Workplace Supported Recovery: New NIOSH Research Addresses an Evolving Crisis

Introduction

The nation continues to struggle with a complex, ever-changing substance use landscape and an increase in related overdose deaths. Substance use disorders (SUDs) represent an important public and occupational health issue that is costly for society and limits an individual’s success and opportunities in many important areas of life (e.g., family, friendships, employment).^1,2

The complex nature of SUDs and recovery may not be understood fully by employees, unions, employers, and many occupational health researchers. A better understanding of SUDs, SUD recovery, and the workplace’s potential influence on recovery may promote effective workplace policies and interventions to encourage and sustain recovery efforts among employees facing an SUD and spur the development of new research.

A new article published in Occupational Health Science provides a broad review of existing research relevant to workplace supported SUD recovery.² We summarize some key issues below.

SUDs in the Workforce

National U.S. data show² that 70% (about 13.6 million workers) of all adults with an alcohol or illicit drug use disorder are employed, making the workplace an important setting to address SUDs. The 13.6 million workers with an SUD represent nearly 9% of all employed adults. About 1.9 million workers (1%) receive treatment annually for an SUD, and about 13.3 million workers (nearly 9%) report that they are in recovery or have recovered from a past or present substance use problem. Finally, among individuals with an SUD, approximately 53% have a mild disorder, 23% have a moderate disorder, and 24% have a severe disorder.^3,4 The term addiction often is used to characterize severe SUDs.^1,5

Recovery Themes: What Is SUD Recovery? 

SUD recovery is a complex and dynamic process that takes time and involves many life changes that can differ among individuals. Several general themes in the recovery literature characterize the recovery process:²

• Recovery represents more than a complete or progressive move away from substance use and the associated harms. Importantly, it involves accumulating positive benefits obtained by developing or rebuilding a healthy, productive, and meaningful life.^1,6-9
• There is no single path to recovery. Individuals differ in the causes, severity, and outcomes of an SUD, and internal (e.g., self-esteem, motivation to change, functional coping skills) and external (e.g., social support from family, friends, and coworkers, financial assets) resources available to address the disorder.⁹ Research suggests that recovery is sustainable and empowering and needs to be voluntary and self-directed. Using medications in conjunction with behavioral treatments or involvement in peer support groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, Medication-Assisted Recovery Anonymous) is considered first-line treatment for severe opioid and alcohol use disorders. However, no FDA-approved medications exist for other severe SUDs. Additionally, formal behavioral treatment or involvement in peer support groups without medication may be sufficient for some individuals with mild to moderate SUDs and unnecessary for others.¹⁰ Therefore, multiple pathways to recovery exist.
• The stage of recovery will differ across individuals based on its length and its level of impact on an individual’s functioning in daily activities: (1) early recovery—1 to 11 months, (2) sustained recovery—1 to 5 years, and (3) stable recovery—5 or more years.^7,8,11,12 As the recovery length increases, the annual risk of SUD recurrence drops substantially. Among individuals who have been in recovery for 5 or more years, the chance of recurrence of their SUD is approximately the same as the chance of someone in the general population developing a substance use disorder.¹³
• SUD recovery benefits from adopting a chronic care model.^10,14 The traditional acute care model promotes an expectation that single or short-term treatment episodes will cure individuals with an SUD. However, such an expectation does not exist for other chronic health problems, like diabetes or asthma, for which there is no cure.^15,16 In the acute care model, SUD treatment often is considered ineffective when symptoms of SUD return. In contrast, a chronic care model recognizes the potential need for multiple cycles of treatment, symptom remission or recurrence, and reestablishment of treatment and self-management before a person achieves stable recovery.^14,17,18 In fact, the symptom recurrence rate for SUDs due to nonadherence to treatment is similar to that for Type 1 diabetes, hypertension, and asthma.^15,16 Therefore, the recurrence of symptoms during or after treatment does not indicate that SUDs are untreatable.¹⁸ Instead, it is consistent with other chronic disorders requiring a lifelong commitment to treatment, including adjustments or multiple treatment approaches and methods treatments for its management. ^1,14
• Having an SUD or being in recovery from an SUD can lead to stigma and discrimination in the workplace. Specifically, the stigma associated with an SUD may result in²
  • difficulty obtaining or maintaining employment;
  • precarious employment or a restriction to lower-paying work;
  • unfair oversight that reduces job performance;
  • limited promotion opportunities;
  • experiencing social exclusion; and
  • difficulty obtaining employer accommodations.

