Summary:
Conclusions and Recommendations

This report is concerned with the implications of drug use for workplace safety and productivity. It examines the prevalence of alcohol and other drug use by the U.S. work force, the impact of such use on job-related behavior, and the effectiveness of workplace drug intervention programs. This emphasis on workplace productivity rather than social consequences affects the purpose, methods, and evaluation criteria used in this report, just as it often affects researchers investigating these issues.

THE COMMITTEE'S CHARGE

The committee was charged with: (1) analyzing the available research knowledge on the prevalence and etiology of drug consumption by the work force; (2) studying the impact of drug behavior on work performance, productivity, safety, and health; and (3) evaluating the effectiveness, costs, and benefits of organizational drug intervention programs at the work site.

DEFINITION OF TERMS

Three key terms in the committee's charge require clarification, because their definitions have a significant bearing on the committee's interpretation of the scope of its work.

Drug: The committee defines the term drug to include any psychotropic



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Under the Influence? Drugs and the American Work Force Summary: Conclusions and Recommendations This report is concerned with the implications of drug use for workplace safety and productivity. It examines the prevalence of alcohol and other drug use by the U.S. work force, the impact of such use on job-related behavior, and the effectiveness of workplace drug intervention programs. This emphasis on workplace productivity rather than social consequences affects the purpose, methods, and evaluation criteria used in this report, just as it often affects researchers investigating these issues. THE COMMITTEE'S CHARGE The committee was charged with: (1) analyzing the available research knowledge on the prevalence and etiology of drug consumption by the work force; (2) studying the impact of drug behavior on work performance, productivity, safety, and health; and (3) evaluating the effectiveness, costs, and benefits of organizational drug intervention programs at the work site. DEFINITION OF TERMS Three key terms in the committee's charge require clarification, because their definitions have a significant bearing on the committee's interpretation of the scope of its work. Drug: The committee defines the term drug to include any psychotropic

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Under the Influence? Drugs and the American Work Force substance that, if consumed, will affect a person's psychological status or physiological state or behavior. We consider only substances whose use is problematic enough to represent a meaningful threat to the welfare of individual users or others and whose prevalence is high enough among the work force to have the potential to affect business productivity. The report focuses its attention on general drug class categories, includes alcohol within its scope, and briefly addresses issues surrounding tobacco. Use, Abuse, and Dependence: Drug taking can be classified into one of three categories: (1) use, (2) abuse, and (3) dependence. Use is defined as the limited, controlled consumption of a drug (in terms of frequency and quantity) without significant toxic, adverse physical, or psychological consequences to the user (Glantz, 1992). Regular use of prescribed medications, legal drugs such as nicotine, caffeine, and alcohol, and certain illegal drugs can lead to physiological dependence. This simply means that the abrupt cessation of drug taking produces a set of symptoms called a withdrawal syndrome. The presence of physiological dependence does not necessarily imply abuse or dependence in the behavioral sense. Abuse is defined as a level of drug use that typically leads to adverse consequences (physical or psychological). Drug use at this level is not necessarily associated with any particular frequency but is associated with use in quantities sufficient to result in some toxicity to the user, and the patterns of use usually have some characteristics of psychopathological behavior. Dependence in the behavioral sense is defined as a level of drug use that has significant adverse physical and psychological consequences. This level of use is characterized by the consumption of toxic doses of the drug that impair the user's ability to function and is also characterized by a compulsive desire to use a drug repeatedly. Work Force: Although one might confine the question of alcohol and other drug use by the work force to the use of those substances by employees while at work, the committee believes its charge requires a more encompassing definition. By work force we mean to include any active member of the labor force, including those seeking or available for employment. Work force alcohol and other drug use is the use of those substances by any work force member, whether the use occurs on or off the job, so long as the use has potential workplace effects. Consequently, issues concerning hangover or residual effects of alcohol and other drugs taken when not at work, as well as correlates of individual alcohol and other drug use and work force participation, are all relevant.

