Situation: Critical

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 10% of employees will experience an alcohol or illicit drug use disorder at some point during their working years. This is disconcerting, considering that the diagnostic criteria for alcohol, opioid, stimulant and various other substance use disorders in the Diagnostic and Statistical Manual of Mental Disorders includes items such as “recurrent use resulting in the failure to fulfill major role obligations at work, school, or home” and “recurrent use in situations in which it is physically hazardous” (DSM 5).

And this becomes an even more serious consideration in safety-critical industries. Take the transportation industry, for example. Imagine that the 18-wheeler you were just checking out was being operated by a driver wired on crystal meth or hungover from a night of binge drinking…pretty scary. So how are Canadian employers addressing this potentially fatal workplace issue?

The SAP Solution

Employers in safety-critical industries— such as mining, oil and gas, manufacturing, transportation and construction—rely heavily on their employee assistance program (EAP) providers as a first line of defence against employee substance use issues that extend to the workplace. Many of the large EAP companies have Canada-wide teams of substance abuse professionals (SAPs) that facilitate services for these employers. Here’s how they work.

When an employee in a safety-critical role is suspected of substance use or intoxication at work, the employer is required to send him or her for biological drug testing (i.e., testing the urine, blood, saliva or hair). The employee goes to a collection site and provides a biological sample, which is sent to a lab for analysis. If the employee fails the drug test, he or she is required to meet with a SAP for an in-depth interview.

This is usually where the employer’s EAP steps in. The EAP’s SAP assesses the degree of severity of the employee’s substance use issue, the appropriate treatment options, and the trajectory of recovery and eventual return to safetycritical work. This one- to two-hour assessment also determines whether or not an employee’s alcohol or drug issues are diagnosed as substance dependence—a condition that is considered a disability in Canada.

Interestingly, it wasn’t the EAP industry or the Canadian federal government that invented the SAP assessment; it was the U.S. DOT. In the mid-’90s, the Canadian transportation industry was required to comply with U.S. DOT alcohol and drug legislation for commercial motor vehicle operators crossing into the U.S. In the absence of a Canadian federal regulatory framework, companies in other Canadian industry sectors began implementing similar policies to address their safety concerns, further integrating the SAP assessment into Canadian practice.

Fast-forward about 20 years, and those same industries have cultivated a uniquely Canadian approach. According to Barb Butler, an independent expert consultant in Canadian workplace alcohol and drug policies, “while the SAP assessment may have its roots in U.S. DOT policies, its function has become somewhat different in Canada.”

According to a precedent set in Milazzo and Canadian Human Rights Commission v. Autocar Connaisseur Inc., in Canada, an employee cannot be terminated for testing positive for alcohol or other drugs if he or she has a diagnosed substance dependence. In light of this, says Butler, the uniqueness of Canada’s SAP assessment process is that it aims to protect employee human rights and has become a crucial tool for Canadian employers in determining their accommodation obligations.

However, the Canadian framework is not a unified piece of legislation like the U.S. DOT regulations. Canada does not have specific definitions for key elements of the SAP assessment process, meaning that there is much more room for interpretation here than in the U.S. Canadian EAP companies have been key players in crafting definitions for these important components, resulting in dissenting perspectives on the professional qualifications required for SAP assessors as well as on the clinical structure for SAP assessments and reporting procedures.

This divergence has created an extremely diversified market. Employers in safety-critical industries can choose from SAP assessments that range in price from $1,000, at the high end, to as low as $350, depending on the depth of information gathered and the qualifications of the SAP. But the fact remains: for many employers, cost is one of the strongest factors in determining which type of SAP services they choose.

The ABCs of IMEs

Conversely, for employers in the Canadian rail and aviation industries, cost does not even enter into the equation. Due to strict industry standards, following a failed drug test, pilots, train operators and other employees in safety-critical roles are required to undergo a medical version of the SAP assessment conducted by a certified addiction medicine physician. Employers often pay upwards of $4,000 for these independent medical evaluations (IMEs).

Dr. Ray Baker, author of the Rail Association of Canada’s workplace alcohol and drug policies and a leading proponent of the addiction medicine approach to workplace substance abuse, believes that the key difference between the SAP and the addiction IME is the physical examination. “Without a medical exam, you miss key physical characteristics that accompany substance dependence—particularly in late-stage addiction,” which Baker refers to as the “body rot” stage. Regardless of what an employee reports in the assessment, fresh track marks, tremors and other telltale signs of addiction provide concrete evidence for an accurate medical diagnosis. This physiological perspective is ostensibly absent from the SAP assessment, Baker adds.

The addiction IME also includes biological testing—usually a urine screen taken on the day of the assessment. The results of this screen may substantiate or conflict with the employee’s responses in the assessment interview, adding perspective to the physician’s eventual diagnosis.

The legal dimension is another key factor in the pull toward an addiction medicine approach. Employee substance abuse cases that go to litigation or are brought before human rights tribunals are scrutinized from every angle. Employers charged with offences such as wrongful dismissal or employee discrimination spend hundreds of thousands of dollars in litigation fees, as evidenced in the Milazzo case. An employer that determines its disciplinary actions against an employee based on an assessment without a physical exam leaves the company in a potentially indefensible position. Consequently, employers that are at the disciplinary stage with an employee—even those with well-established SAP programs—often opt for the addiction IME.

These considerations for employers seem to favour the addiction medicine approach, but the reality is not so cut and dried. The SAP assessment dominates common practice in safety-critical industries—in large part because it is a defensible, federally validated practice in the U.S. Its affordability also adds to the draw.

A Collaborative Approach

Technology has created new opportunities for highly effective, collaborative solutions to mental health and addiction issues. The addiction e-IME—a videoconferencebased model for addiction assessments— has gained the attention of several large players in the Canadian SAP services industry and is currently being explored as a viable addition to their workplace substance abuse services.

This approach is essentially a hybrid of the SAP assessment and the addiction IME. The SAP and the addiction medicine physician work together via videoconference to assess the employee, arrive at a diagnosis, explore treatment options and craft a plan for the employee’s eventual return to safetycritical work. The e-IME includes a hands-off examination of the employee’s physical characteristics (facilitated by the SAP, with the physician’s guidance), an analysis of the employee’s urine sample and a valid medical diagnosis.

The e-IME is particularly useful for employers in safety-critical industries that have worksites in remote locations. Rather than fly an employee to an urban centre to meet with an addiction physician in person, an employer can save, on average, $800 to $2,000 in travel and accommodation costs (based on current prices) and instead have the employee assessed close to home. The e-IME is 60% to 70% of the cost of a traditional IME.

As Canada’s workplace addiction services industry continues to evolve, employers are increasingly challenged to keep pace with emerging industry standards and service innovation. And while diverse perspectives on service protocols may pull employers in different directions, cost remains a key factor. Technology-enabled models for collaboration that build on the existing infrastructure of services present clinical efficiencies and offer cost-saving solutions that will define the future of workplace substance abuse services going forward.

Aaron Spodek is vice-president, business development and operations, with Vector Assessments.

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