September 23, 2022
Substance Use Disorder (SUD) is the frequent use of alcohol and/or drugs that leads to a series of impairments to someone’s health and behaviors.1 This disorder negatively impacts an individual’s ability to control emotional responses, maintain positive relationships, manage cravings for drugs and/or alcohol as well as fulfill responsibilities at work, school and home. Of particular concern to employers is the major impact that SUD can have on worker safety, productivity, retention and health care outcomes and costs.
In 2021, more than 100,000 people in the U.S died from drug overdose, an all-time record and twice as many as in 2015.2,3 Additionally, more than 52,000 deaths were alcohol-induced (e.g., drunk driving, alcohol poisoning etc.), and another 56,000 Americans died from chronic liver disease and cirrhosis, which are consequences of long-term alcohol use.4 There is no doubt that the urgency to address SUD has never been higher.
Treatment for SUD is chronic and complex. Individuals with SUD often have comorbid anxiety, depression and/or suicidal thoughts, which further complicates treatment strategies. However, the latest data show that only 8.6% of people with SUD receive treatment for their condition.
This article presents an overview of SUD, its prevalence and impact on employers. It also includes employer strategies to increase the chances that employees and dependents with SUD receive appropriate, evidence-based treatment with positive outcomes.
What is Substance Use Disorder?
SUD is a condition that affects a person’s brain and behavior as a result of recurrent alcohol and/or drug use, leading to:
- An inability to abstain from addictive substances and intense cravings for them;
- Neglecting responsibilities at home, work or school;
- Difficulty in maintaining positive interpersonal relationships; and
- Dysfunctional emotional responses.5,6
As with other chronic diseases, many people with SUD go through cycles of relapse and remission.
Defining Terms: Addiction vs. Substance Use Disorder
SUDs fall along a severity spectrum depending on the number of impaired behaviors a person exhibits. The most severe SUDs are sometimes called addictions. This article uses “substance use disorder” throughout in recognition of the needs of individuals who may have mild or very minor symptoms. Referring to someone as an “addict” is also stigmatizing, which can be avoided by using the more inclusive clinical term.
Contributing Factors to Developing a Substance Use Disorder
There are several factors that influence the likelihood of developing a SUD, including family history, genetics and lived experiences in the community.7 Many of these factors are interconnected, including the following:
- Genetics and Development: Up to half of an individual’s risk of developing SUD depends on their genetic makeup.8 This is not determinative but is a significant factor. The earlier that someone is exposed to drugs and alcohol (i.e., fetal, childhood, adolescence), the greater the likelihood that the individual will develop long-term SUD.9
- Emotional Trauma: People who experience traumatic experiences before 18 are at increased risk of developing an SUD. Such emotional traumatic experiences include abuse and neglect.10
- Mental Health Conditions: People with mental health conditions like anxiety, depression, and post-traumatic stress disorder (PTSD) are more likely to use alcohol or drugs to self-medicate; this can offer temporary relief but create long-term dependency.11 Among adults 18+ in 2020 with an SUD, 21% were also experiencing a mental health illness such as depression.12
- Social and Relationship History: Peer or family history of excessive substance use, as well as anti-social behaviors such as verbal abuse and harassment by friends and family, can encourage dangerous behaviors, like substance use.9
- Physical Environment: Local neighborhood attributes, such as poverty, easy access to addictive substances and violence, all increase the risk of SUD.13
Prevalence of SUD Across Demographics in the United States
In 2020, an estimated 14.5% of people had an SUD-related disorder in the U.S.14 The Centers for Disease Control and Prevention (CDC) reported in 2020 that 13.3% of Americans started or increased substance use as a means of coping with elevated stress and difficult emotions related to the COVID-19 pandemic.15
The level of SUDs varies across demographics and regions in the U.S., highlighting significant disparities:
- Race and Ethnicity: In 2021, Black Americans died from overdoses at a rate 16.3% higher than White Americans, and this disparity is trending upward.16 This is in part due to Black Americans with SUD being more likely than others to use drugs that are laced with fentanyl, an extremely potent and lethal synthetic opioid formulation.17 In fact, fatal teen overdoses have jumped in the past 2 years due to fentanyl showing up in more illicit drugs.18 Unintentional overdoses – the ingestion of a drug in quantities much greater than recommended – are increasing in part because people are unaware of high-potency fentanyl being added to substances they’ve used otherwise safely in the past. American Indian and Alaska Native populations have the highest rates of overdose.