Such stigma and discrimination in the workplace may undermine access to treatment, treatment initiation, and sustainability of recovery efforts.

What Is Workplace Supported Recovery?

An important recurring theme in the recovery literature is the importance of employment, which can play a vital role in an employee’s SUD recovery .^19-25 Recognizing the significant role employment and employers can play in workers’ recovery efforts, there are efforts at NIOSH, other national and state level agencies, and recovery organizations to promote Workplace Supported Recovery.

NIOSH defines Workplace Supported Recovery as:

An integrated set of evidence-based interventions and policies that (a) reduce workplace hazards promoting the development or perpetuation of substance use disorders and undermining recovery from substance use disorders; (b) increase workplace supports preventing the development or perpetuation of substance use disorders and facilitating recovery from substance use disorders; (c) help employees maintain or regain employment during recovery; and (d) promote overall growth and well-being among employees, work organizations, families, and communities.²

Efforts to promote Workplace Supported Recovery have primarily focused on the resources provided by employment that can encourage and support recovery efforts. This focus is understandable because employment can provide many critical resources (e.g., income, health benefits, time structure and regular activity, social contacts, purpose and meaning, development of skills, goal achievement, and status and identity).^26,27 However, it is also essential to consider that work and the workplace may expose employees to risk factors for substance misuse and SUDs, such as work stressors, substance availability, and workplace social norms that support substance misuse.^28-30 In addition to potentially contributing to or perpetuating SUDs, these work and workplace characteristics may also undermine the initiation and sustainability of SUD recovery efforts. Therefore, addressing Workplace Supported Recovery benefits from considering both the positive and negative aspects of work conditions and the work environment.

Little direct research exists on the association of workplace hazards and supports with initiating and maintaining recovery efforts among employees with an SUD. However, a larger body of research on the association of the workplace with substance misuse and SUDs points to several work conditions that may either undermine or support the initiation or sustainability of recovery efforts.²

Examples of work-related hazards that threaten recovery may include:

• Negative work conditions and outcomes (excessive demands, bullying, job insecurity, hazardous physical work conditions, work-related injuries);
• Norms and social rituals that increase substance use;
• Physical availability of drugs or alcohol in the workplace; and
• Stigma and discrimination.

Examples of workplace recovery supports may include:

• Positive work conditions (fair treatment and rewards, recognition, promotion opportunities, meaningful work, ability to develop and use relevant skills, social support from coworkers and supervisors);
• Workplace social control (low mobility during work hours, high task interdependence, direct contact with coworkers and the public); and
• Organizational support, which reflects a human capital view of employees as making valuable contributions and warranting time and resources to develop their skills.

Is SUD Recovery Associated with Positive Employment Outcomes?

Some research suggests that SUD recovery may be associated with positive work outcomes. For example, a change from a current SUD to recovery is associated with better work attendance, stable employment, positive job performance evaluations, fewer disciplinary actions, and lower healthcare costs.^31-37 Additional research using stronger study designs is needed to provide more robust evidence for these benefits.²

Promoting Workplace Supported Recovery

More research is also needed on the direct association of the workplace to the various dimensions of SUD recovery. Employers can contribute significantly by partnering with outside researchers to understand this issue better and develop effective policies and interventions. Although more robust research is needed, available research suggests several things employers can do to promote SUD recovery efforts among employees.

