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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Drugs, the Workplace, and Employee-Oriented Programming Paul M. Roman and Terry C. Blum It would probably be difficult to locate any substantial segment of the American public in 1990 who would deny that the nation is facing a major problem with drugs. Beyond such a general statement, consensus within a public sample survey is likely to deteriorate rapidly because defining the ''drug problem" is a task riddled with ambiguity. "Drugs" range from caffeine to heroin, and one group's "problem'' may describe another group's cherished activities. Beyond these difficult specifications, it is evident that a broad series of actions are under way to "combat" the drug problem, to "prevent" the use or misuse of drugs, and even to produce a "drug-free" America. The level of interest and resource investment is a complex variety of activities that in itself constitutes a phenomenon to be explained. No matter how one defines the "drug problem" and its numerous impacts, it is evident that it is only one of many problems currently faced by American society; yet drug-related issues have moved to a high-priority position both in terms of public opinion and governmental action. The focus in this paper is on the responses to perceived problems with drug abuse in the work-place. Our task is to describe this major facet of the "drug problem" in American society by examining the nature of responses to it. It is assumed that a focus on the social and organizational responses to an issue not only elucidates the form and effectiveness of those responses but also provides a crucial context in which to consider the definition of the problem. The sections that follow are first, an overview of major issues, followed by an examination of the sociohistorical pattern of employer response to drug abuse during the past 20 years. Next is a somewhat parallel, albeit abbreviated, consideration of the pattern of employer re Paul M. Roman is with the Department of Sociology and Institute for Behavioral Research, University of Georgia. Terry C Blum is with the Ivan Allen College of Management, Policy, and International Affairs, Georgia Institute of Technology.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment sponses to employee alcohol abuse issues. An effort is then made to pull together these three streams of information into a consideration of the fundamental issues surrounding constructive approaches to drug abuse in the workplace and the factors that facilitate or retard the use of employee assistance programs (EAPs) as part of this overall strategy. THE PROBLEM OF DRUGS AND THE WORKPLACE Scope of the Problem An initial question is, what is the scope of the problem? Limiting that question only to illicit drugs, an authoritative source is the federal agency charged with research drug-related issues, the National Institute on Drug Abuse (NIDA). A NIDA research funding program announcement, which is intended to attract scientists to studies of the scope and distribution of drug use behaviors among workers and in the workplace, indicates that 65 percent of the 18- to 25-year-old population have experience with illicit drugs, with 44 percent of this population segment reporting these experiences during the past year (NIDA, 1987). A report from a national household survey conducted with NIDA support indicates that, in a similar population segment, those aged 18 to 34, 60 percent have used marijuana at least once and approximately 25 percent have used cocaine at least once (Voss, 1988). The director of NIDA offers a somewhat different basis for problem definition: a survey in 1985 revealed that 29 percent of employed Americans in the 20-40 age group had used an illicit drug at least once during the year prior to the survey, whereas 19 percent reported use during the past month (Schuster, 1987). The age segment focus of these data is used to observe that younger persons have a substantially higher rate of reported drug experience than older persons, and that such a difference not only describes a major problem with drugs among persons in this age segment who are employees but also projects a workplace drug problem of continuing seriousness as workers who exhibit such behaviors move through their life careers in the work force. A survey commissioned by NIDA was recently reported in the
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment New York Times, with considerable attention paid to the reports of 79 percent of 224 chief executives of Fortune 1000 corporations, 18 governors, and 23 mayors that substance abuse was a significant or very significant problem in their organization. Evidence of the acute nature of the problem is demonstrated by the finding that only 54 percent of these respondents saw a substance abuse problem of this magnitude four years ago (Freudenheim, 1988). Unfortunately, the reader learns later in this story that the survey generated only a 25 percent response rate, raising the distinct possibility that those for whom the issue was salient may have been overrepresented in the respondent group. These brief statistics show that there is an association between drug use and employment and offer a foundation for projecting a broad series of problematic impacts associated with drug-using behaviors. But a careful