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Under the Influence? Drugs and the American Work Force CONCLUSIONS AND RECOMMENDATIONS Part I: Scope of Alcohol and Other Drug Use Chapter 2 Etiology of Alcohol and Other Drug Use: An Overview of Potential Causes The most vulnerable age and primary risk factors associated with drug use initiation typically precede an individual's entry into the work force. This fact has important implications for work-related prevention interventions designed to prevent the onset of drug use. This means that workplace interventions may have only limited effects on preventing initiation into most categories of drug use. Most alcohol and other drug users do not develop patterns of clinically defined abuse or dependence. The progression from use to abuse and dependence varies with drug type as well as with factors that are specific to individuals and their environments. It is not possible, however, to predict with great accuracy which alcohol and other drug users will become abusers or will eventually need treatment. If use and abuse have different causes, it follows that they are likely to benefit from different types of interventions, so it is important to further explore the hypothesis that any type of drug use at the work site in fact reflects abuse. Among illicit drug users, polydrug use, most often including the use of alcohol and tobacco, is the norm rather than the exception. Recommendation: In evaluating the impact of alcohol and other drug use on behavior, specific attention should be paid to the actions of drugs in combination. • Based on the sparse empirical evidence accumulated to date, alcohol and other drug use by the work force appears to be more a function of the personal qualities of individuals than of their work environments. However, most studies of why workers use alcohol and other drugs have serious methodological flaws. Hence, the work environment cannot be ruled out as a contributing or interactive factor in generating use among workers or protecting them from it. Recommendation: Research is still needed to sort out the relative impact of the work environment and individual traits on workers' alcohol and other drug use. This research should test realistic theories involving such potential critical variables as drug availability,

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Under the Influence? Drugs and the American Work Force local norms, work stress and attending to such complexities as interaction effects and reverse causation. Chapter 3 Epidemiological Evidence: The Dimensions of the Problem Data sources ranging from self-report questionnaires to urinalysis testing to emergency room visits provide important insights about the use of alcohol and other drugs among members of the general population and the work force. Taken together, the data indicate that, since the late 1970s: The prevalence of illicit drug use among members of the general population and the work force has been decreasing, but continues to affect a sizable proportion of the population, especially young adults. Illicit drug use may be decreasing among occasional users, but it may be stable or even increasing among hard-core users who are generally not well represented in surveys. Heavy alcohol use has been relatively stable over the past several years; rates of heavy drinking have been notably high among young adult men, especially those in the military and among workers in such industries as construction, transportation, and wholesale goods. Cigarette smoking has been declining during the past decade for those 18 and older, but has been relatively stable for youths ages 12 to 17. Illicit drug use is more common among unemployed than employed persons, and weekly alcohol use is highest among young employed workers. Illicit drug use is relatively high among male workers in certain industries such as construction and relatively low among professionals. Given these long-term trends, we must be cautious in attributing short-term changes in alcohol and other drug use in either society or in the work force to specific national efforts to stem the use of drugs. Few epidemiological studies are targeted directly at the work force, leaving researchers to rely on data sources designed for other uses. Recommendation: More focused epidemiological studies, including longitudinal studies, are needed to assess the magnitude and severity of alcohol and other drug use among the work force. As a first step, the National Household Surveys on Drug Abuse should be modified to provide specific information about job characteristics, job-related behaviors, and alcohol and other drug use at work. Ultimately a national panel survey devoted to this topic should be instituted. In addition, other studies are needed that provide better

