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Institute of Medicine (US) Committee for the Substance Abuse Coverage Study; Gerstein DR, Harwood HJ, editors. Treating Drug Problems: Volume 2: Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment. Washington (DC): National Academies Press (US); 1992.

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Treating Drug Problems: Volume 2: Commissioned Papers on Historical, Institutional, and Economic Contexts of Drug Treatment.

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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 responses 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 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 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 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 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 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 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 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 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 distribution, 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 for using drugs at work; New York Telephone was using private plainclothesmen to identify "dope-pushing rings," and the company had recently fired 55 employees because of their involvement with narcotics. In addition, "Wall Street firms" were reported to have a ''big problem" with drugs among their younger employees. This article viewed the drug problem as "new" and therefore difficult for companies to understand and combat. It stated that, whereas objective detection for heroin use was possible through urine screening, other drugs could not be detected easily; it suggested that companies should fear widespread law-breaking by their employees and the possibility that employees' drug use would lead to theft and other dishonesty. Furthermore, the effectiveness of treatment intervention was regarded as very poor. Another article in the New York Times (Wilcke, 1970) highlights a theme prominent during this period of concern about workplace drug abuse: that drug problems have moved from the ghetto to the work-place.

For another example, the first author was a speaker at a February 1971 program in New York City sponsored by Advanced Management Research International, Inc. The seminar, designed for corporate executives, was entitled "Narcotics and Drugs in Business: Their Phenomenal Economic Impact, How to Stop the Profit Drain." Much of the program's content focused on theft and the detection of drug rings operating on company premises. Some share of the focus was also on the poor job performance of drug users, the safety hazards they created, and their morale impact on co-workers in terms of creating fear. The strategies presented to deal with the problem were both pre-and postemployment screening; identification by supervisors of the symptoms of drug use; beefing up company security to detect both drug abusers, drug distribution, and drug-related thefts; and corporate education programs designed to create "an employee force that . . . will ultimately form the internal network that forces drugs from your company." This two-day seminar program included nothing about the possibilities of treatment or rehabilitation, although these topics did emerge during discussion at the conference.

In the early 1970s the vast majority of materials in the mass media were emphasizing the threatening nature of the entry of drugs into the workplace. There is little doubt that the employed drug abuser was being situated primarily in a criminological framework. There was, however, early attention to treatment possibilities. This emphasis came from two sources. First, as indicated in a program from a three-day conference on drug abuse in industry in Philadelphia in May 1970, there was a major section of the program devoted to treatment and rehabilitation of the drug abuser. These presentations were made by directors of in-house corporate alcoholism programs. Second, the Philadelphia conference included a presentation by Leo Perlis, then director of the AFL-CIO Department of Community Services, who emphasized labor's commitment to a treatment approach to deal with the employed drug abuser. This was followed by a New York Times article in October 1970 describing the establishment in New York City of referral centers for drug-abusing union members as well as the initiation of a campaign to encourage the negotiators of union contracts to include health insurance coverage for the treatment of drug problems.

Other evidence of the interest in workplace drug abuse during this period was the publication of two books directed toward the workplace (Chambers and Heckman, 1972; Trice and Roman, 1972). The former volume is more in the vein of a "hard-line" approach with an emphasis on detection and screening and considerably less discussion about rehabilitation. The latter volume, co-authored by one of the present authors, was originally drafted with a sole focus on alcohol problems in the workplace. Several of the reviewers of the developing draft urged the inclusion of workplace drug abuse, a suggestion that was followed even though other reviewers urged exclusive attention to alcohol problems. The resulting book was primarily a sociocultural analysis of the work-relevant features of alcohol and other drugs. It was oriented toward emphasizing the gravity of workplace alcohol problems as compared with drug problems, arguing that serious drug abusers were not as likely to appear in the work force as the media suggested, that effective strategies for dealing with alcohol and drug problems in the workplace were very similar, and that a medicalized treatment strategy was a preferable option to punitive approaches.

As part of the federal drug legislation, a National Commission on Marihuana and Drug Abuse was established, and it produced two reports. The second of these, a comprehensive and scholarly volume entitled Drug Use in America: Problem in Perspective (National Commission on Marihuana and Drug Abuse, 1973), is of present interest because of its inclusion of commentary and recommendations regarding workplace drug abuse. The notable features of this inclusion are the brevity of the workplace-relevant discussion (approximately 4 pages out of a 485-page volume), its clarity, its "isolation" from the other observations and recommendations in the volume, and the apparent lack of impact that the recommendations produced. Because of the prominence of this document and its intended role as a major influence on both public and private policy, the workplace-related observations (National Commission on Marihuana and Drug Abuse, 1973:384-387, 480) are worth detailed attention.

The report observes that increased employee drug use seems to be a recent phenomenon that employers generally choose to ignore. It summarizes a study by the Conference Board (Rush and Brown, 1971) that revealed

(1)

considerable interest and concern about the drug abuse problem in a selected group of firms,

(2)

a perception that heroin use among employees was relatively uncommon,

(3)

that the drug problem was greater for firms in large urban centers than for firms in smaller, less urbanized areas,

(4)

that the response to the drug-abusing employee is substantially "sterner" than that to the alcohol abuser,

(5)

that about 40 percent of the surveyed companies do not follow any particular pattern in dealing with drug abusers, and

(6)

that about one-third of the companies offer counseling or treatment and about a quarter immediately dismiss such employees. The Conference Board study also indicated that very few companies had formal written policies dealing with employee drug abuse. The commission conducted its own small study of 45 companies, finding that two-thirds reported no significant employee drug abuse problem and fewer than half intended to take any formal policy or programmatic steps.

The commission offered six distinctive recommendations:

(1)

management and labor should cooperatively undertake a comprehensive study of employee drug use and related behavior;

(2)

when "the nature of the business allows," employees with drug abuse problems should be referred to a counseling or rehabilitation program rather than be terminated;

(3)

in dealing with employee drug abuse, the business community should consider adopting "employee assistance" programs, using a management control system based on impaired job performance and attempting to treat the causes of the poor performance;

(4)

any such counseling or treatment should be fully confidential;

(5)

no job applicant should be rejected solely on the basis of prior drug use or dependence, unless the nature of the business compels management to do so; and

(6)

when preemployment drug screening is necessary, companies should establish appropriate procedures, including physical examination, and the results should be kept confidential.

It is noteworthy that these recommendations, seemingly somewhat more "liberal" than more recent recommendations emanating from the federal establishment, were published more than 15 years ago. As mentioned, these recommendations constituted only a tiny portion of this major report and were far from being given "top billing." That workplace programming was not a high priority in the emerging "drug abuse industry" is reflected by total absence of any mention of employment or workplaces in the prestigious report of the Drug Abuse Survey Project (1972) that had been supported by the Ford Foundation.