examination of these statistics, both alone and collectively, raises many questions about their implications. Especially troublesome is the attribution of drug use as drug abuse and, in the instance of the corporate survey, the substitution of impressions of an escalating drug problem for epidemiological evidence of actual change. This sampling of data provides some flavor of the difficulty of producing statements with any sort of precision regarding the drug abuse problem in the American workplace. Employer Motives to Initiate Action Beyond research precision is a practical question: Why should the workplace show a concern with employee drug use? Although the answer seems "obvious," it is important to note the variability of reasons for this concern. The complexity of these motivations is linked in turn with the structure of the responses the employer initiates or supports. Although neither exhaustive nor meant to represent any hierarchy of importance, the list below provides some indication of the range and complexity of employer motives and the assumptions that may underlie such responses. Drug use is a threat to safety in the workplace. Drug-using behavior is "wrong" and will not be tolerated in the workplace. The presence of illicit drug use is in turn an indicator of illicit "drug dealing," possibly introducing criminality into the workplace as well as increasing the likelihood that "pushing" will occur to encourage nonusing employees to become users. Drug-using habits are expensive and encourage theft from both
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment the employer and fellow employees. Drug use reduces workers' immediate productivity, in terms of both quality and quantity of performance. Drug use reduces workers' careers and long-term productivity, and continued use is associated with subtle declines in work quality and quantity. Drug use creates unpredictable and disruptive behavior in the workplace. Employees' performance and attendance may be affected by drug-using behaviors of their dependents and family members, indicating that a constructive program of help for both employees and their family members can reduce work performance problems. Dealing constructively with employee drug problems is a demonstration of corporate social responsibility. The offer of assistance to employees with drug problems is a relatively low-cost but perhaps morale-boosting improvement in employee benefits. The presence of efforts to eliminate or control drug abuse in the workplace is a benefit to nondrug-using employees by protecting their safety and reducing uncertainty over the behavior of their co-workers. Many employers, including large, well-known companies, have implemented programs to deal with employee drug abuse; therefore, such programs must represent state-of-the-art techniques of human resources management. Drug Screening/Drug Testing and Employee Assistance Programs The combination of some set of the above-listed reasons with the perception of drug use in the employee population has led to two basic types of organizational interventions to deal with drug abuse problems among employees: drug screening/drug testing programs (DSPs) and employee assistance programs (EAPs). There are several different kinds of DSPs, but the most prevalent form is preemployment screening. Some DSPs also test current employees before they are promoted, after they return to work from extended absences, or when they are transferred into jobs regarded as particularly sensitive to the impact of drug abuse. Drug screening "for cause" may be incorporated into a long-standing fitness-for-duty policy. A supervisor with evidence that a subordinate is impaired but without evidence of the cause of the impairment may ask to have the employee's fitness for work verified by a medical functionary, who in turn may use a drug screen. Related to
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment this type of screening is postaccident screening. Another type is universal screening of all employees, sometimes as part of preannounced medical check-ups. Random screening of all or some preselected segments of the work force is a rarely used type of DSP, although it is the subject of the most controversy. EAPs are usually based on a written policy statement. They provide access for supervisors to either in-house or out-of-house professional consultation in dealing with subordinates whose performance is affected by any of a range of personal problems, nearly all of which are encompassed by substance abuse, psychiatric, or marital/family problems. EAPs also provide for employee self-referral. The basic functions of EAP services include clinical assessment of employee problems, referral to appropriate community resources, follow-up of the employee at the workplace following service use, training of supervisors and managers about EAP policy, and provision of consultation to supervisors/managers when the occasion arises for their use of the program to deal with subordinates. An issue of major concern in this paper is the extent to which EAPs constitute a reasonable intervention-solution for dealing with drug abuse in the workplace. This issue is also relevant to DSPs. Although drug screening programs are specifically and exclusively focused on drug abuse in the workplace, they are generally limited in their attention to illegal drugs and