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Under the Influence? Drugs and the American Work Force information about: (1) employment patterns among persons who use alcohol and other drugs; (2) patterns of alcohol and other drug use among workers; (3) patterns of use in heavily using populations to better understand the employment history and work experience of these individuals; and (4) the impact of illicit drug use and heavy alcohol use on work activity. Although the workplace offers a unique opportunity to obtain leverage on the alcohol and other drug problems of some users, there are many serious alcohol and other drug abusers who are not regularly employed, if they are employed at all. In 1990, approximately 7 percent of workers reported having used an illicit drug and approximately 6 percent reported having drunk heavily in the past month, compared with 14 percent and 6 percent, respectively, for the unemployed. Given the relative low base rate of alcohol and other drug abusers in the employed segment of the work force compared with other selected populations, postemployment workplace alcohol and other drug interventions may help a limited number of abusers, but workplace-oriented interventions cannot solve society's problems with alcohol and other drugs. Alcohol and tobacco are the drugs most widely abused by members of the U.S. work force. The adverse health consequences of these drugs are well known. In terms of prevalence rates of work force use and perceived effects of use on performance, alcohol is more likely to have adverse consequences. Recommendation: Any program that addresses drug use by the work force should include alcohol, the drug most associated with perceived detrimental job performance, as a priority. Rates of self-reported alcohol and other drug use on the job vary according to occupation, age, gender, and ethnicity. Excluding tobacco and caffeine, most surveys find that fewer than 10 percent of workers report having used alcohol or other drugs while on the job during the prior year. Some studies, however, report significantly higher usage rates. Much of the difference in the reported rates appears attributable to differences in the samples surveyed and the questions asked. Recommendation: It is important to investigate alcohol and other drug use in different well-specified samples and to develop benchmark measures to allow findings that are comparable across studies.

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Under the Influence? Drugs and the American Work Force Part II: Effects of Use Chapter 4 Impact of Alcohol and Other Drug Use: Laboratory Studies • Laboratory studies of the effects of alcohol and other drugs on behavior have shown inconsistent results. These differences may be due, in part, to differences in the populations tested, the measurements used, and the range of drug doses administered. Recommendation: Benchmark measures should be included in laboratory studies to permit generalization across studies. Funding agencies should consider holding conferences to establish such benchmarks. Laboratory studies show small performance-enhancing effects of commonly used doses of cocaine and other stimulants. Commonly used doses of marijuana produce variable decrements in performance. Alcohol and prescribed sedatives produce decreases in performance depending on the dose, time of consumption, and the time-course of circulating concentrations of the drug's active metabolites, relative to the work schedule. All drug effects are influenced by dose and prior experience. The age of individuals and the presence of other drugs may also mediate the influence of particular drugs. • The use of alcohol and other drugs away from the work site, including prescription drugs and over-the-counter medication, may have detrimental effects during work, especially for those in safety-sensitive positions. Thus, a long-acting drug taken the night before work or alcohol taken at lunch away from the job may have on-the-job effects like those of drugs taken at the work site. In addition, cessation of drug use may produce either withdrawal or hangover effects that affect work site performance. To date there has been little research directed toward any of these issues. Recommendation: Researchers and funding agencies should devote more attention to the ways in which prescription and over-the-counter medications affect job performance, especially for safety-sensitive positions. Recommendation: Studies of work site alcohol and other drug use should encompass off-site use that may have on-the-job effects. Hangover and withdrawal effects should also be considered in assessing the workplace implications of alcohol and other drug use.

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Under the Influence? Drugs and the American Work Force Chapter 5 Impact of Alcohol and Other Drug Use: Observational/Field Studies Field studies have consistently linked alcohol and other drug use to higher rates of absenteeism; they also provide evidence of an association between alcohol (and perhaps other drug) use and increased rates of accidents, particularly in the transportation industry. Less consistent evidence exists linking alcohol and other drug use to other negative work behaviors, although the current research base is insufficient to support firm conclusions. When associations between alcohol and other drug use and counterproductive workplace behavior are found, relationships are most often of moderate or low strength even when they are statistically significant. The empirical relationships found between alcohol and other drug use and job performance are complex and need not imply causation. Relationships may exist for some job performance outcomes like absenteeism but not for others. Alcohol and other drug use may be just one among many characteristics of a more deviant lifestyle, and associations between use and degraded job performance may be due not to drug-related impairment but to general deviance or other factors. Recommendation: To intervene more effectively in improving job performance, we must develop a better research base from which to assess how alcohol and other drug use and other factors act alone and in combination to degrade job performance. • Widely cited cost estimates of the effects of alcohol and other drug use on U.S. productivity are based on questionable assumptions and weak measures. Moreover, these cost-of-drug-use studies do not provide estimates of potential savings associated with implementing particular public policies toward alcohol and other drugs. Recommendation: Further research is needed to develop refined, defensible estimates of how much alcohol and other drug use costs specific organizations and society at large. Business decision makers and policy makers should be cautious in making decisions on the basis of the evidence currently available. Part III: Effectiveness of Workplace Interventions Chapter 6 Detecting and Assessing Alcohol and Other Drug Use • Methods approved by the National Institute on Drug Abuse (NIDA) for detecting drugs and their metabolites in urine are sensitive and accurate.