Why the Concern with Employee Drug Abuse?

What social forces underlay this interest in workplace drug abuse problems in the early 1970s, and why did this fledgling interest seem to "play itself out" until its reemergence in a different form in the mid-1980s? The glib answer to the question of the social sources of this movement is concern over the drug-using behaviors of the youthful cohort that was beginning to enter the work-place at about this time. This is surely one of the factors, but there are more subtle forces that deserve attention.

The first of these is the entry of additional numbers of minority group members into "mainline" employment in the late 1960s and early 1970s through the implementation of affirmative action programs. Whereas employment demands had previously led to the employment of many members of minority groups, affirmative action increased these numbers while notably introducing legal mandates to ensure equal opportunities for promotion and advancement. A careful reading of the media reports of the period reveals a concern over minorities bringing drug-using behaviors to the workplace, a practice that it was believed could spread throughout the workplace in almost contagious fashion.

A second force, related to the first, was the relatively large-scale implementation of methadone maintenance programs for opiate addicts (Trice and Roman, 1972; Scher, 1973), primarily in the Northeast metropolises, and primarily among minority group members. One of the major advantages of methadone was its presumed facilitation of the addict's entry into the work force and his or her movement back toward respectability. Again, a quite subtle fear in some workplaces that employees on methadone maintenance would enter the work force and then resume and spread their opiate-using behaviors was a factor that supported the concept of preemployment screening. A third factor, which was not widely evident until later in the 1970s, was employers' concerns about the drug habits of veterans of the Southeast Asian conflict. This item was part of the agenda of the 1971 conference sponsored by Advanced Management Research (see previous section) and is mentioned, albeit subtly, in other publications. Fourth is the influence of the drug detection industry, which was fairly minor in the early 1970s but which had much to gain, were it to convince employers that biochemical screening for evidence of drug use should be widely adopted.

Given the apparent potency of these forces, what accounts for the absence of wide-spread adoption of workplace programs to deal with drug abuse in the early 1970s? It would appear that many critical "ingredients" were present, yet there is little or no evidence that corporate America was ready to implement these interventions on a large scale. The first and foremost explanation is the level of development of the technology necessary for this implementation. It is assumed that some form of DSP or EAP, or both, would be the basis for such programming. As is elaborated in the following section, EAPs were only in their infancy in the early 1970s, and it would be some time before there was consensus within workplace management that these basic techniques of intervention should extend beyond alcohol problems. It cannot be concluded that either EAPs were widely "in place" at this time or that corporate leaders were widely receptive to them (Roman, 1981).

It is also apparent that there was far from full confidence in the screening technology essential for DSPs. Although objective techniques of drug screening had definitely been developed by this time, they were largely limited to detection of opiates through urinalysis. It was clear that there was considerable concern about the accuracy of this testing (Wald and Hutt, 1972) and that there was little confidence in its claims to detect drugs other than opiates. Some initial discussion was under way regarding the use of gas chromatography/mass spectrometry to identify drugs other than opiates, but this technique appeared to be far too expensive for administration on a large scale. Thus, the basic technology for the widespread implementation of efforts to deal with drug abuse in the workplace was simply not in place.

Second, despite the recommendations of the "blue-ribbon" National Commission on Marihuana and Drug Abuse, there was little evidence of the commitment of public resources to try to promote or facilitate the development of intervention efforts in the workplace. Furthermore, had there been such resources, there was no model to guide their utilization. At this time the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was in the very early stages of designing and implementing a nationwide network of consultants and demonstration projects to promote work-based programs, which initially had alcohol problems as their primary concern. It was some time before there was knowledge about the effectiveness of this strategy. Closely linked to the absence of resources is the absence of a constituency group to promote attention or the allocation of public resources to deal with drug abuse problems in the workplace. It is clear from many other social policy developments that government action and constituency pressure are interdependent.

A third explanation is that the workplace simply did not have a base of experience to provide "readiness" for the implementation of interventions to deal with employee behavioral problems. As mentioned, EAP diffusion was only beginning, and relatively few organizations had programs in place to deal with employee alcohol problems. Thus, from this perspective, there also was no foundation in place. In this regard it may be important to note that the "mixed messages" regarding drug abuse as a deviant/criminal activity versus its being a problem deserving medically based attention reduced the clarity with which action might have been taken.

Fourth, as is reflected in some of the survey information collected by the federal commission, it is evident that many if not most of the population of American employers did not perceive major drug problems within their workplaces. There simply was no firm research evidence on which to base such a conclusion, and it is clear that the intensity of reaction in the workplace did not match the "hysteria" evident in the brief flurry of mass media attention. The development of a firm research base to describe and differentiate the problem of drug abuse in the American workplace is a task that still remains to be done.

Thus, the significant but brief social attention to the problem of drug abuse in the workplace in the early 1970s did not lead to the large-scale development of programmatic activity. There were, however, a series of developments between the early 1970s and mid-1980s that are somewhat important in understanding current policy and the organizational environment surrounding drug abuse in the workplace.

Developments During the 1970s and Early 1980s

One of the first formal efforts to address employee drug problems was evidenced in the 1973 policy adopted by the U.S. Civil Service Commission (now the Office of Personnel Management) covering all civilian federal employees exclusive of high-security operations. This policy was appended to the Federal Employee Alcoholism Policy, which was issued in 1971. This policy was a mixture of treatment and criminal orientations, with more of an emphasis on the former model. The policy suggested that drug abuse be dealt with through what would essentially be regarded as an EAP strategy, adding rather complex concerns related to criminal prosecution, should drug abuse problems be associated with the sale or distribution of illegal drugs. The policy was made somewhat foreboding by the appendage of detailed confidentiality guidelines that also described the intermingling of treatment and criminal procedures under various scenarios of employee behavior.

While constituting a new federal personnel policy, the Federal Employee Drug Abuse Policy was accompanied by neither mechanisms for the enforcement of the policy's implementation nor resources necessary to support implementation. Federal departments and agencies were strongly encouraged to adopt such programs and provide resources for them, with a modest degree of consultation available through a specialized unit located within the Bureau of Occupational Health and Retirement of the Civil Service Commission. The reality, however, was that each agency had latitude in deciding how to go about program implementation, although in practically all instances the policy statement was made part of personnel management guidelines (Beyer and Trice, 1978; Hoffman and Roman, 1984a).