may or may not involve screening for prescription drug use; they rarely if ever deal with alcohol use or abuse. By contrast, EAPs began as industrial alcoholism programs that later broadened their scope to encompass the range of personal and biobehavioral problems that could affect employee job performance. EAPs also serve a broad "self-referral" function in providing a reactive mechanism in the workplace to respond to employee-initiated requests for personal assistance. Thus, EAPs are geared to deal with drug abuse problems within a panoply of other employee problems, but they depend on either supervisory or employee motivation for program use to occur. Thus, EAPs' "target population" differs somewhat from that of DSPs. Whereas DSPs seek objective physiological evidence of drug use, independent of behavior, performance, or self-report, the design of EAPs limits their drug-related service usage to instances of impaired job performance, peer-or self-motivated initiation of requests for personal assistance by drug-using employees, or self-motivated initiation of requests for assistance in dealing with a drug-using family member. Nearly all of these modes of identification involve subjective indices or perceptions, in contrast to the presumed objectivity of drug screening. This difference in target employee populations sets the stage for confusion about the relative utility and importance of the two strategies. It also, however, describes a very crucial point: by their design, neither
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment DSPs or EAPs are equipped to deal with the entire range of drug use and abuse events in a work force or in a workplace. Furthermore, it is not reasonable to conclude that the combined efforts of both programs would accomplish such a comprehensive goal. Both programs have problems in the reliability and validity of their identification strategies. Moreover, neither program has the wherewithal to detect what is probably the most common and perhaps even the most costly drug-related issue in the workplace, the concurrent or recent use of alcohol that creates risks for job performance problems and accidents but that cannot be detected reliably either through performance monitoring or tests of body fluids. At first blush, these two strategies appear to represent distinctively different philosophies and assumptions regarding the exclusion or inclusion in the workplace of the drug-using or drug-abusing employee. Drug testing appears to be a "tough" strategy of "get rid of 'em" in a context of exclusion and protecting the workplace against their impact; EAPs, on the other hand, appear sympathetic toward employees' personal problems and oriented primarily toward rehabilitation within a context of inclusion. Although these characterizations are partly accurate, they fall far short of an understanding of the range of uses to which either program strategy can be put; in addition, they do not reflect the potential impact of interaction and cross-referrals between the two strategies. Another important contextual consideration regarding DSPs and EAPs is that, to date, nearly all of the programs of each type have been voluntarily adopted by employers. At the time of this writing, there is movement toward the implementation of mandatory drug screening in nuclear power installations, in parts of the transportation industry, and in many agencies of the federal government. In many of these instances, regulations are in place that require the establishment of an EAP service for referral usage by employees who are found positive in drug screenings. Again, as with much of the terminology used in this paper, "drug screening" has different meanings in different contexts and, with the variations in use described above, can refer to distinctively different strategies. The essential point is that drug screening mandated by law or public regulation is only in its infancy, and this is even more distinctively the case with EAPs. The fact that so much workplace-based activity has developed in a context of voluntarism is notable, as well as indicative of the further facts that substantial numbers of workplace decision-makers (1) have perceived significant problems in terms of both employee drug and alcohol abuse and (2) have also seen enough merit in DSPs and EAPs to motivate voluntary investments in various levels of implementation. Therefore, an examination of these interventions does not represent a typical "evaluation" of the consequences of regulations or funding initiatives implemented by government. At the same time, the federal