- Income/Education Level: In 2019, overdose rates were concentrated in zip codes characterized by higher rates of poverty and unemployment, as well as lower median incomes and education.
- Sex and Gender: Men are more likely to have SUD, but women are more likely to suffer side effects and overdose because of differences in biological and social makeup.19 Women experience effects of substances more strongly despite using drugs in smaller amounts compared to men.20
- Age: Young adults ages 18-25 have the highest rates of SUD at 24.4%.21 Notably, this age group is in a phase of their life when they are exploring their identities, with an increased sense of independence and exposure to new choices. Unfortunately, they do not always make wise choices.
The Impact of SUD on Individuals
Substance use disorders are associated with several profound health and behavioral impacts that come with significant consequences for individuals, their families, and their employers.
Physical Health Effects
Short- and long-term physical effects will depend on the type of substance (e.g., alcohol, opioids, cocaine, etc.). Short-term effects can include loss of consciousness, tremors and in the case of an overdose, death. Long-term use of most addictive substances increases the likelihood of liver failure, cancer, stroke, depression, and anxiety.22 Even moderate levels of alcohol consumption over time can increase the likelihood of developing several types of cancer.23
Mental Health Effects
Most people with SUDs also have a mental illness.24 Some use addictive substances to cope with symptoms of anxiety or depression, while others may develop depression because they have an SUD. In 2020, 21.0% of people 18 or older had either a mental illness or an SUD in the past year, and 6.7% (17 million people) had both a mental illness and SUD. Among adults with a mental illness, 39.8% reported using illicit substances, whereas only 17.0% of those without a mental illness reported using illicit drugs.21
Although the physical effects of SUD vary depending on the substance, the behavioral impacts are more uniform across substances. Alcohol and other drugs trigger pleasure centers of the brain that over time change the hierarchy of an individual’s needs and desires.
Behaviors associated with SUD include:
- Inability to abstain from addictive substances and serious withdrawal symptoms when use is discontinued;
- Reduced inhibitions leading to risk-taking like driving under the influence;
- Disruptive cravings;
- Difficulty maintaining positive interpersonal relationships; and
- Dysfunctional emotional responses.
Social Health Effects (Employment, Family Life and Stigma)
The impact of SUD on an individual’s community and relationships varies by person. For instance, some will struggle to hold onto a job but will have difficulty doing so due to negative impacts on productivity, interpersonal relationships with colleagues or workplace safety incidents. Others are able to work and largely conceal their disorder for extended periods of time until a serious adverse event occurs.
The highest rates of SUD are among young adults whose parents are working age. These parents often become their children’s caregivers, resulting in increased levels of stress, anxiety, depression and financial stress among this group.
Stigma against people with SUD is widespread and varies depending on the substance an individual is using. For example, those with an alcohol- related SUD may be judged less severely than those with a cocaine or heroin SUD issue. Also, many, including a subset of medical professionals, believe that SUD is a moral failing, blaming the individual for “being an addict” and labeling them as bad, dangerous, or unfit for society.25 This stigma can reduce the likelihood that someone will seek treatment or receive compassionate, high-quality care when doing so.
Impact on Employers
Approximately 9% of U.S. workers (13.6 million workers) have SUDs. It is estimated that 70% of people with SUD are employed.26,27 Most people with SUD can manage to keep their employment. COVID-19, however, exacerbated the use of substances during the workday. In 2020-2021, 25% of remote employees reported going to work after usage of drugs and/or alcohol; meanwhile, treatment centers were disrupted during the worst of the pandemic.28
Absenteeism and Retention
One study found that compared to their peers, workers with SUDs miss 50% more days of work.29 They’re also much more likely to switch jobs frequently; 36% of employees with SUD had more than one employer in the past year due to job loss, while an estimated 25% of workers without SUD had this experience.29
The absence of inhibitions can lead to risk-taking behavior and the potential for making workers and their peers vulnerable to serious safety events. This is especially true in the health care industry and any worksite where heavy machinery is used.
Cost of Treatment
SUD costs the U.S. over $600 billion annually, according to the National Institute on Drug Abuse; this takes into account societal impacts like the cost of incarcerating drug users.30 Hospital-based care, including emergency room and inpatient admissions, associated with SUD diagnoses amounted to $13.2 billion in 2017. Emergency room visits associated with SUD were $1,985 more costly than those for other diagnoses, and inpatient admissions were $9,693 more costly than for those without a primary SUD diagnosis.29
Treatment Options and Settings of Care for SUD
Treatments for SUD have varying levels of intensity depending on the severity of disease. Ultimately, there is no “right way” to treat an SUD. Often, a combination of several treatment pathways is necessary. As the level of intensity of treatment increases, the setting of care—along with clinical resources and cost--will likely advance as well.