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Under the Influence? Drugs and the American Work Force Urine collections systems are a critical component of the drug-testing process, but they are the most vulnerable to interference or tampering. Positive results, at concentrations greater than or equal to NIDA-specified thresholds, reliably indicate prior drug use. There is, however, room for further improvement along the lines of the recommendations emanating from the 1989 Consensus Report on Employee Drug Testing and the 1992 On-Site Drug Testing Study. Moreover, more could be learned about laboratory strengths and problems if data already collected in the Department of Defense and NIDA blind quality control and proficiency test programs were properly evaluated. Recommendation: To obtain accurate test results, all work-related urine tests, including applicant tests, should be conducted using procedural safeguards and quality control standards similar to those put forth by NIDA. All laboratories, including on-site workplace testing facilities, should be required to meet these standards of practice, whether or not they are certified under HHS-NIDA guidelines. Recommendation: The extensive data on the reliability of laboratory drug-testing results that have been accumulated by the DoD and NIDA blind performance testing programs should be analyzed by independent investigators and the findings of their analyses published in the scientific literature. • Government standards have improved the quality of laboratory practices; however, the inflexibility and the difficulty of making prompt changes to established government regulations may inhibit the development of new analytical techniques and better experimental-based procedures. Strict regulation of drug-testing procedures and the National Laboratory Certification Programs are nonetheless justified. High-volume, production-oriented drugtesting laboratory operations require the vigilant forensic quality control of routine repetitive procedures, rather than innovative experimental science. Strict regulation need not, however, mean bureaucratic inflexibility that pointlessly increases costs or retards progress, nor should it interfere with research designed to improve current urine testing procedures or efforts to develop reliable tests using specimens other than urine. Recommendation: Within a regime of strict quality control, allowances should be made for variations in procedures so long as they do not compromise standards and they do reflect professional judgments of laboratory directors and forensic toxicologists about what is required to meet individual program needs. No laboratory should be penalized for any practice that is clearly an improvement on or

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Under the Influence? Drugs and the American Work Force beyond what is required by the HHS-NIDA guidelines. When such innovations are attempted, data on their performance should be systematically collected and shared with NIDA. NIDA should take the lead in disseminating to all laboratories information about such improvements and should provide advice promptly as problems, research results, and new data become available. • At present, urine remains the best-understood specimen for evaluation of drug use, and it is the easiest to analyze. Thus, it must for the moment remain the specimen of choice in employee drug-testing programs. However, other specimens have potential advantages over urine in that they involve less intrusive collection procedures or have a longer detection period. Recommendation: Researchers should be encouraged to evaluate the utility of using specimens other than urine, such as head hair and saliva, for the detection of drugs and their metabolites. • There has been an unnecessary proliferation of drugs included in the urine test battery. Testing for LSD and sedative drugs, for example, is not always justified. Recommendation: Additional drugs should not be added to the drug-testing panel without some justification based on epidemiological data for the industry and region. The analytical methods used to identify additional drugs should meet existing NIDA technical criteria. • Preemployment drug testing may have serious consequences for job applicants. Applicants, unlike most employees, often do not enjoy safeguards commensurate with these consequences. A particular danger of unfairness arises because screening test data are often reported to companies despite the known possibility of false positive classification errors. Recommendation: No positive drug test result should be reported for a job applicant until a positive screening test has been confirmed by GC/MS technology. If a positive test result is reported by the laboratory, the applicant should be properly informed and should have an opportunity to challenge such results, including access to a medical review officer or other qualified individual to assist in the interpretation of positive results, before the information is given to those who will make the hiring decision.