With some notable exceptions in several federal agencies, the policy produced a substantial number of "paper programs" throughout the federal establishment, with the guidelines in place but with minimal allocation of resources. Thus, there was little of the expertise necessary for realistic program implementation, nor were there structures through which the promises of the policy might be realized. It should be noted that the prevailing pattern of departmental and agency autonomy applied to the alcohol as well as the drug policy and has marked the style of EAP implementation for federal employees up to the present time.

The decade of the 1970s saw substantial efforts to address both alcohol and drug problems in the military. The characteristics of the military recruitment process together with the exposure during tours of duty in Southeast Asia of large numbers of military personnel to drugs that were illegal in the United States, were both factors that brought the issue of drug abuse in the military to the forefront much earlier than for other parts of the work force. The military, however, has mixed interests in publicizing its internal personnel and managerial problems in terms of support from the public, especially when such publicity may be genuinely frightening in its implications about military preparedness. Furthermore, because of the distinctions between the characteristics of the military as a "total institution" and its particular manner of bureaucratic governance, generalization of programming experience from the military to other workplaces has been minimal.

An important development in the early 1970s was the establishment of the National Institute on Drug Abuse, first as a unit within the National Institute of Mental Health, but shortly thereafter emerging as a sister agency to the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Mental Health (NIMH). NIDA's mandate was centered on a medical model of drug addiction and drug-related problems, and it was given authority to award and administer demonstration, treatment, prevention, and research grants that more or less were cast within a medicalized approach to the problems of drugs and drug abuse. NIDA's mandate was theoretically differentiated from the drug abuse unit in the White House, which has been known by various names and acronyms over the years, and is charged with oversight of federal efforts focused on drug enforcement and other criminologically oriented efforts to deal with drug use and abuse.

Yet the reality is that NIDA's activities are not fully medicalized, and there is a definite "criminal flavor" to some of the activities that have been funded by its grants and contracts. The existence of these two bases of activity within the federal government are another illustration of the tension between the medical and criminal approaches to dealing with the nation's drug problem. Beyond these bases for policy execution, even greater fragmentation is found in the distribution of policy formulation responsibilities across a myriad of congressional committees and subcommittees.

During the 1970s and into the early 1980s there was little evidence of either NIDA-supported demonstration projects or research activity focused on drug abuse in the workplace. Exceptions were the funding of several small contracts to the Stanford Research Institute for an overview of activities related to workers' drug abuse in a very small sample of companies and unions, one product of which was a set of guidelines for employers that essentially adapted EAP strategies to deal with employee drug abuse (Stephen and Prentice, 1978; see also Vicary and Resnik, 1982, for a later set of suggestions and guidelines in a pamphlet produced under a NIDA contract). There was, however, no office within NIDA that focused on workplace concerns, nor were there specific personnel within the agency whose mandate was to provide assistance and guidance either to researchers or practitioners interested in this particular dimension of the drug abuse problem.

Lest this be interpreted as deliberate neglect toward the workplace on the part of NIDA, it should be pointed out that there was tacit agreement within the umbrella agency over NIDA, NIAAA, and NIMH that the "lead role" for dealing with workplace issues should be centered in the Occupational Programs Branch of NIAAA. As with many federal interagency agreements and understandings, however, this did not afford direct mechanisms for tapping budgetary support for workplace-related activities from either NIDA or NIMH.

Substantial personnel and programmatic changes occurred throughout all three institutes in 1981. These changes were brought about by the termination of these agencies' authorities for direct funding of service activities through congressional legislation that was strongly supported by the Reagan administration. This legislation transferred much of the programmatic support to block grants to the states, which also gained authority over allocations of these monies. The legislation essentially altered each of the institutes' structures, and they became agencies for the support of research initiated by scientists in the field and, to a much lesser extent, initiators of research projects funded through competitive contracts.

The Office of Worksite Initiatives

Very shortly after the termination of direct support for services, the Reagan administration developed its strong and substantial interest in the drug abuse problem, supported very emphatically by both President and Mrs. Reagan. This interest led in 1985 to the establishment of the Office of Worksite Initiatives (OWI) within NIDA, reflecting the administration's interest and concern with employee drug abuse and the subgoal of a ''drug-free workplace" as part of the goal of a "drug-free America."

OWI's initial mission has been to aid the diffusion and implementation of drug screening in the workplace. A variety of initiatives have been developed, including the drafting of standards and the development of certification for laboratories that process the body fluids taken in the drug screening process. In addition, OWI has funded a large research contract to assess the effectiveness of both pre-and postemployment drug screening, provided support for a "hot-line" to provide informational services to employers desiring to take action regarding drug problems in their workplaces, sponsored several research conferences focused on drug abuse in the work setting, and funded a small number of research grants directed toward better understanding of various aspects of the drug abuse problem in the workplace.

The emergence of OWI occurred simultaneously with three other changes that have all contributed to the rapid growth and expansion of program implementation in the workplace to deal with employee drug abuse. The first of these was the stimulation that the federal drug-free workplace initiative created for the organization and distribution of drug screening technology. Multiple laboratories and consulting organizations emerged very quickly, aggressively promoting their services to employers by using mainly the attention-grabbing technique of focusing on the many dangers and costs related to drug abusers in the workplace. This set of new businesses has functioned as a somewhat autonomous force in promoting the development of workplace screening of all types.

A second development also has a promotional facet and is largely based on opportunities for new revenue and organizational growth. This development is the expansion of for-profit alcoholism treatment programs to cover the treatment of drug abuse. This expansion of interest in broadening the scope of treatment beyond alcoholism began in the 1970s as centers found fewer and fewer "pure alcoholics" among their admissions, a difference closely tied to the age of the patient. Younger clients are very likely to be users of drugs other than alcohol and often show a drug other than alcohol to be their primary drug of choice, even though some degree of alcohol abuse is commonly part of the presenting symptoms of the "polyabuser."

To a large extent this expansion of treatment availability has centered on cocaine dependence, corresponding to the apparently rising incidence of cocaine use among the "respectable" elements of society, many of whom are employed and thus have access to third-party health insurance reimbursement for drug abuse treatment. Treatment for cocaine dependence is quite similar or even identical to that for alcohol abuse, allowing a caseload diversification and expansion within treatment centers without any marked technological innovations. The effectiveness of treatment for cocaine-related problems is presently being challenged, but few data are available. Treatment centers also constitute a somewhat autonomous force in promoting both societal and employer attention to drug abuse problems, although it is clear that their messages frequently contradict or are confused with the messages of those promoting drug screening programs.

The third development occurred within EAPs, namely, the dual emergence of increased numbers of drug abusers in EAP referral caseloads and their host employers' growing interest in dealing with drug abuse problems. The interest of treatment centers in providing services to EAP-referred drug abusers, as well as the increasingly visible presence of promoters of drug screening, contributed to the growing salience of drug abuse issues among EAP service providers, including both internal EAPs and external organizations providing EAP services on a contract basis.

