1. Addressing Co-occuring Disorders in the EAP Setting Bernie McCann, MS, CEAP

2. Learning Objectives: 1. Define EAPs, their purpose & skill set used in addressing substance abuse and mental disorders. 2. Review evolution of EAPs in the workplace and the health care market and how these changes are relevant to treating CODs. 3. Illustrate how recent advances and enhanced case management have potential to increase positive COD outcomes in the EAP setting.

3. EAPs : Defined An Employee Assistance Program is a worksite-based program designed to assist: 1)work organizations in addressing productivity issues; and 2)employee clients in identifying & resolving personal concerns, including health, marital, family, financial, alcohol, drug, legal, emotional, stress, or other personal issues that affect job performance.

4. Who gives/gets EAP services?  EA services are provided by trained EAP professionals (often CEAPs), worksite peer coordinators (sometimes CEAPs), social workers (occasionally CEAPs), psychologists, licensed professional counselors, marriage & family counselors, etc.  90% of Fortune 500 firms have an EAP; and approximately. 73% of US employers provided an EAP in 2005, up from 68% in 2001 (Society for Human Resource Management).

5. EAP enrollments, 1955-2003 (by millions of lives)

6. Evolution of EAPs Historical Influences: Employers: Welfare Capitalism Trade Unions: Communal Brotherhood 1950s - Industrial/Occupational Alcoholism Programs 1960s - Slow growth, mostly in mfg/indus sector 1970s - NIAAA recruits ‘Thundering 100’ 1980s - ‘Broadbrush’ approach = ‘modern’ EAP 1990s - Expansion & Integration Managed Care, Work/Life, CISDs, etc. 2000s - Market Pricing & Product Shrinkage EAP as Commodity – price anemia, quality issues

7. Enrollment in EAPs 1993 - 2003, by Type 27.4 20.0

8. Today’s EAPs are designed to impact: Health Claims Human Capital Organizational Goals EAP IMPACT

9. EAP Core Technology Management Consultation Education & Training Organizational Development Program Evaluation Program Orientation & Promotions Client Assessment/Problem Identification Case Management/Follow up Critical Incident Response Organizational Goals Health Claims Human Capital

10. Market Pressure on EAPs  Major shift from internal to external delivery of EAPs has resulted in: 1) a new “occupational profile” of EA providers; & 2) a community-based provider network delivery which is less integrated with the employee’s worksite  Continuing rise in overall health care costs = reduced access to TX for SUDs & MDs  Increased market competition has resulted in diversified EA services/products (and a diluted effectiveness..?)

11. Current Challenges for EAPs Increased market pressure on EAPs to demonstrate: 1) a unique contribution to enhanced workplace productivity, & 2) effectively contain healthcare costs. Current data on substance abuse, mental disorders prevalence (and co-occurrence of these conditions) reveals many more Americans could benefit from intervention (at all levels). Thus, enhanced EAP efforts to identify and assist those employees with co-occurring conditions has potential to demonstrate increased value and better client outcomes.

12. Substance Use & Mental Disorders 15.2 Million 15.4 Million Co-occurring Disorders Substance Use Disorder Only Severe Mental lllness Only 4.6 Million

13. Substance Abuse & Co-Morbidity Adult lifetime co-occurrence of mood, anxiety, anti-social personality disorders & severe mental illness with substance abuse problems is approximately 50%. The presence (and resolution) of co- morbid factors is a primary and critical success factor in sustaining recovery from substance use disorders.