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Under the Influence? Drugs and the American Work Force • Drug-testing results may reveal drugs taken legally for medical treatment that do not seriously affect an employee's job performance. These drugs may, however, be associated with conditions that the employee for good reasons wishes to keep private. Recommendation: In the absence of a strong detrimental link to job performance, legally prescribed or over-the-counter medications detected by drug testing should not be reported to employers. Furthermore, such results should not be made part of any employment record, except confidential health records with the employee's permission. • Alcohol and other drug use by work force members cannot be reliably inferred from performance assessments, since performance decrements may have many antecedents. Conversely, performance decrements are often not obvious despite alcohol and other drug use. More direct measures of the likely quality of worker performance hold promise for determining workers' fitness to perform specific jobs at specific times, regardless of the potential cause of impairment. Efforts to identify such measures, however, are still in their infancy. Recommendation: If an organization's goal is to avoid work decrement (e.g., accidents, injuries, performance level) due to impairment, then research should be conducted on the utility of performance tests prior to starting work as an alternative to alcohol and other drug tests. • Integrity testing and personality profiles do not provide accurate measures of individual alcohol and other drug use and have not been adequately evaluated as predictors or proxy measures of use. Using these tests to aid in employment decisions involves a significant risk of falsely identifying some individuals as users and missing others who actually use drugs. The accuracy of these tests is affected not only by their validity but also by the characteristics of the population being tested. Urine tests, by contrast, can be quite accurate in detecting recent drug use. Recommendation: If an organization treats alcohol and other drug use as a hiring criterion, it should rely on urinalysis testing that conforms with NIDA guidelines to detect use rather than on personality profiles or paper-and-pencil tests.

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Under the Influence? Drugs and the American Work Force Chapter 7 Impact of Drug-Testing Programs on Productivity The empirical evidence pertaining to the efficacy of preemployment drug testing indicates that such programs may be useful to employers in choosing wisely among job applicants. However, regardless of the magnitude of the correlations between drug use and dysfunctional job behavior measures, the practical effectiveness of any drug-testing program depends on other parameters, such as the prevalence of drug use in the population tested. The presence of significant relationships between drug use and workplace performance measures does not necessarily mean that an effective drug-testing program will substantially improve work force performance, and a program that substantially improves performance with some employees or in some job settings may do little to improve performance with other employees or in other job settings. Despite beliefs to the contrary, the preventive effects of drug-testing programs have never been adequately demonstrated. Although, there are some suggestive data (e.g., see the military data in Chapter 3) that allude to the deterrent effect of employment drug-testing programs, there is as yet no conclusive scientific evidence from properly controlled studies that employment drug-testing programs widely discourage drug use or encourage rehabilitation. Recommendation: Longitudinal research should be conducted to determine whether drug-testing programs have deterrent effects. Many studies of alcohol and other drug use by the work force have been flawed in their designs and implementation. Organizations that conduct their own drug studies can, by encouraging their researchers to publish in professional journals, enhance quality control and contribute to a knowledge base that will enable them to deal more effectively with future alcohol and other drug problems. Different objectives have been suggested for work site drug testing and diverse alcohol and other drug intervention programs. These include improving workers' performance, preventing accidents, saving on health costs, and working toward a drug-free society by deterring drug use. The effectiveness of alcohol and other drug intervention programs cannot be adequately evaluated unless the goals of such programs are clear. Recommendation: Organizations should clearly articulate their objectives prior to initiating alcohol and other drug intervention programs and should regularly evaluate their programs in light of these objectives.