In their attempts to establish a role in workplace programming as well as to develop supportive constituencies, the personnel of NIDA's OWI initiated a variety of interactions with representatives of the EAP field. At first these contacts were not constructive: OWI representatives and some of their drug-testing provider constituents promoted the notion of DSPs as the primary and most important means of dealing with the workplace drug abuse problem, and EAP representatives tended to hold fast to minimizing drug screening and utilizing EAP techniques as the primary modality for dealing with the employed drug abuser. Underlying this relatively short-lived climate of conflict between the two groups were the criminal and medical models of drug abuse problems, with OWI holding a position somewhat between these two models and EAP representatives strongly committed to a medicalized approach.

This conflict was largely resolved by OWI's movement toward a position of EAP advocacy, urging to a degree that offers of assistance through generic EAP mechanisms follow the identification of employed drug abusers through DSP mechanisms. This is not to say that all of the differences have been resolved, but, as described later in this paper, there is clear evidence that EAPs and DSPs can and do coexist and that the potential for genuine cooperation has been at least partially realized in some cases.

Employer Interest in Alcohol Problems

The principal mission of this paper is to offer a broad understanding of the potential contribution of EAPs to efforts to deal with workplace drug abuse. Part of that understanding is centered on the context in which EAPs have arisen and on the foundations for their support. In the decades following the 1930s, slow but gradual changes in the institutional responses to alcohol problem issues became evident. Although a primitive version of the disease concept of alcoholism was present (Levine, 1978), the cultural residue of the prolonged experience with the temperance and prohibition movements, coupled with the preoccupations of the Great Depression, was a disinterest in problems of alcohol abuse and alcoholism. Change became evident when Alcoholics Anonymous (AA) demonstrated that simple and explicit ''steps," coupled with an environment of acceptance and support, could produce recovery from alcoholism. Despite its apparent simplicity, one of the fascinating ironies of the AA strategy is the necessity of its reliance on a medical model of alcoholism (Trice and Roman, 1970). This attachment to a medicalized concept has been critical for the broader roles AA has played in facilitating the growth of alcoholism intervention, especially in the workplace.

The steady entry of recovering alcoholics into the fabric of "normal" society, with these persons representing all social class segments, provided a sort of verification of the AA strategy and its disease model foundations. These processes were facilitated by the activities of the National Council on Alcoholism (NCA) designed to educate the public about the treatability of alcoholism, the illness (Sonnenstuhl and Trice, 1986). It is important to note that there has never been a highly visible, reputable coterie of recovering drug addicts who have paralleled AA's organizational activities, nor has there been a voluntary organization centered on a disease concept of drug addiction paralleling NCA. Among NCA's activities was the promotion of the workplace as a setting for alcoholism rehabilitation (Presnall, 1981; Trice and Schonbrunn, 1981).

Without an adequate survey data base, it is difficult to evaluate the success of NCA's efforts in terms of public attitude change by the end of the 1960s. One notable consequence of these efforts, which some regard as extremely important in creating the eventual broadening of the concept of alcoholism as a treatable illness affecting large numbers of the population, was the legislative decision within the American Medical Association in 1955 to regard alcoholism as an illness. Furthermore, organized labor had an early interest and involvement in the activities of NCA at both the national and local levels, and there is no doubt that labor's early efforts at some bargaining tables to provide coverage for alcoholism treatment created both a foundation and an impetus for later efforts. It is definitely to NCA's credit that by the end of the 1960s many states had some form of effort to provide treatment services for alcoholism, but the image of most of these services was their availability to public inebriates.

In many ways based on the influence structures of NCA, and facilitated by the presence in the U.S. Senate of Harold Hughes of Iowa whose openness about his own recovery experience was reflected in political advocacy (Beauchamp, 1980), the alcoholism-as-a-disease movement achieved what appeared to be a major triumph in the establishment of NIAAA in December 1970. Although this move resulted in part from the influence structures of NCA, one should not underestimate the direct impact of the persistence and charisma of Senator Hughes, who in organizational terms was a critical "idea champion." Nevertheless, care should also be taken to recognize the many unheralded giants of the past in AA, NCA, and organized labor on whose shoulders Senator Hughes was able to stand.

In some very significant ways, NIAAA represented a continuation of the activities of NCA. As a federal agency, however, its personnel were recruited through open bureaucratic procedures that resulted in the presence of very few recovering alcoholics on the NIAAA staff. More importantly, it brought to the alcoholism field many times the resources than had previously been available. These resources included funds for public education about alcoholism, which could build on NCA's earlier activities. However, both the projects mandated by NIAA's enabling legislation and its own initiatives went far beyond the scope of the efforts in which NCA had been engaged, most of which were concentrated at the level of local affiliate councils rather than as campaigns or programs of national visibility.

Despite the interrelationships in the early days of NIAAA's development, NCA leaders later became extremely critical and disappointed in NIAAA's pursuit of its perceived mission. This disappointment was generally not the case for funding from NIAAA to NCA for workplace-related programming, for in this area the NIAAA monies were extremely generous and, indeed, permitted NCA broad latitude to test a particular labor-management programming model, albeit with limited success.

The mission of NIAAA is captured in the goal of mainstreaming alcoholism into the health care delivery system, a goal that might be viewed as continuous with NCA's long-term efforts to medicalize public attitudes. In contrast to NCA, NIAAA had access to resources through demonstration project grants and other grant mechanisms, which led to a considerable increase in the availability of alcoholism treatment services directed toward the norms and lifestyles of the middle classes and in health insurance coverage to pay for those services. The demonstration projects had the effect of generating constituency groups to lobby for NIAAA's funding and to provide other support for the mainstreaming effort. It is not correct, however, to infer that these demonstration projects or contract support emanating from NIAAA were the direct precursors of the large number of specialized, freestanding alcoholism treatment centers that arose during the 1970s.

For patients to flow into these centers, health insurance coverage for alcoholism treatment was essential, and it was here that NIAAA's impact was the greatest. The institute offered strong encouragement through formula grants, project grant support, and, ultimately, state-directed incentive grants to support state-level lobbying efforts to mandate health insurance coverage for alcoholism treatment. All of these efforts were critical to mainstreaming, but without a reliable source of clients covered by health insurance, there was little prospect for the system's growth and independent sustenance.