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment government has played an active role in attempting to facilitate the implementation of both types of programs in the private sector and has played a more proactive role in the development of such programs for federal employees. Thus, it is also incorrect to view either DSPs or EAPs as primarily the products of "grassroots" social movements, initiated by employees or other activists at the level of the individual workplace. Contrasts Between Attitudes Toward Alcohol and Toward Other Drugs To a considerable extent, constructive approaches to dealing with alcohol problems in American society and the American workplace have become normative over the past 20 years (Roman, 1988b). Such a claim cannot be made, however, for reactions to other drug problems. There is a marked ambivalence surrounding the notion that "drug problems can be dealt with just like alcohol problems," or its converse, "alcohol problems are just another form of drug problem," or even "alcohol is a drug." A comprehensive overview of the similarities and differences between and within alcohol and other drug categories is far beyond the scope of this paper. However, one major difference pervades many considerations, and that is the apparent degree of acceptance of the notion that the most reasonable and rational approach to the individual with an alcohol problem is some form of medicalized/treatment-oriented strategy as an alternative to punishment or exclusion. The acceptance of the disease concept of alcoholism in American culture is far from complete (Blum et al., 1989), but some degree of such acceptance is found in the majority of those queried in nearly all research samples. By contrast, if one uses the mass media and publicity emanating from the federal government as a guide, public acceptance of some form of a disease concept of drug problems is much less than that associated with alcohol. Most media presentations characterize drug abusers in a deviant or criminal category, often without a clear distinction between the drug dealer and the drug user, as if the two categories were completely overlapping. This characterization may be curiously out of step with public opinions, for research has recently shown that more than 80 percent of a public sample in a presumably conservative state (Georgia) favor medicalized treatment rather than a punitive approach in dealing with persons dependent on cocaine, one of the drugs around which much media emotion is projected (Blum et al., 1989). Governmental pronouncements on drug abuse in the workplace give a double message. They suggest preemployment drug screening as a way of reducing the drug problem by refusing to accept drug users into the
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment work force while at the same time recommending that employees who are found positive in drug screenings be offered referral and rehabilitative assistance through an EAP (Walsh and Hawks, 1986; Backer, 1987). The combination of these messages might not appear contradictory if a rather complex assumption is accepted: the responsibility for dealing with drug users lies solely with the community except in those instances in which an employed drug user chooses to take advantage of help that may or may not be proffered by an employer. On the other hand, the ground is laid for considerable confusion in the common scenario in which evidence of drug use (which is all that preemployment drug screens reveal) is not only an acceptable basis for refusing employment but a practice actively supported and recommended by the same federal agency that advocates a treatment approach for dealing with a person whose urine sample produces similar results but who is already employed. These policies support an image of an Alice-in-Wonderland kind of affliction, with the definition of identical phenomena varying with the employment status of the source of the drug-positive urine specimen: those not yet employed are in the deviant or criminal category, whereas those already employed are in the sick or disabled category. There is little doubt of the sincerity of the authors of such recommendations, and careful reading of most documents shows their explicit recognition of the contradictory stance being exhibited. The mischief and confusion may arise as such documents are perused by the busy or harried executive or human resources manager who has little intention or desire to become an expert on substance abuse in the workplace. In a nutshell, it is clear that the national policy toward drugs in the workplace is not clear. However, culturally based definitions of different behaviors play a large role in determining the acceptability of different responses to drug and alcohol problems, an issue considered in greater detail in the sections that follow. DEVELOPMENT OF EMPLOYER RESPONSES TO DRUG USE Historical Perspective Although the past several years have seen a great deal of attention to efforts to create a "drug-free workplace" in the United States, this is at least the "second round" in the battle against employee drug abuse. A brief history of the events related to this issue over the past 20 years may inform an understanding of the viability of current responses to the problem. As with alcohol, the history of various drugs in American culture reflects differing attitudes and definitions across different periods. Alcohol