• Prevent work-related injuries and illnesses and reduce negative work conditions that could exacerbate substance use among employees with a current SUD or contribute to a return to use among employees in recovery.
• Support the development of favorable work conditions that provide internal (e.g., self-efficacy) and external (e.g., peer and supervisor support) resources needed to initiate and sustain recovery efforts.
• Promote using nonpharmacologic treatments and nonopioid medications, when appropriate, for pain management associated with a workplace injury or illness.
• Provide information and access to care for an SUD when needed, including access to medication-based and/or individual counseling.
• Support employment of individuals in treatment and recovery.
• Extend workplace accommodations and other return-to-work assistance.
• Offer peer support and peer coaching to bolster the social supports available to workers in recovery.
• Promote a work culture that supports workers in recovery (for example, awareness building, stigma reduction, and alcohol-free social events).

As we strive to prevent and address SUDs among workers, it is crucial to understand better the role of work and the workplace in recovery. Please join NIOSH’s efforts to advance Workplace Supported Recovery for those with SUDs. What steps has your organization taken to assist workers’ initiation or maintenance of their recovery efforts?

Michael R. Frone, PhD, is a Research Professor with the Department of Psychology, University at Buffalo, The State University of New York. 

Jamie C. Osborne, MPH, CHES® is a Public Health Analyst with the NIOSH Office of the Director.