An additional element—routes for access by patients covered by health insurance—was necessary if alcoholism treatment paid for by third-party payers was to be utilized on a large enough scale to be a cost-effective addition to the health care system. It is here that the role of workplace programming becomes evident, for the employed population is most likely to be covered by health insurance and to be attracted to treatment facilities that are designed for working-and middle-class clients. Thus, the introduction, on a large scale, of referral routes for employed clients was critical if the mainstreaming process was to be successful. Although it was possible to target families and friends of alcoholics as the sources of referral and to undertake large-scale educational programs to encourage such actions, the use of the industrial alcoholism program model as a means for creating these routes was very attractive and had an established track record of success (Presnall, 1981).

A crucial ingredient in NIAAA's construction of a new political economy of alcoholism intervention is what has elsewhere been called the "new epidemiology" of alcoholism (Roman and Blum, 1987a). The temperance movement's contribution to American culture was the notion of inevitable downward mobility accompanying enslavement to alcohol use (Gusfield, 1958), a construct that has been viewed more or less as a precursor to the disease concept of alcoholism (Levine, 1978). The imagery of the alcohol-troubled person in the immediate post-Prohibition era was the skid row bum.

The visibility of skid row inebriates in many American cities supported this image and offered an ambulatory moral lesson for the public (Rubington, 1974). Whereas AA had contributed many recovered alcoholics of middle and upper status backgrounds, this was only a partial counter to the skid row image. However, NIAAA undertook as a central theme of its public education campaign the idea that alcoholism was a disease affecting all social classes, that its unknown biological source put everyone at an unknown level of risk, and that, indeed, at most 5 percent of American alcoholics could be found on skid row (Beauchamp, 1980; Wiener, 1981). Publicity directed in support of the workplace programming movement at one point used the logo "Project 95" to indicate that it was directed at the 95 percent of American alcoholics not on skid row.

It may be parsimonious to view the construction of a new epidemiological distribution of alcohol problems as crucial to the mainstreaming strategy. Acceptance of the belief that alcoholism is found with equal likelihood at all social levels encourages the readiness to identify and refer employed alcoholics, who in turn utilize the new clinical facilities and have their treatment paid for through their health insurance coverage. It is also the case that creation of a new epidemiology created political potentials for the alcoholism field through confirmation that its disease was, indeed, like any other, that everyone could be at risk, and that the social and economic welfare of the larger society was being undermined by agents more insidious than skid row inebriates, namely "hidden alcoholics" (Rubington, 1974).

These "hidden alcoholics" (exemplified by "Sam the Half Man," a cartoon character employee who erodes company profits through his on the-job absenteeism, high scrap rate, and unpredictable behavior that disrupts his work group) were the targets of the workplace intervention programs that were to constitute a major new thrust for NIAAA's support. The initial marketing of workplace programs placed great emphasis on these costs and characterized them as being both hidden and in the billions. Thus, within the new epidemiology, the hidden alcoholic in the work force (and his counterpart in the home, the gin-sipping housewife) came to replace the skid row bum as the "typical" alcoholics, limited not only to blue-collar operatives but with particular attention to the middle or upper level executive with the liquor bottle in the desk drawer.

How does one explain the emergence of the EAP model? First was the necessity for the new workplace-directed effort supported by NIAAA to obtain its own identity, separate from predecessor activities such as the industrial alcoholism promotion effort conducted by NCA. Second, the basis for much of NIAAA's support of the broader program model was the contention that the efforts developed under the industrial alcoholism model fell far short of reaching the employed alcoholic population. This notion, however, remains a contention without a data base and exists despite some evidence to the contrary (Franco, 1960).

Third, there was a related belief that the stigma associated with alcohol problems precluded the success of the workplace effort at two levels: leaders in the workplace would not be receptive to adopting programmatic strategies with an alcoholism label, and the same reluctance would retard the use of such programs by employees. Fourth, the possibility of a greater resource base and broader constituency was envisioned through a combination or intermingling of alcohol problems with other problems targeted by other agencies or organizations. This possibly contributed to the mainstreaming process, although this "force" is less overtly evident than the others.

The EAP model might be very simply summarized as resting on supervisory identification of job performance deterioration that cannot be explained by the conditions of work. Procedures generally call for the supervisor to use some form of constructive confrontation under these conditions. Should the employee elect to use the company program, it is strictly within the purview of the program coordinator to conduct or arrange for a diagnosis of the individual's problem and offer referral advice as to how the problem might be dealt with. Utilization of such assistance remains at the option of the employee, although it is evident that a degree of coercive pressure may characterize the encounters with the EAP as well as the earlier encounter with the supervisors. Should the individual be able to resume job performance after this intervention, routine follow-up occurs for a prescribed period, and the case is closed. Should performance remain below standard, disciplinary action and dismissal may be ultimate outcomes.

The critical difference between this model and the older industrial alcoholism model is the intense emphasis on supervisory avoidance of problem diagnosis and the focus of exclusive attention to job performance issues in dealing with the employee. The critical effect on program outcomes is that the job performance "screen" produces cases of many personal or "behavioral-medical" problems other than substance abuse, making the programs truly directed toward employee assistance.

There is no doubt that NIAAA attached its organizational identity to this innovation, as was demonstrated in an early and widely diffused pamphlet-type publication (NIAAA, 1973). This move coincided with the new occupational group launched with NIAAA funding, the occupational program consultants (OPCs), and the importance of their having an identifiable and distinct ideology as well as a set of theoretical principles to guide their work (Blum, 1988).

The EAP strategy was not developed out of thin air. In part, NIAAA based its program design recommendations on the reports of outcomes associated with the Kennecott Copper "Insight" program, operated by a pioneer industrial social worker and referred to by NIAAA at that time as a "broad-brush" approach. This company's effort to provide assistance to employees with a whole range of personal problems was seen as generating a more desirable level of penetration into employee alcohol problems than was apparently evident in the case records of companies utilizing the industrial alcoholism strategy (Jones, 1975).

The research cited to back the value of the broader, job performance-based model was indirectly supportive at best. One example was a retrospective study of alcoholic employees wherein employees were asked to rate the sequential visibility of their different behaviors during the course of their alcoholism. Although equivocal, these data were taken to indicate that signs of job performance deterioration occur earlier in the alcoholism progression than the stereotypical symptoms of the disorder (Maxwell, 1960). A second effort was a carefully designed experimental study in a single organization. In this research effort, supervisors who received training lectures about troubled employees in general were significantly more likely than subjects who heard lectures about alcoholic employees to report that they would take action regarding hypothetical subordinates with alcohol problems (Trice and Belasco, 1968). The NIAAA interpreters of this study regarded the hypothetical behaviors as proxies for referral to a broadly focused workplace program and thus as support for moving beyond the industrial alcoholism strategy.

