Alcohol Screening and Brief Intervention in the Workplace: Opportunities for Early Identification and Intervention Tracy McPherson, PhD 1 ; Kathy Lusby-Treber 2 ; Eric Goplerud, PhD 1 ; Thomas Walsh 2 1 Ensuring Solutions to Alcohol Problems, The George Washington University, Department of Health Policy 2 Network of Employers for Traffic Safety Abstract Research Objectives To conduct a comprehensive review of the literature that presents the science supporting the effectiveness of alcohol screening and brief intervention (SBI) as an approach to early detection and intervention in medical and non-medical settings, economic and clinical outcomes of SBI, the use of SBI as a clinical practice standard, and SBI training/competency recommendations. To identify best (and promising) practices and products/services that employers and vendors of employee assistance and managed behavioral healthcare can use to address unhealthy alcohol use, in particular current SBI practices. To develop SBI approaches that are feasible and testable in work-related settings. Methods Performed a literature review covering the last 10 years using Medline and other online databases, reviewed guidelines and standards of professional organizations, federal agencies, health insurers and business groups. Using a cross-sectional design, 265 employers in all major industries and 71 vendors from across the U.S. completed a web-based survey on SBI practices; a sub-sample (20 employers, 9 vendors), who reported offering SBI, participated in an in-depth follow-up telephone interview. A Product Development Work Group comprised of employer, vendor, drug testing, and business coalition representatives; employee assistance and occupational health professionals; clinicians; federal agency representatives; and researchers was convened to shape the development of SBI approaches and supporting implementation materials. Analysis Quantitative analysis of employer and vendor SBI surveys. Qualitative analysis of in-depth telephone interviews with employers and vendors. Principal Findings There is substantial empirical support for SBI in medical (primary care, trauma, ED) but not in non-medical settings. Many vendors offer SBI products but many employers don’t conduct SBI, despite being very interested in implementing it in their worksite. Rather, employers often rely on alcohol/drug testing and supervisor observation of job performance to detect alcohol problems. Employers doing some level of SBI generally do not use a specific model. Employee assistance programs (EAP) and occupational health and wellness programs appear promising for delivering SBI. Two promising SBI approaches emerged: Post Bioassay + EAP Approach Occupational Health and Wellness + EAP Approach Conclusions A systematic investigation of promising approaches to SBI is needed to determine best practice in workplace settings. Opportunities exist for the integration of SBI into existing workplace and vendor policies and practices, and for providing training to supervisors, employee assistance and occupational health and wellness practitioners. The workplace remains underutilized for delivering alcohol SBI to workers. Implementation of SBI in work-related settings is likely to increase early identification and intervention, facilitate referral and treatment, reduce long-term healthcare service utilization and related costs, and improve health and productivity metrics. Specific Findings Literature Review Little evidence of SBI programs delivered in workplace settings (e.g., HP/wellness programs or occupational health) exists. SBI in non-medical settings is primarily done by EAP but not routinely or systematically. SBI is integral to evidence-based clinical practice standards for treatment of substance use problems disseminated by professional medical societies and international health organizations. 17 medical professions recommend SBI training and the demonstration of clinical competency for professional education. Federal agencies responsible for public health and safety recommend routine SBI. Major commercial health insurers and business groups consider SBI a core component of clinical practice guidelines used to determine medical necessity and reimbursement. 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. Figure 1. Post Bioassay + EAP Approach Acknowledgement Research supported by a cooperative agreement between the Network of Employers for Traffic Safety (NETS) and National Highway Traffic Safety Administration (NHTSA) Employer and Vendor Surveys Employers: 90% are “very” to “moderately” concerned about unhealthy alcohol use by employees. 81% disseminated information about unhealthy alcohol use and treatment options (mostly through HR, EAP, supervisors, outreach programs, company intranet). Only 29% (n=78) conducted alcohol screening. Among those that screened, 60% (n=47) conducted BI and almost all provided referral for intensive treatment. EAP was the primary resource used for conducting SBI. Almost all who conducted SBI had a Drug-free Workplace Policy and bioassay testing program in place, and relied on supervisor observation of job performance (e.g., signs and symptoms recognition) to identify employees who use alcohol in hazardous ways. 61% were interested in receiving more information on developing an SBI program for their employees. Vendors: 73% (n=52) offered alcohol screening products and services. 66% (n=47) offered BI products and services. EAP, web-based self-assessment/education programs, and work/life wellness programs were the primary resources used to offer employers SBI. 75% recommended standardized screening tools (AUDIT, MAST, CAGE). 86% were interested in receiving more information on developing an SBI program for employers. Employer and Vendor Interviews Employers: Of the 20 who agreed to be interviewed, only 8 confirmed the use of a standardized tool (primarily the AUDIT, CAGE, or MAST) and 12 equated screening for unhealthy alcohol use with any form of identification (i.e., supervisor signs and symptoms recognition or positive breath test). Although 13 of 20 reported conducting BI, only 6 used evidence-based techniques (e.g., motivational interviewing, cognitive behavioral); the other 7 equated conducting a BI with “intervening” in any way (e.g., supervisor confronting employee and making a referral to EAP). No specific SBI model or approach was used systematically or routinely and none reported evidence of program effectiveness. Employers indicated that in cases where bioassay testing is the predominant method of detecting an alcohol problem and supervisor signs and symptoms recognition processes are in place, the EAP (internal or external) is likely the most promising vehicle for delivering SBI to employees. See Figure 1. Post Bioassay + EAP Approach. Employers indicated that in cases where occupational health and wellness programs are in place, the most promising vehicles for delivering SBI are health risk assessments (HRA) and educational outreach programs (conducted by nurse or health promotion practitioner), combined with the EAP (internal or external). See Figure 1. Occupational Health & Wellness + EAP Approach. Vendors: Of the 9 who agreed to be interviewed, 8 used a standardized screening tool (AUDIT, MAST, or CAGE), often in conjunction with a clinical interview or other psychosocial, mental health, or drug use assessment. 8 of 9 offered BI using some combination of evidence-based techniques (typically motivational interviewing/cognitive behavioral). 8 of 9 offered referral for more intensive treatment. Vendors indicated that employers should rely on trained professionals (e.g., counselors) to provide SBI services rather than managers or HR/administrative staff. Vendors felt strongly that supervisors should play an indirect role in SBI by facilitating the referral process, but should not conduct the alcohol screening or BI. Vendors strongly supported supervisor training that focuses on awareness building, signs and symptoms recognition, and conducting referrals to EAP or health plan. No specific SBI model or approach was used systematically or routinely and none reported evidence of effectiveness of their SBI products/services. Ongoing Research Activities In collaboration with the Workplace SBI Product Development Work Group we are developing a prototype Workplace Alcohol SBI Guide containing implementation, training, and evaluation materials and resources. Post-test survey of employer and vendor SBI practices is currently underway. Figure 2. Occupational Health and Wellness + EAP Approach More Information on SBI and Brief Report Available “Alcohol Screening and Brief Intervention in the Workplace” Contacting Author Information Tracy L. McPherson, PhD