Center for Integrated Behavioral Health Policy

1. Center for Integrated Behavioral Health Policy Department of Health Policy, George Washington University Medical Center Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) in the Workplace: Connecting with the “BIG” EAP Industry Initiative Eric Goplerud, Ph.D., Tracy McPherson, Ph.D NIATx Webinar November 18, 2010

2. Workplace Alcohol SBI Project: The BIG (Brief Intervention Group) Initiative • Seed Funding: • NHTSA • CSAT • SAMHSA • NETS • Alkermes • Corporate Sponsors • Pilot Sites: • Aetna • OptumHealth • ValueOptions • Trainer: • Denise Ernst PhD

3. Historical Context of EAPs in US • Began in 1950’-60’s with a primary focus on Alcohol and Substance Abuse/Addiction among workers. • Originally programs were internal to organizations, known as Occupational Alcohol Programs and staffed by recovering substance users. • Interventions focused on medical withdrawal, 28 day inpatient treatment and mutual support group involvement (Alcoholics Anonymous). • In the early 90’s EAP service delivery moved from internal programs to external managed care driven programs using large networks of general mental health providers resulting in reduced focus on substance use intervention and identification. • The qualifications and professional training of general mental health provider professionals had with regard to alcohol use focused primarily on addiction and not inappropriate use interventions.

4. Increased adoption of EAPs http://www.shrm.org/Research/SurveyFindings/Documents/08-0335_BenefitsSR_FINAL_.pdf

5. Percentage of workers with access to EAPs is growing Stoltzfus E (2009) Access to Wellness and Employee Assistance Programs in the United States. Bureau of Labor Statistics, 2009. http://www.bls.gov/opub/cwc/cm20090416ar01p1.htm

6. NHTSA/CSAT Workplace SBI Project (2006-2010) • Overall Aim: • Adapt alcohol SBIRT approaches developed in medical settings for work-related settings: • EAP • Occupational health & safety • Health promotion and wellness • Disease management

7. cont… • Conduct extensive literature review, surveys and interviews • Convened Workplace SBIRT Product Development Work Group. • Developed a model of workplace SBI.

8. U.S. Workplaces at Risk • 80% binge and heavy drinkers are employed.1 • 9% heavy drinkers work full-time.1 • Young adult workers (age 18-25) have highest rates of SU disorders2 • 9.2% worked with a hangover in the past year.3 • Heavy drinkers are more likely to have worked for 3+ employers in the past year.4 • Heavy drinkers are more likely to have skipped work 2+ days in the past month.4 • Workers reporting alcohol dependence/abuse more likely to have missed 2+ days of work due to illness or injury .4 • 9 in 10 heavy drinkers work for small and medium sized firms.5 • 1Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD. 2Substance Abuse and Mental Health Services Administration. (2006). “Substance Use Disorder and Serious Psychological Distress, by Employment Status” The NSDUH Report Issue 38. 3Frone, M. R. (2006). Prevalence and distribution of alcohol use and impairment in the workplace: A U.S. national survey. Journal of Studies on Alcohol, 76, 147-156. 4 Larson, S.L., Eyerman, J., Foster, M.S., and Gfroerer, J.C. (2007). Worker Substance Use and Workplace Policies and Programs (DHHS Publication No. SMA 07-4273, Analytic Series A-29). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 5Larson, S.L., Eyerman, J., Foster, M.S., and Gfroerer, J.C. (2007). Worker Substance Use and Workplace Policies and Programs (DHHS Publication No. SMA 07-4273, Analytic Series A-29). Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

9. A Feasible Workplace SBIRT Approach (telephonic or face-to-face)

10. cont… • Developed protocols that could be seamlessly integrated into existing EAP practice. • Conducted “proof of concept” studies to pilot test approaches and protocols in EAPs. • Launched “BIG Initiative” to facilitate EAP adoption of alcohol SBIRT through dissemination of materials and pilot test findings, and training.

11. What is “BIG”? • EAP industry-wide campaign kicked-off in Dallas at EAPA to adopt alcohol SBIRT as routine practice of US and Canada EAPs by October 2011. • System change campaign, similar to NIATx Action Campaign • Learning collaborative facilitated by GW which brings together 100+ organizations in the workplace SBIRT “supply chain”.

12. “BIG” Members • EAPs/MBHOs • Employers • Professional Associations • Clinicians • SBIRT/MI Experts • Researchers and Consultants • Pharmaceutical Companies • Federal Agencies

13. Brief Intervention Group (“BIG”) National Highway Traffic Safety Administration Substance Abuse and Mental Health Services Administration Network of Employers for Traffic Safety Aetna Behavioral Health/EAP OptumHealth/UBH ValueOptions Office of Drug and Alcohol Policy and Compliance, Department of Labor Office of Demand Reduction, Office of National Drug Control Policy, Executive Office of the President U.S. Nuclear Regulatory Commission Department of Defense Maine State Government Federal Occupational Health (FOH) University of Maryland School of Social Work Chestnut Behavioral Health First Sun EAP SELECT, Inc CIGNA Magellan Anthem/WellPoint Masi Consulting Burke Consulting Caterpillar Northrup Grumman Johns Hopkins University and Hospital JP Morgan Chase Hawaii Business Health Council National Business Group on Health UPS Amtrak Continental Airlines RAND Corporation Baltimore Gas & Electric Halliburton 3M EAPA EASNA Center for Clinical Social Work NAADAC Association of Flight Attendants AON St John’s Mercy First Advantage The Rainier Group Reckitt-Benckiser