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment was extensively used and considered largely nonproblematic in the American colonies and in the early years of the Republic, up until the 1820s when a serious temperance movement emerged (Clark, 1976). Although there are many varieties of drugs, it is important to note that two drugs that later have become of central concern as problems, opiates and cocaine, were widely used (as painkillers in the former case and as over-the-counter medications for a wide variety of ills in both cases) and generally were viewed as of little concern in American culture until the last quarter of the nineteenth century. From this time onward, however, increasingly stringent and intense controls developed and are clearly at one with the ideology of prohibition of distribution and the intense efforts to prevent use of these substances that prevail today. Commentaries published during the 1800s occasionally noted the presumed linkage between drug use and "stress," offering hypotheses not altogether different from some proposed today but with several contradictory perspectives (Morgan, 1981). On the one hand these nineteenth-century writers would point to the use of drugs as a means for dealing with the extreme stresses accompanying some professional occupations, especially medicine. Discussions would describe the use of drugs as coping mechanisms and impugn large-scale social change in America as the genesis of such extremely stressful conditions. On the other hand were writers who offered a quasi-disease concept of addiction to drugs, pointing out that, although many people used drugs, only those with "neurological weakness" would become addicted to them. In between these notions is the hypothesis that the "stimulus of liberty" and its attendant demands on the mind were etiological factors in drug addiction (Thwing, 1888, in Morgan, 1974). Although there is little evidence of drugs in the workplace as an issue of social concern in the United States until the early 1970s, one notable exception is a report of an apparently informal survey of experience with workplace drug addiction (Blair, 1919, in Morgan, 1974), published for diffusion to industrial and occupational physicians. The motivation for this report is unclear, although brief reference is made to considering the effects on the work force of the Harrison Act of 1914. The report itself suggests little if any evidence of significant drug problems in the workplace, although several observations foreshadow issues that assume prominence 70 years later. The report provides several valuable insights into the thinking of the day, with the author writing from a workplace perspective: Although addiction to drugs is reportedly rare in 1919, "drug tippling" is "as common among industrial workers . . . as among other employed people." This reference to the perceivedly inconsequential
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment occasional or nonaddictive use of drugs contrasts with the subsequent focus of drug screeners on any use of illicit drugs. Referring later in his essay to the possibility of detecting drug usage through medical examinations, Blair posits that "tipplers" probably would not be detected through such examinations. He then states that "it does not seem to me necessary for an industrial plant to set out a drag-net for minor disabilities or minor addictions" (p. 75), a position contrasting markedly with the philosophies of some drug screening today. A similar contrast with contemporary problem definitions is found in Blair's description of a long-term user of morphine who has not escalated his use over a 14-year period shows no apparent ill effects, and whose highly responsible and respected position offers no support for a notion of adverse job performance impacts of routine opiate use. According to Blair, the drug problem is most common among "drifting" and "floating" industrial work forces. Among the specific categories cited are gang workers on docks, transportation workers, bituminous coal miners, and both farming and nonfarming occupational groups in sparsely populated rural areas. Blair sees drug problems as extremely rare among skilled industrial workers and among the "better classes" of workers generally. In terms of social control efforts in the workplace, Blair observes that if an industrial worker were to become "one of the degenerate type of addicts," he would be "physically unable to work and would not be tolerated by his fellows if he tried to do so." Blair states that labor unions "rarely tolerate the confirmed drug taker" and that the average industrial worker ''despises dope'' and would promptly report drug-related incidents. However, "a degree of prophylaxis in an industrial organization is advisable. Morale should be kept up in every way and the idea disseminated that it is not manly to tipple with 'dope.' The 'Treat 'em Rough' idea as regards peddlers of drugs will make this cowardly class keep away from the works" (p. 72). Blair also includes recommendations that "will go a long way to prevent drug tippling" in the workplace. These include good housing for workers, adequate medical care, good sanitation, minimal night work, "an interest in the men and their families," and, interestingly, "reasonable regulations regarding the use of alcoholic liquors." That the final recommendation appeared on the eve of national prohibition of alcohol distribution is especially curious. It is further noteworthy that Blair's preventive recommendations bear little resemblance to the solutions popular at present. Notable in this report are a definition of the problem, a distinction between serious and nonserious use, some projections about problem dis-
