The authors are affiliated with the Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, MS 035, 415 South St., Waltham, MA 02454-9110 (e-mail: merrick@brandeis.edu). Shelly F. Greenfield, M.D., M.P.H., is editor of this column.

The workplace provides a unique opportunity to address the entire spectrum of substance use problems, both diagnosable abuse or dependence and other problematic use. Most adults with substance use problems are employed, and an estimated 29% of full-time workers engage in binge drinking and 8% engage in heavy drinking; 8% have used illicit drugs in the past month (1). Substance use problems contribute to reduced productivity (2), absenteeism, occupational injuries, increased health care costs (3), worksite disruption, and potential liability as well as other personal and societal harms.

Employee assistance programs (EAPs), which grew out of occupational alcohol programs, have dramatically evolved into a more comprehensive behavioral health resource that is widely available. Given the current level of concern regarding health care costs and productivity—and the awareness that substance use problems are underrecognized and undertreated—it follows that interest in EAPs is stronger than ever. This column describes the contemporary EAP, explores key issues in service delivery, and proposes a research agenda to help drive the future direction of this important behavioral health resource.

EAPs are workplace-based programs designed to address substance use and other problems that negatively affect employees' well-being or job performance (4). About 66% of worksites with 100 or more employees (5) and 90% of Fortune 500 firms have an EAP (6). Most contemporary EAPs are "broad-brush" programs that address a wide spectrum of substance use, mental health, work-life balance, and other issues (7). EAPs typically offer three to eight visits for assessment or short-term counseling or both, with no copayment. Employees may be referred by supervisors for poor job performance related to substance use or other problems, or—more commonly—they may self-refer. Services are often extended to family members. In some cases, short-term counseling is sufficient to address a client's needs. In others, the client is assessed, referred to behavioral health treatment outside the EAP, and provided follow-up support as needed.

Contemporary EAPs typically deliver services off site through contracted networks of managed behavioral health care organizations. An EAP can be a separate benefit feature or it can be integrated with behavioral health benefits. Although a utilization rate of 5%—8% has been suggested as a desirable target (8), reported utilization rates vary widely, partly because of differences in services and segments of the population counted. Often a sizeable minority of EAP clients have substance use problems, although they do not always have a substance use diagnosis. EAPs also provide services at the organizational level to improve the work environment and enhance job performance—for example, by developing workplace substance abuse policies, providing consultation to supervisors dealing with problem employees, and implementing drug-free workplace and other health promotion activities.

Discerning the effects of EAPs

Many organizations find that EAPs are useful and generate cost savings, which accounts for the near-ubiquity of EAPs in large workplaces. In fact, a substantial body of literature describes the impact of EAPs on outcomes, health care utilization, and direct and indirect costs. Reviews of EAP research, only some of which is specific to substance use problems, indicate that most studies have found improved clinical and work outcomes and positive economic effects measured in a variety of ways (4,9,10,11). However, the complexities of determining cost-related effects are illustrated by evidence that EAP users' health care costs may actually rise temporarily, possibly because of EAPs' facilitation of needed services (12).

Reviews have also noted significant methodological limitations in this body of research (4,9,11) and a relative dearth of recent studies applicable to current EAP models (10,13). Many studies are limited to single cases, lack control or appropriate comparison groups, have threats to validity because of self-selection bias or regression to the mean, or were conducted in program models that are now rare. Thus questions remain regarding how contemporary EAPs affect outcomes and costs.

Implications of changes in service delivery

Some observers postulate that the evolution to a broad-brush approach delivered by external practitioners has diluted EAPs' traditional focus on substance use problems. Providers in managed behavioral health networks may be mental health practitioners with scant workplace-specific substance abuse training, historically a core competency for employee assistance professionals (7). A lack of close relationships between off-site EAP providers and supervisory personnel may reduce opportunities for early problem identification. However, because stigma and fear of work-related consequences are often even higher for workers with substance use problems than for those with other behavioral health problems (14), embedding services for substance use problems in broadly configured EAPs may increase acceptability.

Optimal utilization of EAPs and their effectiveness in addressing substance use problems may depend on how services are promoted. The presence of an EAP is highly correlated with an organization's guidelines against the use of alcohol at work-related functions and the existence of no-smoking policies, suggesting that some workplace cultures more strongly emphasize proactive approaches to employee behavioral health (15). Strategies to increase utilization through enhanced outreach can be effective (16). Factors such as employee awareness of the EAP, positive attitudes toward company policy, and belief in EAP confidentiality improve willingness to use EAPs (17,18). Supervisor training is also important.

Evaluation and comparison of EAP services has been made more difficult by the lack of common performance measures. Performance measures can be used for quality improvement, accountability, and performance-based contracting and can be incorporated into research to yield more comparable evaluations. Following the overall trend in health care, there is a growing movement toward developing and adopting standardized performance measures in the EAP field (19). This trend will benefit all stakeholders, including purchasers, providers, and ultimately service users.

Employers continue to offer EAPs as well as a growing number of other health promotion, disease management, and disability programs. Although this expanding menu of health-related initiatives may be designed to encourage access, fragmentation and redundancy of services are potential pitfalls. Employer groups and advocacy organizations have called for increased coordination and integration between EAPs and other programs to enhance quality of care (20,21).

The evolution of EAPs and the key issues noted above give rise to a new agenda for research. Areas for research include descriptive studies of EAP utilization and costs to provide an up-to-date picture of services; investigations of how externally delivered, broad-brush programs address substance use problems, including management consultation for early identification; further studies of EAPs' effects on outcomes and costs, including a focus on productivity and outcomes for work groups; systematic examination of the relationship between EAP activities and other workplace resources; efforts to further identify facilitators of and barriers to EAP utilization; and finally, development, testing, and validation of EAP performance measures.

Methodological approaches to help implement this research agenda include fielding larger-scale studies that encompass multiple work sites and employers; using group-level randomization, quasi-experimental designs, and statistical techniques to reduce selection bias, identify causal connections, and control for group differences; capturing a wider range of factors in multiple domains to more accurately measure utilization, outcomes, and costs; and making greater use of standardized instruments when measuring clinical outcomes and productivity.

In the contemporary U.S. work environment, there is great interest in EAPs as a way of addressing substance use problems, which can be costly and detrimental to both individuals and their employers. EAPs are uniquely positioned to provide relatively barrier-free preventive services and screening, early identification, short-term counseling, referral to specialty treatment, and other behavioral health interventions for the privately insured population. As EAPs continue to evolve, a well-defined research agenda is crucial to understanding and capitalizing on EAPs' potential for addressing substance use problems through workplace programs.

This work was supported by grant P-50-DA-010233 from the National Institute on Drug Abuse through the Brandeis-Harvard Center for Managed Care and Drug Abuse Treatment. The authors thank Laura Altman, Ph.D., Vanessa Azzone, Ph.D., Deirdre Hiatt, Ph.D., Dominic Hodgkin, Ph.D., Frank Holt, B.S.N., M.S.Ed., and Sharon Reif, Ph.D., for their helpful comments.

The authors report no competing interests.