L. Casey Chosewood, MD, MPH, is Director of the NIOSH Office for Total Worker Health.

John Howard, MD, Director, National Institute for Occupational Safety and Health

For more Information

NIOSH Workplace Supported Recovery

Recovery-Ready Workplace Resource Hub

References

1. Office of the Surgeon General. Facing addiction in America: The surgeon general’s report on alcohol, drugs, and health. Washington, DC: U.S. Department of Health and Human Services; 2016.
2. Frone MR, Chosewood LC, Osborne JC, Howard JJ. Workplace Supported Recovery from Substance Use Disorders: Defining the Construct, Developing a Model, and Proposing an Agenda for Future Research. Occup Health Sci (2022). https://doi.org/10.1007/s41542-022-00123-x
3. Hasin DS, Kerridge BT, Saha TD, et al. Prevalence and correlates of DSM-5 cannabis use disorder, 2012-2013: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions-III. American Journal of Psychiatry. 2016;173(6):588-599.
4. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757-766.
5. National Institute on Drug Abuse. Drugs, brains, and behavior: The science of addiction. In. Bethesda, MD: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.; 2018:1-32.
6. UK Drug Policy Commission. The UK drug policy commission recovery consensus group: A vision of recovery. In. London: Author; 2008.
7. Betty Ford Institute Consensus Panel. What is recovery? A working definition from the Betty Ford Institute. Journal of Substance Abuse Treatment. 2007;33:221-228.
8. White WL. Addiction recovery: Its definition and conceptual boundaries. J Subst Abuse Treat. 2007;33:229-241.
9. Ashford RD, Brown A, Brown T, et al. Defining and operationalizing the phenomena of recovery: A working definition from the Recovery Science Research Collaborative. Addict Res Theory. 2019;27:179-188.
10. Sheedy CK, Whitter M. Guiding principles and elements of recovery-oriented systems of care: What do we know from the research? In. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2009.
11. el-Guebaly N. The meanings of recovery from addiction: Evolution and promises. Journal of Addiction Medicine. 2012;6:1-9.
12. O’Sullivan D, Xiao Y, Watts JR. Recovery capital and quality of life in stable recovery from addiction. Rehabilitation Counseling Bulletin. 2019;62:209-221.
13. Kelly JF, Greene MC, Bergman BG. Beyond abstinence: Changes in indices of quality of life with time in recovery in a nationally representative sample of U.S. adults. Alcoholism: Clinical and Experimental Research. 2018;42(4):770-780.
14. Arria AM, McLellan AT. Evolution of concept, but not action, in addiction treatment. Subst Use Misuse. 2012;47(8-9):1041-1048.
15. O’Brien CP, McLellan AT. Myths about the treatment of addiction. Lancet. 1996;347(8996):237-240.
16. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association. 2000;284(13):1689-1695.
17. White WL, Kelly JF. Recovery management: What if we really believed that addiction was a chronic condition. In: Kelly JF, White WL, eds. Addiction recovery management: Theory, research and practice. New York: Springer; 2001:67-84.
18. Dennis M, Scott CK. Managing addiction as a chronic condition. Addiction Science & Clinical Practice. 2007;4:45-55.
19. Brown AM, Ashford RD. Recovery-informed theory: Situating the subjective in the science of substance use disorder recovery. Journal of Recovery Science. 2019;1:2-15.
20. Borrelli MR, Mantori S, Kaar S, Kelleher M, Bell J. The meaning of “recovery” for addiction treatment and research. Journal of Addiction & Addictive Disorders. 2017;4: 012.
21. Grover C, Paylor I. No one written off? Welfare, work and problem drug use. Drugs: Education, Prevention & Policy. 2010;17:315-332.
22. Laudet AB, White W. What are your priorities right now? Identifying service needs across recovery stages to inform service development. Journal of Substance Abuse Treatment. 2010;38(1):51-59.
23. Room JA. Work and identity in substance abuse recovery. Journal of Substance Abuse Treatment. 1998;15(1):65-74.
24. Monaghan M, Wincup E. Work and the journey to recovery: Exploring the implications of welfare reform for methadone maintenance clients. Int J Drug Policy. 2013;24(6):e81-e86.
25. Worley J. Recovery in substance use disorders: What to know to inform practice. Issues in Mental Health Nursing. 2017;38:80-91.
26. Jahoda M. Work, employment, and unemployment: Values, theories, and approaches in social research. American Psychologist. 1981;36(2):184-191.
27. Jahoda M. Employment and unemployment. Cambridge, England: University Press; 1982.
28. Frone MR. Employee psychoactive substance involvement: Historical context, key findings, and future directions. Annual Review of Organizational Psychology and Organizational Behavior. 2019;6:273-297.
29. Frone MR. Alcohol and illicit drug use in the workforce and workplace. Washington, DC: American Psychological Association; 2013.
30. Ames GM, Moore RS. Substance use in specific settings: The workplace and the military. In: Sher KJ, ed. The oxford handbook of substance use and substance use disorders. Vol 2. New York: Oxford University Press; 2016:579-599.
31. Arbour S, Gavrysh I, Hambley JM, Tse A, Ho V, Bell ML. Addiction treatment and work-related outcomes: Examining the impact of employer involvement and substance of choice on absenteeism, tardiness, and productivity. Journal of Workplace Behavioral Health. 2014;29:73-90.
32. Slaymaker VJ, Owen PL. Employed men and women substance abusers: job troubles and treatment outcomes. Joutnal of Substance Abuse Treatment. 2006;31:347-354.
33. Goplerud E, Hodge S, Benham T. A substance use cost calculator for US employers with an emphasis on prescription pain medication misuse. Journal of Occupational and Environmental Medicine. 2017;59(11):1063-1071.
34. Laudet A. Life in recovery: Report on the survey findings. Washington, DC: Faces & Voices of Recovery; 2013.
35. McQuaid RJ, Malik A, Moussouni K, Baydack N, Stargardter M, Morrisey M. Life in recovery from addiction in Canada. Ottawa, Ontario, Canada: Canadian Centre on Substance Use and Addiction; 2017.
36. Best D, Albertson K, Irving J, Lightowlers C, Mama-Rudd A, Chaggar A. UK life in recovery survey 2015: The first national UK survey of addiction recovery experiences. Sheffiled, UK: Helena Kennedy Centre for International Justice, Sheffield Hallam University; 2015.
37. Best D. The Australian life in recovery survey. Melbourne, Australia: Turning Point, Eastern Health; 2015.