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment tribution, recognition of the importance of informal social controls in the workplace, suggestions for a "drug-free" work culture, and a program for primary prevention of drug abuse in the workplace. The next evidence of commentary about workplace drug problems does not appear until the early 1970s. The almost complete submergence of concern about drugs in the workplace over this period tends to support an assumption that drug abuse tended to be concentrated among those in marginal social categories. Other than occasional commentary about drug use and addiction among medical professionals (Winick, 1961; Smith and Blachly, 1966; Simon and Lumry, 1969) and those in the performing arts (Becker, 1953; Winick, 1960), there is no literature in the ensuing period that describes any general pattern of nonalcohol drug problems in the workplace. Awareness of a national drug problem is best documented by the passage of Public Law 91-513, the Comprehensive Drug Abuse Prevention and Control Act of 1970. It is well known that the cohort entering young adulthood during this period had become extensively interested in and involved with illegal drugs, with marijuana and the hallucinogens gaining the most attention. The drug issue was escalated in the mass media by its association with the "dropped-out" youth from middle-class and more prosperous backgrounds. The image of "flower children," characterized by illicit drug use coupled with expanded sexual freedom, was reflected in the popular cultures of music, dress, and various public events of high visibility. These themes were intermingled with a more serious and dramatic set of behaviors, beginning with opposition to the war in Southeast Asia and escalating to various "anti-establishment" perspectives and behaviors within this cohort. Curiously, a parallel disrespect for law and order that emerged during the 1920s contributed to the public decision to repeal national prohibition of the manufacture and distribution of alcohol. In the late 1960s, however, much of the reaction to the association between drug use and social rebellion was centered on increasing social control. The First War on Drugs in the Workplace Interest and concern about drugs in the workplace arose in concert with the congressional action cited above. Much of the tone of this brief "movement" was centered on the drug abuser as a "menace" who threatened order and profitability in the workplace. Representative of media attention at the time was an article in the May 4, 1970, issue of the Wall Street Journal (Malabre, 1970). The article reported that Metropolitan Life Insurance had an alarming increase in the number of employees dismissed
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment percent higher among those who tested positive as compared with those who tested negative. However 38 percent of the total sample had not shown any absenteeism over the first six-months, suggesting that the distribution of absenteeism can certainly change. The turnover data are somewhat more revealing in that turnover does not vary according to whether the new hires were positive or negative at their preemployment drug test. Only involuntary turnover is significantly different. Those who tested positive had a 40 percent higher rate of involuntary separation from the Postal Service. This rate represents about 1.5 times as many firings among those who were drug positive as compared with those who were drug-negative. The base of the "40 percent higher rate" is interesting to examine because it constitutes a difference of 3.8 percentage points in the rate of involuntary turnovers between drug-positive and drug-negative new hires. Thus 9.5 percent of the drug negative persons were fired, as compared with 13.3 percent of the drug positive individuals (13.3 percent minus 9.5 percent = 3.8 percent and 3.8 percent of 9.5 percent = 40 percent). This difference is statistically significant—and substantively significant as well. Utility analyses could indicate its long-term costliness to the employing organization. There is, however, quite a different perspective from which these data can be examined, namely, that 86.7 percent of the new hires who were drug positive at a preemployment screen are on the job and are maintaining job performances that do not warrant their being fired during their first six months of employment at new jobs. This perspective can be sharpened further by observing that this 86.7 percent "survived" a 90-day probationary period during which one might presume a more intense level of supervision than would ordinarily be the case. A question that should be raised regarding the typical organizational policy of excluding drug-positive persons from employment is whether such persons stop their drug use when not hired and subsequently gain employment elsewhere, or whether their unemployment encourages increased drug use, which keeps them excluded from employment. These questions cannot be answered with the data sets that are currently available. In light of the almost 87 percent of drug-positive persons who are performing at least well enough not to be fired six months after being hired, another policy question is raised. Does the practice of preemployment drug testing interfere, even unintentionally, with affirmative action principles? The Postal Service data confirm the findings of other epidemiological surveys, which reveal that the odds of being drug positive are higher for blacks, males, and people between the ages of 25 and 35. An especial concern is that the drug-positive rate for blacks was twice that of whites (14 percent versus 6.5 percent), with blacks more than six times
