These slides were used for a guest lecture to graduate students attending course on substance abuse counseling at Cambridge College in Boston, MA.

1. Addressing Co-morbidity in the
EAP Setting
Bernie McCann, MS, CEAP
Cambridge College
January 24, 2007

2. Learning Objectives:
1. Discuss EA competencies and skill set
utilized in workplace substance abuse and
mental disorders.
2. Review recent advances in evidence-
based treatment and case management of
CODs relevant to EA practice.
3. Illustrate how both a renewed
emphasis & new information
have the potential to increase
positive COD outcomes in the
EAP setting.

3. Historical Development of EAPs
19th Century Influences:
Employers: Welfare Capitalism
Trade Unions: Communal Brotherhood
1940s - 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 Expansion & Product Shrinkage
EAP as a Commodity – Price anemia, Quality issues

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

5. EAP enrollments, 1993-2003
(in millions)
90
80
70
60
50
40
30
20
10
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2003

6. Enrollment in EAP
1993-2003, by Type
60
50
52.8
40
30
20
27.4
20.0
10
7.2
0
1993 2003
EAP only EAP + MBH

7. Current Challenges for EAPs
• Increased pressure on EAPs to demonstrate a unique
contribution to enhanced workplace productivity and
health care cost containment; as an increased
responsibility/accountability for safety-sensitive
situations.
• Current data on substance abuse, mental disorders
prevalence and cooccurance of these conditions reveals
many more Americans could benefit from intervention
(at all levels).
• Enhanced EA efforts to identify and assist those
employees with cooccuring conditions has potential to
demonstrate increased value and better client outcomes.

8. Major Factors on EAP Effectiveness
 Major shift from internal to external delivery of
EAPs has resulted in:
1) new “occupational profile” of EA providers; and
2) community-based provider network delivery less
integrated with employee’s worksite & productivity
 Increased market competition has diversified EA
services and products (diluted effectiveness?)
 Rise in overall health care costs = reduced access to
TX for SUDs & MDs

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

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

11. Some Explanations for Co-morbidity
1. Substance-induced temporary mental
conditions
2. Substance use (extent variable) may
intensify prior psychiatric disorders
3. Some psychiatric disorders likely to
increase risk factors for substance use
disorders

12. Sadness vs. Depressive Symptoms in
Alcoholics/other addictions
• 80% Experience some level of sadness
• 30% - 40% meet DSM criteria for
‘Depressive Episode’
• ‘Chicken or Egg?’; ‘self medication’? –
little neurological evidence to resolve

13. CODs in Insured People with SUDs
Of 774 patients in a large HMO:
Patients without SUDs Patients with SUDs
Depression 3% 29%
Injury/Overdose 12% 26%
Anxiety 2% 17%
Lower Back Pain 6% 11%
Headache 4% 9%
Major Psychoses 0.4% 7%
Hypertension 3% 7%
Asthma 3% 7%
Arthritis 1% 4%
Cirrhosis (Liver) 0.1% 1%
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.

14. 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

15. Treatment of SUD & MH Problems - 2004

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

17. 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, and 56.3%
thought that it would be better if they were dead.
• Rates went higher when depression was co-occuring
with alcohol or other drug abuse - rate of suicide
attempts rose 14% percent among binge drinkers,
and 20% higher among those who used illicit drugs.
Source: SAMHSA Suicidal Thoughts, Suicide Attempts, Major
Depressive Episode, and Substance Use Among Adults
– JT Online Summary, 9/19/2006

18. Nicotine Dependence: a COD health cost factor
• Smoking is the most preventable cause of death in
American society. Nearly 1 in 5 US deaths results from
the use of tobacco; more than 400,000 die from smoking
in the U.S. each year alone.
• 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 and smoking.
• Cigarette smoking exacerbates alcohol-induced brain
damage. Recent neuroimaging studies of chronic
smokers have shown brain structural and blood-flow
abnormalities

19. Universal Screening “Widens the Net”

20. Screening vs. Assessment
• Screening - a process to identify an
individual’s characteristics of problem drinking,
substance abuse or dependency through
established criteria, & which may indicate more
in-depth assessment.
• Assessment - more extensive analysis of
substance use, abuse or dependency -
specifically for level of severity, contributory
factors, & any associated consequences.

21. COA EA Practice Standard: Assessments
 Clinical assessments should include:
• Review of physical illnesses, somatic
variables, medical treatment
• Use of alcohol and any other drugs
• Behavioral and cognitive patterns
leading to health risks
• When appropriate: legal, vocational,
and/or nutritional needs of employee
Source: Intake, Assessment and Service Planning.
Council on Accreditation Requirements, 2nd Edition XI.4.01

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

23. Enhanced EAP Worksite Approach
Pressure points for an EAP might include:
• Increase screening for SUDs/MDs + CODs
• Increase worksite awareness efforts
• Provide web-based information & referrals
• Increase level of supervisory training
• Expand support for workers in recovery

24. Enhanced Case Management for CODs
 Integrated SA & MH assessments
 Use of evidence-based
 motivational interviewing, cognitive-behavioral
and family counseling approaches
 EAP as the primary, central case manager
 More frequent, structured follow-up and/or
compliance monitoring - à la Impaired
Professional Committees in health professions

25. MI = Progressive Continuum of Support
Follow-up
Engage client in behavior change
Establish action steps
Review motivation for change
Ascertain client goals
Education
Assessment
Screening

26. Maximizing EA Effectiveness in
Co-occuring SUD/MD Interventions
1. Earlier screening for identification of risky drinking,
problem drinking, pre-morbid substance abuse
2. More comprehensive assessments for appropriate,
cost-beneficial treatment referrals
3. Use of motivational interviewing for optimum
intervention and maximum client compliance
4. Closer EAP case management & increased follow up to
ensure greater adherence to treatment plans
5. Greater use of performance measures and outcome
reports to support continued expansion of services.

27. Demonstrating Value to Employers
• Tell them about it – Starting with
Orientation and Management training
• Incidence stats/Industry prevalence
• Conduct a quantitative worksite study
• Keep detailed records of services
• ‘Cost-out’ services provided
• Conduct case reviews of actual costs
& outcomes, to demonstrate the
savings/benefits of interventions

28. Thanks for your attention