Because of fears that proper attention to employee alcohol problems would be diminished, the EAP model was for a time the subject of considerable controversy, but ultimately it was widely diffused and accepted. This diffusion effort played a major role in shaping the contemporary alcoholism intervention enterprise in the United States. It has, however, resulted in some major changes that deserve comment.

The introduction of the EAP model for workplace alcohol abuse programming brought with it a shift in the behavioral expectations for supervisors. Implementation of the performance-based strategy automatically transformed the focus of programs from alcohol abuse to all nonwork factors that could affect job performance. As the program model was implemented across different types of organizations and occupations, an unexpected development occurred. Employees were recorded as coming for program services on a "self-referral" basis, with these rates ballooning rapidly over time to the point that they are the major route for program use in most EAPs today. This trend in turn both reflects and affects the extent to which these programs are effective in dealing with employee alcohol problems. It also has considerable implications for their long-term effectiveness in dealing with employee drug problems.

Scope Of Employee Assistance Programs

Elsewhere the authors have provided a detailed description of the principal functions served by EAPs and their core technology (Roman, 1988b; Blum and Roman, 1989a). These functions are summarized in Table 1.

Table 1. Core Aspects of Employee Assistance Programs.

Table 1

Core Aspects of Employee Assistance Programs.

Employee Assistance Program Distribution

One of the remarkable features of EAPs has been the rapidity of their diffusion across American workplaces. Data on EAP prevalence were initially focused on major corporations (Roman, 1982). In 1972, 25 percent of the Fortune 500 firms had some form of program for providing constructive assistance to problem drinking employees; subsequent surveys revealed these proportions grew to 34 percent in 1974, 50 percent in 1976, and 57 percent in 1979, by which point the survey was asking specifically about the presence of EAPs (Roman, 1982). There are no post-1979 national survey data on the prevalence of EAPs among the Fortune 500 corporations; however, the authors' own and others' informal estimates indicate that nearly all Fortune 500 corporations currently have an EAP. It is also evident that there is great variation in the level of investment in these EAPs.

In 1985 a telephone survey of 1,358 private-sector worksites with 50 or more employees (86 percent response rate) was conducted for the U.S. Department of Health and Human Services, and it revealed that 24 percent of the worksites offered an EAP (Kiefhaber, 1987). Worksite size was significantly associated with the availability of an EAP: 14.8 percent of worksites with fewer than 100 employees had an EAP, compared with 28.1 percent of worksites with 100 to 249 employees; 34.7 percent of worksites with 250 to 749 employees and 51.7 percent of worksites with 750 or more employees provided EAPs.

A survey of 7,500 private-sector nonfarm business establishments was conducted in the summer of 1988 by the U.S. Department of Labor (1989) to collect information on the extent and characteristics of employer-instituted EAPs and drug testing. The survey revealed that 31 percent of employees who work in private-sector nonagricultural establishments have some form of employee assistance program coverage. The survey also revealed that employees in larger organizations were more likely to be employed in organizations that had EAPs. The range of EAP coverage is from 86.8 percent of those who work in organizations with 5,000 or more employees and 71.9 percent of those who work in organizations with 1,000 to 4,999 employees, down to 11.2 percent of those who work in organizations with 10 to 49 employees and 4.2 percent of those who work in organizations with less than 10 employees. Larger organizations are much more likely to have EAPs; most employees, however, work in smaller establishments.

The prevalence of EAPs varied considerably by industry, ranging from a high of 76.1 percent in communications and public utilities establishments to 10.6 percent in construction establishments. The survey also indicated that the majority (55.5 percent) of the EAPs operated through external contracts, whereas 44.5 percent were internal programs.

EAP diffusion is not limited to the large-scale private sector. In the early 1970s, the federal government mandated the establishment of EAPs for all civilian employees, but two research studies that involved onsite assessments and interviews regarding the nature of these programs in samples of federal installations revealed uneven implementation (Beyer and Trice, 1978; Hoffman and Roman, 1984a). Thus, although federal civilian employees are supposed to be covered by EAPs, each federal department or agency is responsible for finding the funds to support the implementation of the service, and enforcement is limited.

Much of the current growth in EAPs is in externally contracted services to accommodate the needs of smaller employers. There are, however, some smaller organizations with internal programs and some larger employers with external programs. A 1988 sample survey in the Atlanta standard metropolitan statistical area (SMSA) directed by the second author of this paper revealed that 55 percent of the worksites with 1,000 or more employees had EAPs, and 65 percent of them were internal programs. Forty percent of worksites with 500 to 749 employees had EAPs, with 80 percent of these programs based on external service contracts.

Patterns of Employee Assistance Program Utilization

Data from the study of 439 internal and external EAPs indicate that an average of 5 percent of employees used the EAP in the 12 months prior to the 1984-1985 data collection. Assuming low turnover and relatively low reutilization of the EAP by the same employees, a substantial number of employees use EAPs over a several-year period. Approximately 30 percent of the caseloads were composed of employee substance abuse cases, with marriage and family problems the largest single caseload category.

Data collected in 1988 from the 1984 panel of internal programs revealed similar utilization rates, with approximately 1.5 percent of a work force using an EAP in a given year for their own alcohol or drug problem. Alcohol, as the primary drug of choice, outnumbered cocaine/ crack as the primary drug of choice by almost 3 to 1 across the EAPs.

The 1984 data from the 439 organizations indicated that an average of 80 percent of the employees who had used the EAP for problems that were not related to substance abuse were on the job with adequate job performance one year after initial contact with the EAP. The comparable rate for alcohol and other drug problems was 66 percent. An average of 8.4 percent of the employee alcohol cases were reported as leaving the job involuntarily within the 12-month period after EAP access, with another 5.2 percent leaving voluntarily. Among the nonsubstance abuse cases, 9 percent left the organization voluntarily. These rates are similar for the internal programs for which data were collected during 1988.

Although alcohol and other drug cases constitute a minority of the EAP caseload (albeit numerically substantial), 54 percent of the EAP coordinators studied in 1988 responded that these cases take much more of their time compared with nonalcohol or drug cases. Another 28 percent responded that these cases take a bit longer. Sixty-five percent of the EAP coordinators indicated that alcohol/drug abuse treatment insurance coverage in their organizations was adequate, with 35 percent claiming that it improved between 1984 and 1988 and another 16 percent claiming it had deteriorated in their organization during the same time period.

Data collected by the present authors in 1988 from 1,961 managers in a southeastern organization with 55,000 employees indicated that 37 percent of the supervisors have formally referred an employee to the EAP at least once during the EAP's 12-year existence (Blum, 1989). In addition, a large proportion of the supervisors have suggested that an employee use the EAP but did not make a formal documented referral.