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment as likely to test positive for cocaine and almost twice as likely to test positive for marijuana, as compared with whites. Thus, the practice of preemployment drug testing is likely to exclude blacks from employment at greater rates than whites. Taking a broad view, it may be argued that, in the case of these individuals, employment may be a strong buffer against continued drug use. Employment may also provide the conditions under which abstinence from drugs or undertaking treatment to bolster attempts at abstinence may be strongly encouraged, using some version of the constructive confrontation strategy that operates within EAPs. Thus, micromotives underlying work-entry drug screening that excludes drug-positive persons may influence macrobehavior that unintentionally contributes to a bifurcated society. The micromotives for keeping drug-positive job applicants out of the work force may also interfere disproportionately with the macrobehavioral goals of affirmative action in hiring. As a result, "a vicious circle" may ensue. Within such a circle, potential employers would be encouraged to use what economists call "signaling" to discriminate against a whole group of potential employees based on their ascribed characteristics (race) because of the information that that characteristic is associated with a behavioral characteristic, drug use. Variations in the Scope of Program Services Although DSPs by themselves have a fairly constricted scope of activity, the design and philosophy of EAPs offer almost unlimited possibilities for service expansion. Many have criticized the tendency in EAPs to become all things to all people. This benevolent expansionism often occurs at the cost of EAPs' performing their most important services for both employers and employees, namely, maximizing the potential for effective intervention in dealing with alcohol and drug problems. One of the consequences of this expansion in EAP scope has been the perception that EAPs could be more cost-effective within their host organizations than they currently are. Such concern is usually found under the rubric of health care cost containment; the implementation of improvements in cost-effectiveness within EAPs is labeled managed health care. Two aspects of health care cost containment raise important issues. First is the increasing tendency for EAPs, especially those operating under external contracts, to provide employee referrals with direct counseling for their problems. Usually, these arrangements allow a limit of six to eight counseling sessions, after which the employee would presumably be referred to a community resource if the need for further treatment is indicated. On the face of it, such a trend seems both efficient and a direct cost-
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment cutting strategy, although there are no data from controlled studies to indicate that this is, indeed, the case. Still, the strategy raises numerous important questions: Can company-or contractor-administered "treatment" provide the same objectivity in terms of diagnosis, prognosis, and prescriptions for needed care as would obtain in an external treatment organization free from ties to the employing organization? The obvious context of this concern is that the employer may be motivated to minimize the costs of intervention in the interest of returning the employee to work as quickly as possible. In part, the concern over such employer conflict of interest was the basis for the original design of EAPs as mechanisms for external referral in the community, explicitly keeping the employer out of the role of a deliverer of treatment services to employees. Is there assurance that either in-house or EAP service provider organizations are staffed by individuals who have the diagnostic skills to provide a full regimen of care to the people who seek their help? The current absence of standards governing either the staffing or operation of such EAP units is the basis for this concern. Can the company or external contract counselor break through the cover-up and denial that usually characterizes an employed substance abuser, particularly when it is evident to the employee client that the counselor is a company employee or direct contractor? Conversely, it would appear that such a perception would both encourage and bolster denial and cover-up, not only on the parts of the affected employees but also on the part of their peers and even their supervisors. The second cost-containment concern centers around the provision of EAP services to employee dependents. Although it is apparent that some EAPs are providing substantial attention and services to employees' adolescent children with substance abuse problems, there is no data base available at present to specify the actual scope of such services through the EAP. Conversely, some EAPs are moving in the direction of limiting services only to employees because of the tremendous caseload growth that occurs when services are extended to dependents. Beyond the issue of reducing demands on EAP staff is the question of the extent to which dependent-oriented services actually increase the health care cost burden to the employer. Concerns arise as the work-family nexus becomes more complex and the employers voluntarily and involuntarily adopt roles as providers of behaviorally oriented services to employees' family members and to entire family units. It is presently clear that there are familial structural arrangements that are more conducive to productive employment and to