The SUD treatments listed below are grouped according to settings of care where they can be delivered with the fewest clinical resources. Generally, treatments that can be delivered in the home or community setting can also be done in outpatient or residential centers.
For many people with SUD, medication-assisted therapy (MAT), provided concurrently with behavioral health interventions, can be beneficial.31 For opioid use disorder, extended-release of naltrexone, buprenorphine and methadone can help individuals in acute detox situations wean themselves from prescription opioids or heroin. MAT is also used for active ongoing treatment to help patients with SUD live a functional life. For alcohol use disorder, naltrexone and acamprosate are effective for many people as a way to prevent a return to drinking. Many MATs can be taken at home.
MAT is often associated with methadone clinics, which are highly stigmatized and associated with criminality.32 Methadone, along with other MAT options, are evidence-based and beneficial for a significant number of SUD patients. Unfortunately, this stigma has led to under-prescribing and a dearth of providers in many areas.
Community and Home Care
The Role of Primary Care and Behavioral Health Services
The integration of primary care services and behavioral health services into multiple settings has expanded the reach of providers who treat SUD and the comfortability of PCPs to address SUD alongside their colleagues with mental health expertise.
PCPs form the front line of identifying patients in need of treatment for SUD. For many with SUD, going directly to a behavioral health provider for treatment may be too difficult to navigate and carries stigma. It is often patients’ PCPs who identify the need and support them in accessing appropriate treatment.
Nonetheless, 57% of PCPs don’t feel adequately prepared to screen patients for substance use disorder, let alone treat it, so integration of primary and behavioral health care is vital.
Providing treatment in the community (e.g., YMCA, church, etc.) or the home can be beneficial because it gives patients and providers the ability to address some of the environmental risk factors that facilitate substance use, like peers or family members who may also have SUD. Inpatient treatment is necessary for some people, but there is a risk: removing people from the normal context of their lives to recover, followed by putting them right back in that situation after discharge, may lead to a relapse. Community and in-home care eliminate this concern.
SUD treatment for lower acuity patients can be delivered in the home by visiting nurses and/or virtually. Treatment can include in-home drug testing, MAT injection, counseling and other services. In-home care may be more convenient depending on how far someone lives from the nearest providers, or less stigmatizing for people uncomfortable with seeking treatment in a medical facility. Care in the home should be coordinated with a patient’s behavioral health and primary care providers.
Individual and group counseling is the most common treatment for SUD. It can be delivered in community settings, the home or outpatient treatment facilities. Counseling focuses on skill-building to reinforce positive behaviors, cognitive behavioral therapy (CBT) and motivational enhancement. Evidence suggests that 12-step programs and other peer support groups like Alcoholics Anonymous offered in the community improve rates of sobriety by just as much, if not more, than many clinical interventions.33
Outpatient Treatment Centers
Outpatient treatment centers provide many of the same treatments as those listed above but are often used for intensive care at the beginning of a patient’s SUD treatment. This may involve several treatment sessions a week before a patient is prepared to move toward community and home care.
Residential Treatment Facilities
Residential treatment facilities are reserved for patients with the greatest risk for serious adverse events (e.g., overdose) and those in need of 24-hour supervision. Patients may commit themselves to several days or weeks of treatment during which they are monitored, receive intensive therapy, and are often helped through withdrawal symptoms that can be intense and dangerous.
Unfortunately, not all residential treatment facilities adhere to evidence-based treatment, and some have unethical or even fraudulent practices.34 For example, some facilities advertise spa-like treatment facilities to encourage patients and their families to travel for this type of treatment. There are some providers who offer to waive a patient’s cost sharing while charging the plan significant sums of money for treatment not coordinated with the patient’s health care providers in their home community.35 This ends up costing large sums of money and usually leads to readmission. Other facilities that own their own labs have been flagged for running unnecessary urine and blood tests on their SUD patients; health plan precertification should catch unnecessary or excessive testing, but implementation is inconsistent. These practices underscore the importance of helping patients who need residential treatment find high-quality centers.
Identifying High Quality Treatment Facilities
The brain’s complexity, evolving standards of care and decades of stigma might explain why the field of substance use care is behind others in quality measurement. The lack of easily identifiable data on the quality of SUD facilities has led patients to be susceptible to claims of excellence by unaccredited out-of-network facilities. Organizations like Shatterproof have recently created measurement sets for SUD treatment being deployed by health plans and employers to guide network creation.