14. What does “BIG” do? • Four Committees • Board of Directors –thought leaders, industry decision-makers provide direction of BIG strategy • Clinical – change EAP provider and network affiliate practice • Systems and Operations – change call center and internal EAP practice • Quality Improvement – identify common metrics (program performance, client outcomes)

15. How do participants benefit from “BIG”? • www.EAPBIG.org • Share experiences, materials, support, competition with others in industry • Gain attention of purchasers and internal organizational leadership • Reverse trend towards commodity pricing of EAPs by demonstrating value • Receive free SBIRT Training, Resources, CEUs

16. Prescreening = AUDIT-C (items 1-3) • How often do you have a drink containing alcohol? • Never • Monthly or less • 2-4 times a month • 2-3 times a week • 4 or more times a week • How many drinks containing alcohol do you have on a typical day when you are drinking? • 1 or 2 • 3 or 4 • 5 or 6 • 7, 8 or 9 • 10 or more • How often do you have five or more drinks on one occasion? • Never • Less than monthly • Monthly • Weekly • Daily or almost daily

17. How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily 9. Have you or someone else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative or friend or doctor or another health worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Full Screening = AUDIT-C + 7 Remaining AUDIT Items

18. Brief Intervention Based on risk level

19. Aetna / GWUAlcohol SBIRTPilot Research Findings

20. Site Characteristics: • Large U.S. Employer (Financial Services Industry) • 147,000 employees • 33% young adults(≤30 yrs), 53% adults(31-50),14% older adults(≥51) • 70% female, 30% male • 93% self- or management referrals • Non-emergent, self-referral cases • Design: • Pre-test Post-test One Group Pre-experimental • Training: • Face-to-Face and Telephonic Coaching

21. Pilot: Initial Results @ 5 months • 295 employees offered SBIRT • 93% (n=274) completed AUDIT-C (7% ineligible/refused) • Prescreen Results (n=110 positive)

22. Pilot: Initial Results @ 5 months • 87% (n=96) prescreen positives completed full AUDIT • Screening Results (n=50 positive screens)

23. Pilot: Initial Results @ 5 months • IDENTIFICATION RATE (Aetna) • 18.23% based upon standardized screening for hazardous/harmful drinking or alcohol dependence • 6% based upon presenting problem while using SBIRT protocol • IDENTIFICATION RATE (prior vendor data) • < 1% • 78% agreement to follow-up (members offered SBI at intake) • 72% set an appointment for face to face counseling (members offered SBI at intake)

24. EAP Return On InvestmentUsing SBI and The Work Limitations QuestionnairePreliminary Findings

25. Work Limitations Questionnaire -SF Developed and well validated tool by Dr. Debra Lerner (Tufts University) to measure productivity and presenteeism Generates - A summary score of productivity loss due to presenteeism • Productivity Loss Score - estimated percent difference in an employee’s at-work productivity compared to employees who do not have health-related work limitations (a healthy benchmark group). • Degree of Impact of Health Problems (Physical & Emotional Health) on Work Four scale scores (4 work limitation scales) • Time Management • Physical • Mental-Interpersonal • Output • Past 2 Weeks • Self Report • rate the frequency of difficulty (or, on one scale, ability) performing specific job demands • persons who are currently employed • Suitable for Repeating at Multiple Time Intervals

27. Average Audit Score: All Cases

28. Average AUDIT Score: Moderate and High Risk at Intake

29. Most Limited Least Limited

30. WLQ Productivity Loss Due to Overall Presenteeism

31. WLQ EAP Participant Productivity Loss and Estimated Cost Impacts 31

33. OptumUnited Alcohol SBI Pilot Greenwood G, Goplerud E, McPherson T (2010) Delivering brief alcohol-related interventions with a telephonic EAP. Journal of Employee Assistance. 16-18.

34. What comes next?The BIG Initiative Strategic Plan • Wider and deeper penetration of EAPs to deliver alcohol SBIRT • Broad, ubiquitous training of office-based clinicians in SBIRT. • EAPA, EASNA, NAADAC, CCSW common SBIRT training plan. • Outcomes evaluations, especially business relevant outcomes • Extension of BIG to additional conditions • Broadening financial base for sustainability

35. Workplace SBIRT Resources World Health Organization’s SBI Manuals: AUDIT: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6a.pdf Brief Intervention: http://whqlibdoc.who.int/hq/2001/WHO_MSD_MSB_01.6b.pdf SAMHSA SBIRT Initiative: http://sbirt.samhsa.gov/ Motivational Interviewing: www.motivationalinterview.org/ TIP 35 Manual: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.61302 Workplace SBIRT Toolkit: www.ensuringsolutions.org/solutions/solutions_show.htm?doc_id=450551 Alcohol Education/Self-Help: Rethinking Drinking: www.rethinkingdrinking.niaaa.nih AlcoholScreening.Org Workplace SBI Publications: What Employers Can and Should Do About Excessive Alcohol Use: www.ensuringsolutions.org/resources/resources_show.htm?doc_id=673239&cat_id=963 Literature Review www.ensuringsolutions.org/allies/allies_show.htm?doc_id=431629&cat_id=969 McPherson, T.L., Goplerud, E., et al. (2009). Workplace alcohol screening, brief intervention, and referral to treatment (SBIRT): A survey of employer and vendor practices. Journal of Workplace Behavioral Health, 24(3). EAPA Learning Center (Free session) New Tools for EAPs to Deliver Higher Levels of Value (2009 World Conference) http://www.softconference.com/eapa/sessionDetail.asp?SID=184750 35

36. THANK YOU!