productivity, decreased number of workers with alcohol problems, decrease in benefit use over time, and reduced related morbidity. 

Next Steps

Based on the information gleaned in Year One, the next step is to bring together employers, vendors, researchers, clinicians, and experts to further develop and refine the approaches discussed above- examining the feasibility of implementing the approaches; the barriers/challenges and strategies for overcoming them; associated costs and resource requirements; necessary infrastructure; and impact on organizational policy, practices guidelines, and contractual agreements. These activities will be conducted in Year Two of the project beginning January 2007. The goal of Year Three, anticipated to begin in 2008, is to pilot and field test the SBI approaches refined in Year Two in one or more worksites using a rigorous evaluation design to determine program effectiveness.