14. CODs in the Workforce Among full-time employed adults, 10.6% met clinical criteria for having a SUD, 10.2% experienced serious psychological distress (SPD), and 2.4% had a co- occurring SPD & SUD during the past year. Full time employed adult males were nearly 2X as likely to have a past year SUD than their female counterparts (13.2% vs. 6.9%). Females were nearly 2X as likely to have SPD than males (14.2% vs. 7.3%). Of 2.9M full time employed adults with co-occurring SPD and SUD, nearly 60% were not treated for either problem and less than 5% were treated for both. Source: SAMHSA National Survey on Drug Use & Health, 2004

15. CODs in Insured People with SUDs 4%1% Arthritis 1%0.1% Cirrhosis (Liver) 7%3% Asthma 7%3% Hypertension 7%0.4% Major Psychoses* 9%4% Headache 11%6% Lower Back Pain 17%2% Anxiety* 26%12% Injury/Overdose 29%3% Depression* Patients w/ SUDs Patients w/out SUDs Of 774 patients in a large HMO: Source: Mertens JR, Lu YW, Parthasarathy S, et al. Medical & psychiatric conditions of alcohol & drug treatment patients in an HMO. Arch Intern Med. 2003;163: 2511 - 2517.

16. Substance Use & Depression - 2005 Source: SAMHSA National Survey on Drug Use & Health, 2004

17. Mental Disorders in EAP Settings Generalized Anxiety Disorder* Post Traumatic Stress Disorder* Panic Disorder Social Phobias* Obsessive-Compulsive Disorder Dysthymia* Depression *May actually be occupationally induced – OSHA has declared stress to be a workplace hazard.

18. TX of SU & MH Problems in Working Adults Source: SAMHSA National Survey on Drug Use & Health, 2004

19. CODs: Clinical Implications  More prevalent than earlier appreciated  Related to reluctance to seek TX  Implicated in failure to engage in TX  Contribute to higher relapse rates for both SUDs and MDs

20. Suicide as a risk factor for CODs 10.4% of adults who suffered a major depressive event attempted suicide, 14.5% made a suicide plan, 40.3% thought about killing themselves, 56.3% thought that it would be better if they were dead. Rates were higher if depression was co-occurring with alcohol or other drug abuse - rate of suicide attempts rose 14% among binge drinkers, and 20% higher among those who used illicit drugs. Source: SAMHSA Suicidal Thoughts, Suicide Attempts, Major Depressive Episodes & Substance Use Among Adults – JT Online Summary, 9/19/2006

21. CODs = health risk (cost) factor Smoking is the most preventable cause of death in American society. Nearly 1 in 5 US deaths results from use of tobacco; more than 400,000 die from smoking in the U.S. each year alone. (American Cancer Society) Smoking actually kills more alcoholics than alcohol. Pharmacological interactions between alcohol & nicotine are critical determining factors in the very common co- occurrence of chronic drinking & smoking. Cigarette smoking exacerbates alcohol-induced brain damage. Depression is the second leading cause of disability in the US (WHO). Depression results in more “bed” days than many other common medical ailments, i.e., ulcers, diabetes, high blood pressure & arthritis (Rand Corp).

22. EAP Best Practices – CODs Failure to address co-occurring disorders leads to shorter lengths of abstinence and more frequent relapses (an estimated 20 - 30% reduction in treatment effectiveness). A comprehensive assessment for SUDs indicates a psychiatric assessment for presence of co-occurring disorders and vice-versa. Treatment referrals, case management, aftercare and follow up should consider the duality of any co-occurring diagnosis to ensure effectiveness.

23. Enhanced Case Management for CODs  Integrated SA & MH assessments  Use of evidence-based therapeutic therapies such as: motivational interviewing, cognitive- behavioral & family counseling approaches  EAP as the primary, central case manager to ensure attention to coordination of SUD & MD treatment  More frequent, structured follow-up and or compliance monitoring - à la the Impaired Professional Committees in health professions

24. Enhanced EAP/Worksite Approach  Pressure points: Increase screening for SUDs, MDs, & CODs Increase worksite awareness efforts Provide web-based information & referrals Increase level of supervisory training Expand supports for workers in recovery

25. Demonstrating Value to Employers Tell them about it – starting with Orientation and Management training Use incidence stats/industry prevalence Keep detailed records of services - ‘cost-out’ services provided for CODs Conduct case reviews of actual costs and outcomes, to demonstrate savings and benefits of interventions