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Under the Influence? Drugs and the American Work Force Among job applicants and workers, testing for drugs other than alcohol is already common and generally accepted. Of young men in a 1991 general population survey of high school graduates, 33 percent reported that they had been tested, 61 percent reported that they approved of preemployment testing, and 60 percent reported that they approved of postemployment testing. Approval rates were even higher among those who had been tested. • Very little is known about what happens to job applicants who are not hired or to employees who are fired as a consequence of a positive drug test. Recommendation: Research should be conducted on the impact of drug-testing programs with attention to those who remain within the organization as well as to those who are not hired or are dismissed. In particular, more information is needed about the impact of drug-testing programs on the health and productivity of the work force. Recommendation: In light of the relatively low rates of alcohol and other drug abuse among the work force (see Chapter 3), the moderate predictive validity of testing programs (see Chapter 7), and the fact that many factors other than drug use may cause performance deficiencies seen in drug users (see Chapter 5), drug-testing programs should not be viewed as a panacea for curing workplace performance problems. Nonetheless, drug testing for safety-sensitive positions may still be justified in the interest of public safety. Chapter 8 Employee Assistance Programs • Recovery from alcoholism and other drug use disorders is a process that can take months or years of continuing care. The continuing abuse of alcohol or other drugs is a chronic disorder, and the evidence suggests that the ameliorative effects of brief treatments without follow-up are seldom sustained over the long run. Employee assistance programs (EAPs) are well situated to oversee that follow-up, which is essential to a long-term recovery. Recommendation: Because of high dropout rates in substance abuse treatment programs, EAPs should monitor treatment participation and provide for long-term follow-up. • EAPs are not generic across work sites. EAPs should and do vary across work sites and over time. Thus, it is misguided to ask whether the generic EAP is an effective program.

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Under the Influence? Drugs and the American Work Force Recommendation: EAPs should be evaluated in terms of the amount and quality (including process evaluation) of the services they provide and not just by patient count. Researchers should seek to understand how EAPs contribute to a range of different outcomes in a range of different settings. This requires more high-quality critical case studies of EAPs, perhaps with some common criteria of programmatic effectiveness. Care must be taken to secure adequate control groups, and, rather than attempting to evaluate the overall effectiveness of supposedly static programs, attention should be paid to the effects of particular EAP services and their dynamic nature. • Given the measurement limitations of drug test results in assessing drug abuse or dependence (see Chapter 6), not all individuals testing positive require or are likely to benefit from treatment, counseling, or other administrative actions that might be triggered by a positive drug test result. Blanket rules referring all positive-testing employees to treatment can be costly to employers without providing commensurate benefits to them or their employees. Care is required to determine the appropriate course of action in the event of a positive test. Recommendation: Persons reviewing test results should be required to demonstrate expertise with respect to toxicology, pharmacology, and occupational medicine. Standards should be set and continuing education and certification should be required. Such individuals should be involved in the interpretation of the results of drug-testing programs, and in the case of positive postemployment tests, should assist other professional staff in interpreting the seriousness of revealed drug use and provide guidance in determining the best course of action for coping with any drug problems (e.g., evaluation referral to proper medical specialist if needed). Appendix A Methodological Issues • The most powerful methodology for evaluating the effectiveness of workplace alcohol and other drug intervention programs is the randomized field experiment. The implementation of new work site alcohol and other drug intervention programs or significant changes in existing programs provide propitious occasions for experimental assessment. Recommendation: To enhance scientific knowledge, organizations instituting new work site alcohol and other drug intervention programs should proceed experimentally if possible. Funding agencies

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Under the Influence? Drugs and the American Work Force should make field experiments a priority and should consider providing start-up aid to private companies that are willing to institute programs experimentally and subject them to independent evaluation. REFERENCE Glantz, M.D. 1992 A developmental psychopathology model of drug abuse vulnerability. Pp. 389-418 in M. Glantz and R. Pickens, eds., Vulnerability of Drug Abuse. Washington, D.C.: American Psychological Association.