Supervisory referrals of subordinates were significantly more likely when the managers perceived top management support for the EAP, when they perceived EAP support by their immediate supervisors, when they believed the EAP helped improve organizational productivity, when they believed the EAP was an integral part of the company, and when they were familiar with policies related to the EAP and discipline.

Comparisons of Drug Screening Programs and Eaps

What are the similarities and differences among EAPs and DSPs? Implementation of any type of DSP may be viewed as a ''technological short-cut'' (Etzioni and Remp, 1973) for resolving what is perceived as a threatening intrusion into the organization from the external environment. DSPs are distinctively different from EAPs, both conceptually and strategically, but they share the common goal of providing a means for the employer to cope with the issue of employee substance abuse. The conceptual distinction is that EAP principles call for supervisory intervention only where there is evidence of deteriorating job performance, with the next step holding the employee responsible for correcting the performance decrement. DSPs, on the other hand, use the evidence of drug use as prima facie evidence that intervention is necessary, without the requirement that a performance decrement must be the basis for employer action.

Fitness-for-duty screening may overlap with the EAP in principle in that each is identifying problem employees based on objective criteria. DSPs differ otherwise from EAPs in that referrals to EAPs are based on evidence of job performance deterioration or on self-, peer, or family referral. DSPs, on the other hand, are much more subject to bureaucratic review in terms of specific steps in taking urine samples and testing/ retesting the samples for evidence of drug use. The strategy may thus be seen as less "mystified" than the confidentiality-bound EAP referral.

In contrast to EAPs, DSPs do not rely on professional clinical judgment, confidentiality from management, or employee trust. Indeed, DSPs have objectivity of measurement as their strongest value in contrast to what some might regard as the subjectivity of clinicians' identification of drug abuse "syndromes." It is further noteworthy that employees who are mislabeled through DSPs have a means for collective action and a potentially supportive constituency, whereas dissatisfied EAP clients (generally unknown to one another because of confidentiality) are not likely to form or have access to such a constituency.

EAPs and DSPs may overlap when drug screening is performed for employees who have gone through a treatment program and who are screened as part of a follow-up process to ascertain their abstinence from drugs. Many in the treatment community consider this step part of treatment and thus regard it as separate from other workplace screenings.

In what may be the most important area of overlap for the concerns central to this paper, EAPs can be coordinated with DSPs in that individuals who have verified positive drug screens can be referred for assistance. In unpublished remarks at a small conference of EAP specialists (including the present authors) sponsored by NIDA in May 1987, Dr. D.A Macdonald, the White House special advisor on drug abuse stated that the Reagan administration believed that workplace drug screening would be accepted by the American people only if it were considered fair and humane. Macdonald indicated that this suggested the possibility that the entry of drug screening into the workplace could be coupled with an already acceptable program, the EAP.

If this logic is correct, then medicalizing drug abuse (Roman, 1980) may be necessary for the drug screening technique to be acceptable to the vast majority of employees who do not use illicit drugs. Whereas drug testing may represent bureaucratic social control in the workplace, its acceptability may rest on the social construction of beliefs that co-workers will be helped rather than punished if they test positive for illicit drug use. Yet because drug screening does not measure current use or impairment, or even history of usage, it may be difficult to apply "disease concept" labels to those who screen positive. Not all of those who come up positive need treatment, but medicalized policy statements, especially those advocated by EAP specialists, typically require that those with positive drug screens be offered counseling or rehabilitation. It is assumed in such a model that clinicians associated with an EAP will be able to discriminate effectively between those with positive screens who do and do not need assistance. Nonetheless, clinical screening is notorious for discovering some form of disorder among practically all referrals.

Thus, some individuals may be "unnecessarily" referred to counseling or treatment, with such a judgment variable across clinicians and nonclinicians and their different standards in defining a need for external assistance. This referral to treatment of individuals who may not require intensive treatment or who may not respond to treatment can ultimately contribute to escalating health care benefit costs. There are, of course, organizations that conduct drug screening but that do not offer EAPs before a test is ever performed or after a positive confirmation is made.

The U.S. Department of Labor (1989) survey referred to earlier concerning the prevalence of EAPs also presents data concerning the prevalence of drug testing in private, nonagricultural establishments and the overlap between drug testing and EAPs. The survey indicates that 19.6 percent of employees work in organizations with some form of DSP. The DSP may include only applicant drug testing or combinations of current employee drug testing, or both. The different types of drug screening may refer only to some categories of employees under some categories of conditions, such as probable cause. Drug testing of current employees under conditions of some random selection criteria is very unusual.

The Department of Labor survey can be extrapolated to examine the proportion of employees who work in establishments with DSPs, with the notion of "program" interpreted rather loosely to include organizations that have adopted policies but that have not actually implemented them by testing anyone or by testing anyone after an initial set of screenings. Thirty percent of employees who work in organizations that have DSPs, which may not even apply to them or other current employees, work for organizations that do not provide EAPs. More than one-half of the employees who work in organizations that have fewer than 250 employees and that have drug-testing programs are in settings that do not provide EAPs. This proportion may be compared with the 27 percent of employees in organizations with between 250 and 999 employees in which there is a DSP but not an EAP. More than 16 percent of those who work in establishments with 1,000 to 4,999 employees and 5 percent of those who work in establishments with more than 5,000 employees are in organizational settings that have DSPs but that do not offer EAPs.

The issue of drug testing without offering assistance to job applicants who test positive may be a short-term solution for a particular establishment. Over the longer term, however, the macrosocial consequences of excluding these individuals from a chance at gainful employment is a problem that policymakers will have to address. This issue might become more important in the future. Although at present there is no distinct constituency directly interested in the rights of those who are tested for drugs before employment, this situation may change if exclusion from the work force unintentionally contravenes the goals of other social policies, around which vested interests and constituencies are already organized. This possibility is detailed in the conclusion of this paper.

Of considerable concern are employers who test current employees for evidence of drug use but who do not offer EAPs to help persons with drug dependencies preserve their jobs. This practice is highlighted by the demography of the work settings with DSPs but without EAPs. Many of these organizations are among the smaller and more numerous worksites and owing to their size may be harder to reach vis-a-vis providing an internal EAP service and are certainly less profitable contracts for EAP external providers. Furthermore, in terms of their insurance coverage, such organizations are less likely to provide third-party payment for alcohol and other drug treatment. Those that do may be in the precarious position of not being able to absorb the high costs of treatment in their premiums, compared with larger companies that spread risk over many employees. In addition, these organizations are likely to be located outside of large cities, which also exacerbates their ability to access quality substance abuse treatment options. Coupled with the increasing awareness of drug usage in rural America as both a real and perceived issue, more worksites may adopt those practices that seem relatively straightforward, simple, and inexpensive—such as urine sampling followed by drug testing through express mail arrangements with drug screening laboratories at distant locations.