One large retail company created a Center of Excellence network (COE) of residential treatment facilities by reviewing the following metrics: clinical outcomes, average length of stay, “step up or step out” treatment options (moving from a more intense treatment to a less intense one or vice versa), member satisfaction, survival rates and 30-, 60-, 90- and 180-day readmission rates. This employer has communicated this network heavily to employees and waives all cost-sharing to encourage the use of these high-quality facilities. Early results have been positive. Most health plans have also created COE networks for residential treatment in the past few years. Criteria for inclusion will vary by plan.
Virtual Care Services
Virtual care can extend the reach of existing SUD providers, as well as provide supports for people at home to manage their SUD outside of clinical settings. The percentage of SUD treatment facilities that deliver services via telehealth grew from 25.7% in 2015 to 58.6% in 2020, a trend accelerated by the COVID-19 pandemic.36
Several virtual health vendors have also hit the market in recent years. In some cases, they contract directly with employers, and in others they are made available to employees and their families through their employee assistance program (EAP). In contrast to traditional telehealth, which essentially recreates an in-person visit over the phone or computer, these new programs often use technology that allows them to stay in touch with patients more often (e.g., text or chat) and create additional levels of accountability through at-home sobriety testing linked to an app. These virtual care providers can be made available to employees through an EAP or well-being vendor or communicated directly to employees.
1| Coordinate with EAPs, health plans and other partners to conduct anti-stigma campaigns and peer support training programs to encourage the use of behavioral health resources.
Stigma can be a barrier for employers in connecting their employees to SUD treatment. In particular, stigma affects marginalized populations, such as people of color, low-wage earners, LGBQT people and others. EAP providers, health plans and other organizations conduct peer support and manager trainings to help employees and managers better understand the importance of mental health and how to support their coworkers, as well as get a refresh on resources available to them. According to Business Group on Health’s Large Employers’ Health Care Strategy and Plan Design Survey, in 2022, 74% of employers conducted manager trainings to help managers recognize mental health issues and learn how to direct employees to appropriate services, and 70% led anti-stigma campaigns. These trainings can be done in concert with company campaigns to create awareness about specific mental health challenges, including SUD. For more information on addressing stigma in the workplace, see the Business Group’s Reducing Mental Health Stigma: Employers FAQs.
2| Consider first-offense forgiveness policies that, in the case of an SUD-related workplace incident, trigger treatment interventions rather than immediate termination.
The fear of losing one’s job leaves some employees hesitant to seek SUD treatment. Some employers have instituted policies that forgive an employee’s poor performance or a safety event if it is related to a SUD as long as they sign a contract to receive treatment, adhere to EAP recommendations and avoid a second offense. This policy can create an environment that is supportive of struggling employees and may encourage people with SUD who have not experienced an adverse event to seek treatment before one occurs.
3| Steer employees to high-quality, evidence-based care in inpatient, outpatient, and community facilities.
There are several approaches employers can take to help employees get connected to high-quality, evidence-based care:
- Ensure that your vendors, including navigation services, health plans, EAP and others, are educated on company resources for SUD and incentivize cross-referrals.
- Consider virtual care options using similar quality metrics as for in-person care. Ask vendors about what other outcomes metrics they may use to track success that isn’t claims-based.
- Consider reducing or eliminating cost-sharing for COE facilities. Curating a custom COE network affords employers the flexibility to tailor it to their employee population, but existing health plan COEs will be easier to implement. Based on findings in Business Group on Health’s Large Employers’ Health Care Strategy and Plan Design Survey, in 2023, 34% of employers had COEs devoted to substance use disorders. Ask your health plans what metrics they use for COE determinations and what results they’ve achieved as compared to their broader network facilities.
- Consider offering travel reimbursements for patients and a family member when they go to COE facilities.
- Eliminate out-of-network coverage for non-accredited residential and outpatient facilities. There are several accrediting organizations to consider, but all of them will ensure a minimum level of safety for their patients.37 Some employers looking to simply eliminate coverage for “spa-like” facilities that encourage people to travel have put geographic limits on how far a patient may travel from their home to get coverage (e.g., mile limits or state restrictions). Coverage elimination must be balanced with patient disruption.
- Ask health plans and EAPs for data on the performance of their in-network providers. The Shatterproof ATLAS for identifying high-quality providers for SUD includes several quality metrics to consider.