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment the ''smooth careers" of both men and women workers. To what extent can employer involvement in "counseling," a process that is frequently subjective and value laden, reduce the independence of family-oriented decision-making, which presumably represents a basic American cultural value? On the other side of this coin is the trend in some EAPs to be required by their host employers to provide "gatekeeping" or "channeling" referral for all employees and dependents who desire third-party reimbursement for any form of substance abuse or psychiatric service. There are reasons for suggesting that such an arrangement can, indeed, be effective in controlling costs for the employer while at the same time being beneficial to employees and their families by directing them to services that will be most effective for their problems. Arguments against such a strategy point to the choice of treatment as an implicit right accompanying health care benefits, as well as to the potential conflicts of interest that occur when the employer's agents and their perceived power and expertise dominate the choice of treatment. In sum, the drug abuse issue in the workplace is far from being ignored. In the typical course of the emergence of social problems, the attention to this issue has been rapid, and the scope of social response has been broad. DSPs and EAPs are potentially complementary responses to drug abuse in the workplace, yet the potential conflicts between the two strategies should not be minimized. Experience is accumulating on a daily basis, and the workplace is concerned beyond the simplicities of ridding itself of drug abuse through dramatic but singular remedies. It is extremely clear that a broader base of well-designed empirical research is badly needed and that this research must extend beyond the rather mechanical approach of program evaluation to consider the theoretical and ideological implications of programmatic strategies that impact and rebound well beyond their targets at the level of the individual employee. REFERENCES AND BIBLIOGRAPHY Backer, T.E. (1987) Strategic Planning for Workplace Drug Abuse Programs. National Institute on Drug Abuse, Office for Research Communications. Pub. No. ADM 87-1538. Washington: U.S. Government Printing Office. Beauchamp, D. (1980) Beyond Alcoholism. Philadelphia: Temple University Press. Becker, H.S. (1953) Becoming a marihuana user. American Journal of Sociology 59:236-242.
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Treating Drug Problems: Volume 2, Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment Postal Services. Interim report to the Office of Worksite Initiatives, National Institute on Drug Abuse, Rockville, Md. Phillips, D.A., and H.J. Older (1977) A model for counseling troubled supervisors. Alcohol, Health and Research World 2:24-30. Presnall, L.F. (1981) Occupational Counseling and Referral Systems. Salt Lake City: Utah Alcoholism Foundation. Roman, P.M. (1980) Medicalization and social control in the workplace: prospects for the 1980s. Journal of Applied Behavioral Science 16:407-422. Roman, P.M. (1981) From employee alcoholism to employee assistance: an analysis of the de-emphasis on prevention and on alcoholism problems in work-based programs. Journal of Studies on Alcohol 42:244-272. Roman, P.M. (1982) Employee programs in major corporations in 1979: scope, change and receptivity. Pp. 177-200 in J. Deluca, ed., Prevention, Intervention and Treatment: Concerns and Models. Alcohol and Health Monograph No. 3. Washington, D.C.: U.S. Government Printing Office. Roman, P.M. (1988a) The disease concept of alcoholism: sociocultural and organizational bases of support. Drugs and Society 52(3/4):5-32. Roman, P.M. (1988b) Growth and transformation in workplace alcoholism programming. Pp. 131-158 in M. Galanter, ed., Recent Developments in Alcoholism, Vol. 6. New York: Plenum. Roman, P.M. (1990) Drug abuse intervention in employee assistance programs: results from field surveys. Pp. 271-286 in S.W. Gust and J.M. Walsh, eds., Drugs and the Workplace: Research and Evaluation Data. NIDA Research Monograph No. 91. Pub. No. ADM 89-1612. Rockville, Md.: National Institute on Drug Abuse. Roman, P.M., and H.M. Trice (1968) The sick role, labelling theory and the deviant drinker. International Journal of Social Psychiatry 12:245-251. Roman, P., and T. Blum (1985) The core technology of employee assistance programs. The ALMACAN 15:8-19. Roman, P., and T. Blum (1987a) Notes on the new epidemiology of alcoholism in the USA. Journal of Drug Issues 17:321-332. Roman, P., and T. Blum (1987b) The relation of employee assistance programs to corporate social responsibility attitudes: an empirical study . Pp. 213-235 in LE. Preston, ed., Research in Corporate Social Performance and Policy, Vol. 9. Greenwich, Conn.: JAI Press. Rubington, E. (1974) Alcohol Problems and Human Society. Columbus, Ohio: Charles Merrill, Inc. Rush, H., and J. Brown (1971) The drug problem in business: a survey of business opinion and experience. The Conference Board Record
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Representative terms from entire chapter: