Volume 4, Issue 2

Introduction to This Issue of The Bridge
By Paul Roman, PhD, University of Georgia
Editor, The Bridge

Learning from Past Experience:  EAP Lessons for SBIRT

Increasing the involvement of physicians in the treatment of substance use disorders (SUDs) is the topic of this issue of The Bridge. This of course is directly linked to the question of greater integration of SUD treatment into the medical care system that we are considering across several issues of this publication. Central to the effort to involve physicians is the acronym SBIRT, now commonly understood to represent Screening, Brief Intervention and Referral to Treatment. SBIRT is definitely in the broad category of significant innovations in approaches to SUDs, and research studies have affirmed it as being within the broad category of evidence-based practices (EBPs) in its use for alcohol problems but not for drug problems.

Here’s how this issue of The Bridge was developed. Rather than have our Editorial Board members offer their opinions and concerns about SBIRT, we wanted to assure that our discussion was close “to where the rubber meets the road.”  In other words, hardly anyone would oppose the implementation of SBIRT, and most would agree that it’s a good idea that deserves resources. But we all know that its implementation is far short of ideal and faces a lengthy list of barriers. In fact its implementation may be very much at the “Baby Step” phase of development. How can it move forward?

To get some good substance into the discussion for this issue, I posed the following challenge to the Editorial Board members:

The Editorial Board of The Bridge is comprised of professionals working in different sectors of the substance abuse treatment world. What could each of us be doing to enhance the spread of physician involvement in SBIRT?  Assuming we had the time and money, what could each of us do, using our own skill sets and opportunity structures, to further physician involvement in providing appropriate assistance to patients with AUDs and SUDs?  

To start the discussion: I am a researcher who has spent a career trying to contribute to change and improvement in substance abuse treatment. How can I bring those research skills to promote diffusion and acceptance of SBIRT practices by physicians encountering patients in both primary and specialty care? I could try to answer that question by listing all the research studies that need to be done, but my time is limited, both figuratively and literally, so I won’t go down that path, boring as it might be.

Instead, does the past that offer lessons for SBIRT implementation? Much of my career was spent in workplace research, focused on the adoption and implementation of employee assistance programs (EAPs) for employees with alcohol problems who were motivated to keep their jobs. We learned a lot over those years, and not all of it was inspiring. Perhaps the main principle is that in contrast to ourselves as substance use specialists, most of the world is either not very interested in these issues, has strange ideas about them, and/or is to some degree repulsed by them. We certainly learned that in the workplace, which is why, in the early 1970s, we ended the pattern going back to the 1940s of trying to establish employee alcoholism programs. Workplace leaders did not want to talk about alcohol problems. The lesson there is already evident, but perhaps being denied:  Physicians in primary care and other specialties are not very interested in alcohol and drug use disorders and indeed may have strong negative attitudes toward them.

That is a rather big and quite indigestible lump, so let me move to some very specific lessons from EAP implementation in the workplace that link closely to SBIRT and suggest some enlightening parallels.

The core technology of EAPs is based on strong evidence that employees whose lives are insidiously disrupted by alcohol or drugs use the security of their jobs as the core of assuming that they do not have a problem. And for some or many of these people, this is true:  they are the “high functioning” individuals with AUDs or SUDs who are successfully managing their addiction and their job performance. In a weird way, that is beyond this discussion; our cherished diagnostic criteria actually can fail to capture “high functioning” individuals, and unless they eventually slide down the Jellinek curve, they are an anomaly for much of our science.

Continuing with EAPs and letting the high functioning folks continue to function, it is assumed that many of those who are drinking or using in excessive or destructive ways will eventually manifest declining job performance in the form of poorer quality or quantity of work, attendance problems, relationship problems, chronic “presenteeism,” or role-set shrinkage (doing well at core tasks but dropping peripheral responsibilities). It is the documentation of this performance decline that becomes the tool for EAP intervention. As should be evident, this intervention has the potential for being considerably “hard-nosed” compared to the stereotypical family-based intervention where loved ones’ emotional grandstanding may be the best tool available. The EAP intervention (“constructive confrontation”) uses the written evidence of declining performance for setting limits for the improvement of job performance, with failure to do so leading to the beginning of progressive discipline. It is at this point that the employee is offered the opportunity for confidential counseling with the EAP professional, who in turn can make a preliminary diagnosis and offer a plan for treatment. This is really the SBIRT package but with different labels.

The key actor in this process is the employee’s supervisor, parallel to the primary care physician in SBIRT. Supervisors and managers learn the EAP policy, their key implementation roles in terms of documenting job performance, and set the stage for interventions when necessary.

As with SBIRT, those of us promoting and studying the EAP concept thought we had a really good idea, an idea that really was pretty water-tight. The huge challenge was to involve first-line supervisors as the vital actors in program implementation. For EAPs to really produce the promised impacts with alcohol-troubled employees, the supervisor had to be the agent of identification and follow-through to assure that the employee had a clear choice of seeking treatment and felt as motivated as possible.

This parallels the expected involvement of physicians in SBIRT. As with SBIRT, everyone agreed that problem drinking employees should be identified as early as possible to reduce the likelihood that their behaviors would become deeply embedded and increasingly difficult to change. Like SBIRT, everyone agreed that this early intervention could not only save lives, but save jobs, save money, reduce impacts on families, and even reduce impacts in the employment setting itself, in contrast to the consequences of inaction and waiting until “natural processes” created some sort of disaster that demanded emergency action.

So far, the parallels EAP supervisory involvement with SBIRT are clear:  the signs of a developing drinking or drug problem should be evident early to the physician, whereas others might not have these observational opportunities. Like the supervisor, the physician has the role, the authority, and the expectation to deal with these problems. With EAPs, we felt we were not introducing any new demands for supervisors, but simply emphasizing that supervisors use their legitimate and expected roles to enhance a goal that was well within their mandate. This also directly parallels SBIRT: knowing the long-term and multiple organ impacts of unchecked alcohol or drug abuse is evidence upon which the physician should act.

What lessons from the EAP experience might enhance the adoption and implementation of SBIRT among physicians? First, EAP experience made it very clear that supervisors needed face-to-face training in order to carry out this role. Within the organization of most workplaces, this training had to be mandatory. The training providing direction in how to approach, confront, and follow-through with the employee whose performance problems were likely due to alcohol. Experience indicated that without training, and even with what appeared to be excellent guidelines on paper and in pamphlets, policy implementation just did not happen.

And there were “latent functions” of the training itself. By bringing supervisors together in training, it was clear to all that this was a shared expectation by the workplace, not an option. Further, the group training experience was usually participative and thus gave supervisors opportunities to raise questions, express their doubts, and bring up difficult circumstances for policy execution in an environment they were sharing with their fellow supervisors. Supervisors wanted to learn the details of exactly how to execute the policy, and where they could find help in carrying out the process correctly. Role-playing that posed complicated and difficult circumstances was often part of the training. Finally, the group training experience included company staff (not outsiders) as presenters. Ideally the training was introduced by a high-level company manager, underlining the legitimacy of the new expectations, and again indicating that use of the policy was not an option but a new part of their job.

What does this training experience suggest about the implementation of SBIRT?  Such physician training is definitely needed, yet it is not clear that there are research projects underway that are testing models of SBIRT-related training to find an empirical base for what works best. The best ways to recruit physicians for SBIRT training has received little attention, assuming that training is even considered. Mandatory training is certainly not possible on a universal basis at present, but it may be possible within the limits of organizations where multiple physicians work.

But more importantly, training cannot be willy-nilly. When training is conducted, there needs to be an evidence base about exactly which steps do and do not work for physicians to really learn what they need to do, and to do it with a modicum of assured effectiveness. In EAP implementation, we relied on a sound experimental study that showed supervisory involvement in training was enhanced when the training stayed close to emphasizing their jobs as supervisors, rather than dwelling on education about alcohol abuse and alcoholism; it was hoped that this would minimize feelings of stigma and rejection. In fact, supervisory readiness to act was linked to greater rather than lesser feelings of social distance toward the alcoholic employee.

Do we have evidence to help physicians deal with patient resistance? Here physicians do not have the leverage paralleling the supervisor's.  Physicians are accustomed to a model where patients seek help and are anxious for information, whereas screening for alcohol and drug problems leads to resistant and potentially angry behaviors. Studies that inform how to deal with this resistance need to be built into training.

Note also that EAP training was conducted by workplace “insiders,” not by persons coming in from outside the organization. I would argue that successful SBIRT training requires delivery by physicians who have implemented SBIRT and who can function as both experts and role models. This not only adds to legitimacy, but offers the possibility that the trainees will actively identify with the trainer, and thus be more likely to absorb the training materials. Such SBIRT-experienced physicians are more likely to be persuasive that “it works,” compared to a non-physician “outsider” (such as a substance abuse treatment provider) whose lack of direct SBIRT experience, or do-gooder motives, might be suspect, and thus undermine possible training impact.

In line with the training experience, research on EAPs showed that top management support was vital for program interest and implementation. The extent of top management support often determined the extent to which supervisory training was delivered, so rarely could researchers examine the effects of top management support by itself. This points to the greater likelihood of successful implementation of SBIRT in multi-physician practices where there is a chain of authority. It would also indicate that the adoption process must start with top management. Once there is assurance of top management’s “buy-in,” physician training can begin, bolstered by top management involvement and evidence that SBIRT implementation is an expectation for staff physicians.

Further, when EAPs were being implemented in companies in the 1970s and 1980s, unions were of greater importance than they are today. But it was very clear from research that union involvement and support for an EAP were necessary for successful policy implementation. While perhaps not immediately obvious, the physicians’ professional associations are parallel to union involvement and support. We are yet to see substantial and sustained support for SBIRT implementation from the American Medical Association, primary physician specialty associations, other medical specialty associations, or the very important state and local level medical societies. This is not to be confused with the very visible but expected high level of support for SBIRT from the American Society of Addiction Medicine. Medical societies’ support and buy-in offer the only promise that SBIRT training or even certification could become mandatory.

Without this support from the leadership of the broader medical profession, SBIRT continues to face a barrier of legitimacy. One of the goals of professional associations, like those of unions, is to assure continuing respect and high social status for their members, along with assurance that the appropriate boundaries around physicians’ activities and expectations are maintained. We have few reports of perceptions of SBIRT from the physician side. Payments received for executing SBIRT are modest. Beyond this, the well known resistance of many who are misusing alcohol or drugs, coupled with the highly volatile, criminalized, and threatening reputations of drug abusers that the government has generated through its various Wars on Drugs, lead to real questions about physicians’ overall rewards for this participation.

The final lesson to be learned from the parallel between supervisors in EAP-related roles and physicians in SBIRT-related roles is that at least in the early stages of policy execution, they cannot and they should not be expected to “go it alone.”  This is where the presence of the EAP professional in the workplace was key to successful EAP implementation. Supervisors who had identified an employee who seemed appropriate for an EAP intervention were urged to contact the EAP professional for advice and coaching. This surely is essential for successful SBIRT implementation, but I am not aware of a coaching model being introduced into SBIRT implementation. Hopefully this idea is under development.

Finally, my critics are sure to ask this question:  Why are you recommending an EAP model that once was dominant but is now hard to find? This is indeed true, but the mechanisms that are described here still remain sound even though “internal” EAPs are still found only in some very large corporations. Did the model fail? What happened?

In the late 1980s, with the emergence of managed care, all workplaces became concerned about reducing their expenditures on health care. EAPs’ widespread (in some cases, unvarying) utilization of inpatient alcoholism treatment came under attack, and third-party reimbursement shrank relatively quickly to sharply limit inpatient treatment utilization and to reimburse only for outpatient care. At the same time, to save money, companies were encouraged to “out-source” as many of their human resource functions as possible. External EAP providers were already on the scene attempting to build a market, claiming that it was unnecessary and expensive to have company staff operate internal EAPs that could be managed much more cheaply from the outside, and with no reduction in services. In fact, they effectively exploited company executives’ lack of knowledge about the functioning of EAPs by claiming that the external EAP would generate at least as many if not more employee referrals than the internal EAP.

Once external EAPs were in place, it was obviously impossible to continue to involve supervisors in identifying and referring employees, since there was no one in the workplace to offer supervisory training, to provide consultation in EAP implementation, or to follow-through in getting employees to treatment when necessary.

What emerged was a very low cost model of telephone access that is still labeled EAP. Depending on how access is promoted, employees may use telephone service and referral somewhere within a network of contracted therapists for what have become primarily family problem resolutions and minor mental health problems. In other words, the model has been completely transformed to a self-referral approach where employees select the problems for which they want help rather than have supervisory involvement to address serious job performance issues that appeared unresolvable by other means. Thus it is an essentially different program, and the model that parallels SBIRT can only be found in a few locations.

This unfortunate transformation offers a single final lesson for SBIRT implementation. What killed (or deeply maimed) the internal EAP model was the absence of top-level management support for sustaining the value embedded within the internal model. Savings-oriented executives were persuaded to abandon their internal EAPs on the basis of relative cost and on the basis of sustained number of referrals, regardless of the reason for referral and thus the extent to which these referrals were actually solving serious management problems.

Are there parallels here?  Will large scale implementation of SBIRT lead to an increase in health care costs? I think most leaders are confident that the results will be in the opposite direction, namely reduced costs, but other evidence indicates that when these cost measurements are taken is important. Persons with alcohol and drug problems do show an upswing in medical care for a period after identification, a trend that tends to eventually move downward and stay lowered for a group of treated patients. Timing of measurement could however present problems to those who promise cost-savings.

Getting to the top of the physician community for support of SBIRT also appears as a vital lesson based on EAP experience. This means support from medical leadership of all types, including those at the top of medical care delivery organizations, as well as professional associations and local medical societies. Given the importance of medical leadership for medical change, local level influence as an ideal location for implementation needs to be considered together with influence at the top. There can be no doubt that the EAP field completely failed at educating top executives about the importance and value of an infrastructure within workplaces to deal with employee alcohol problems.

We invite readers to respond to the ideas presented.To the extent they are appropriate, these reactions may be included in future issues of The Bridge. Please address your comments to Paul Roman at the University of Georgia (proman@uga.edu).

 

The opinions expressed herein are the views of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, CSAT or the ATTC Network. No official support or endorsement of DHHS, SAMHSA, or CSAT for the opinions of authors presented in this e-publication is intended or should be inferred.



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