4| Cover evidence-based treatments such as MAT.
MAT drug treatments such as naltrexone, buprenorphine, methadone, acamprosate and others should be covered. With patients for whom they are medically appropriate, these treatments have a strong evidence base of effectiveness; coverage should not be a barrier. COE networks for residential care generally require in-network facilities to offer MAT, but self-insured employers do not universally cover them.
5| Work with health plans to promote integrated behavioral and mental health treatment into primary care, acute care and surgical support programs, or directly contract with health systems that have done so.
As many health systems take on financial risk for the total cost of care for attributed patients, they must implement comprehensive strategies for increasing access to evidence-based SUD treatment. Currently, 37% of employers are offering coverage for out-of-network treatment for mental health and substance use disorder services, according to the Large Employers’ Health Care Strategy and Plan Design Survey from Business Group on Health. When considering whether to provide some form of steerage to an accountable care organization (ACO) or to a high-performance network, employers should ask providers and health plans about their behavioral health integration into primary care, primary care provider training to treat and triage SUD patients and overall timely access to behavioral health services. Surgeries are often associated with significantly debilitating events (e.g., a heart attack or accident) and/or require long periods of recovery; this can lead to depression and anxiety. Having behavioral and mental health services incorporated within surgical support programs can help patients find healthy ways to address depression and anxiety, rather than self-medicating with alcohol or other drugs.
6| Support and provide resources for caregivers with dependents that are a coping with a substance use disorder.
Caregivers experience significant challenges when caring for someone with SUD. It often leads to mental health challenges that stem from stress, guilt and secondary trauma of caring for someone with SUD. More than 80% of employees with caregiving responsibilities said this additional work affected their productivity, showing the toll of caretaking; strategies to support employees who are caregivers can be found in the Business Group on Health’s Family Benefits Bundle on caregiving.
7| Take steps to prevent SUD from happening in the first place.
Much of what leads to SUD happens outside of an employer’s ability to make a difference, but there are still steps employers can take to reduce its likelihood among their employee population:
- Limit exposure to potentially addictive medications to treat pain, like opioids. This can be done through coverage limitations, plan design preference for tamper-resistant formulations and steerage to COEs for other medical services that normally require pain management (e.g., musculoskeletal procedures). Similarly, consider implementing virtual physical therapy programs that can manage pain while limiting opioids.
- Reconsider the extent to which alcohol is included when creating healthy office event policies. In the same way that your cafeteria may feature healthy foods, create gatherings that encourage social interaction without centering around an addictive substance that some employees may struggle with.
- Support the health and well-being of employees holistically. Sometimes circumstances such as mental health issues, financial insecurity or past trauma can lead to heavy substance use. Providing benefits like bereavement leave to cope with loss and financial wellness courses can help mitigate challenging employee circumstances and possibly curb a substance use disorder from arising.
8| Create opportunities for employees to find support from their employee peers through their journey to sobriety and/or for caregivers of dependents with SUD.
Some employers have taken the step to create sober-focused employee resource groups (ERGs) or affinity groups to give employees who are sober, working toward sobriety or taking care of people with SUD a place to find peer support.38 This is not a replacement for group therapy, but a place where people can build camaraderie, share thoughts with employer leadership about supporting healthy use of alcohol and other drugs, and learn about company resources to support them. This will require company leadership support, as many employees will be reluctant to admit they have challenges with alcohol or drug use in the workplace.
9| Promote services that connect employees and dependents to community resources that support people with SUD.
Several public and private organizations exist to help connect people with SUD to community resources that can augment the benefits that employers provide. This can include mutual support groups like Alcoholics Anonymous that meet in community facilities such as the YMCA, community centers or churches. Some of these organizations are public, such as findhelp.org (formerly called “Aunt Bertha”), and others are offered by third-party vendors that work with health plans and providers to make connections between plan members, patients and social services in their communities. Concierge and navigator programs have begun to add capabilities to connect members to community resources. Employers should ask their vendor partners how they are leveraging social services to support employees and their families and include public resources into communication campaigns.
SUD can have a profound impact on an employee’s ability to safely and productively work, making the condition of health and workforce imperative for employers. Fortunately, SUD can be treated with evidenced-based care, and the appropriate resources, including medication and mental health supports, if available. Employers can support employees and their families in several ways; combatting stigma, supporting caregivers, and helping employees find high-quality treatment for themselves and loved ones all make a big difference for individuals and the company.
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