The central concern about such arrangements is that these organizations may be the least likely to be able to afford due process protections and a bundle of other employee benefits and educational opportunities that larger employers are able to provide. The overall impact on employee welfare could be dramatic. Thus, the chance for abuse in smaller organizations, especially in rural locations, is an issue that must be addressed as drug testing becomes a more popular practice.

The 1988 Department of Labor survey reported that in those organizations in which some form of DSP was shown to have been in place, fewer than 1 million current employees were tested for drugs and nearly 4 million job applicants were tested during the 12 months preceding the survey. The rate of positive drug screens reported for job applicants was 11.9 percent. For current employees who were tested, the rate of positive drug screens was 8.8 percent.

There is reason to question the validity of these DSP "outcome" data. It is likely that the respondents in the Labor Department survey rounded off percentages or tended to "guesstimate," Of considerably more importance is that the survey did not have control over the positions occupied by the workplace-based survey respondents. Thus, the respondents were in organizational positions with differential access to accurate information about drug testing results. Consequently, the information about the presence of policy and programs was more likely to be accurate, and the information about the reports of positive rates was less likely to be accurate.

The Department of Labor reports of drug testing prevalence that were published in January 1989 were almost immediately criticized by proponents of drug testing as being already out of date. In all likelihood, applicant drug testing, the most prevalent type of testing, has and will continue to increase in prevalence as an organizational policy, if not as an actual practice, unless there are regulations that prohibit it or specify the conditions under which it can be utilized. Drug testing of current employees, however, is not likely to increase dramatically except for safety-sensitive and national security positions. Given the direction of court decisions in which broad definitions of "sensitive" positions are being challenged in the context of required drug screening of current employees, it is likely that "safety-sensitive" and "national security" characterizations of occupations will have to be carefully justified if litigation is to be avoided.

Applicant drug testing seems at first glance to be the most reasonable kind of testing and provides a way for employers to exclude potentially troublesome and costly applicants from gaining employment in their organizations. Yet although the deterrent effect of drug testing is a plausible argument for applicant testing, there are nevertheless a series of issues that may be of concern to the communities in which the organizations exist in terms of appropriate assignment of responsibility for drug problems.

Currently, evidence about the impact of drug screening on employee drug usage is not available. Many of the organizations that have drug screening policies do not systematically utilize them, indicating a disjunction between policy adoption and program implementation. Data collected in 1984-1985 in the authors' study of 439 private-sector sites with EAPs indicated that there were no significant differences in the drug-and alcohol-related caseloads of EAPs in organizations that did or did not perform preemployment drug screening. Companies that spot-checked their current employees using various procedures (locker searches, urine tests, etc.) also were not distinguished from organizations without these practices in terms of proportions of the work force that came to the EAP with drug or alcohol problems through its various routes of referral (Blum, 1989). It should also be noted, however, that another analysis of this data set indicated that drug abuse problems could be dealt with effectively through the EAP. In addition, the analysis suggested that the extent of successful attention to drug abuse problems within the EAP appears to be a function of the extent to which the program is integrated into organizational functioning and characterized by the presence of key elements of EAP core technology (Roman, 1989).

In this regard it is important to note that the military has reported decreased rates of those testing positive for illicit drug use during the years that their various drug screening programs have been in place, and these decreased rates are pointed to as evidence of the success of drug screening. Yet worldwide surveys based on self-reported use of alcohol among military personnel have shown that both alcohol consumption and problems associated with that consumption have not similarly decreased over time. Although there are some significant decreases in self-reports between 1982 and 1985, the larger increases in productivity loss associated with alcohol abuse between 1980 and 1982 (Bray et al., 1983, 1986) are certainly a relevant consideration if improved performance and predictability in the work setting is, indeed, an overarching goal covering all of these intervention programs. Generally, the evidence from the treatment community of increases in polysubstance abuse and of the switching of drugs of choice as different chemicals are more readily available or culturally acceptable must have some bearing on workplace strategies for dealing with workplace effects of alcohol and other drug dependencies (Blum, 1989).

Furthermore, the impact of drug screening on employee morale, satisfaction, commitment, turnover, accidents, productivity, and other work-related outcomes is not known. A survey of a random sample of Georgia adults (N = 524, 67.5 percent response rate) conducted in 1986 by the authors indicated that 12.6 percent strongly approved of drug screening and 37 percent approved, whereas 28.1 percent disapproved and 18.1 percent strongly disapproved (3.1 percent responded that they did not know; Blum, 1989). The same data set, however, indicated that 75 percent of the employed individuals in the sample would be willing to be screened for drugs. All of those who strongly agreed with the hypothetical drug screening policy and 96 percent of those who agreed indicated that they would be willing to submit a urine specimen, in front of a witness, to a representative of their employer for the purposes of drug screening.

Drug Screening and Employee Assistance Programs and Potential Future Dilemmas

The workplace is involved in dealing with both drug and alcohol issues, creating in many ways a "new world" of addressing human problems and their consequences. In conclusion, the authors review two "dilemmas" highlighted by issues involved in drug and alcohol programming in the workplace: potential conflicts among program strategies with very different intentions and the effects of broadly scoped services provided by employers.

Micro-Organizational Motives and Macro-Social Consequences

Many issues discussed here are highlighted by an interpretation of the findings in the first six months of a two-year study of the job performance of employees of the U.S. Postal Service who were drug positive at their preemployment screen as compared with those who were drug negative at the preemployment screen. Perhaps the best designed study of the effects of applicant drug testing on job performance, this study is being conducted on Postal Service employees at 21 locations around the United States (Office of Selection and Evaluation, U.S. Postal Service, 1989; Normand and Salyards, 1989). The essence of this research design is that those with positive preemployment drug screens were nonetheless hired, allowing a follow-up of their work performance compared to those who screened negative.

Drug test results were obtained by the researchers for 5,465 job applicants. Traditional personnel selection practices and other factors not related to the drug test were used, with 78 percent of the eligible job applicants who tested negative for drugs eventually hired, compared with 69 percent of those who tested positive. The 4375 applicants who were hired represent the study sample. Within this sample, there was an overall drug-positive rate of 8.4 percent at the preemployment screen.

Although the study will follow for two years the job performance of those hired, the preliminary results include the six-month effects on turnover and absenteeism. The absenteeism rates are approximately 43 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 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 costcutting 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 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.

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Footnotes

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.

Copyright © 1992 by the National Academy of Sciences.
Bookshelf ID: NBK234748

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