Substance use and work

Introduction

The inappropriate use of substances by employees may face European employers with problems at workplaces. These include increased absence due to sickness, higher accident risks, lower levels of performance and reduced productivity of staff. Companies should find the best way to deal both proactively and reactively with the issue of substances and their impact on work and employment. Due to the huge legal and cultural differences in the Member States, there is no universal solution. Resources can be tailored to comply with national requirements and best suit the actual situation at the shop-floor level. Substance issues do not solve themselves and the fundamental is an appropriate company policy with a strong focus on prevention.

Substance use, addiction and workplace

Definition of substance use and addiction, brief description of substances

This article covers illicit drugs and alcohol. Substance abuse and dependence appear on the continuum of "Substance Use Disorder", which replaced the former categories in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders. The new label stretches from occasional "substance misuse" to the chronic state of "addiction".^[1] Severity is based on the number of criteria endorsed.^[2] However, a clear distinction is necessary to differentiate between an occasional user and an addicted person.

Substance use ranges from social (occasional), via heavy (exceeding the safe limit value) and problem (causing various problems in life) to dependent (cannot carry on without). Even social use can be risky in certain situations (driving, operating machinery) and the above mentioned steps represent growing risks for safety and health in and outside of work.

Problem drug use is defined by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) as 'injecting drug use or long duration or regular use of opioids, cocaine or amphetamines'.^[3]

Distinction must be made between acute and the chronic effects in the following brief descriptions of the most relevant substances.

Alcohol blocks inhibitory brain cells making the consumer feel relaxed and more sociable. It also hinders thorough decision making, spoils reaction efficiency, causes sleepiness and may give way to risk-prone and aggressive behaviour. Chronic heavy drinking can lead to malfunctions of the liver, the pancreas, the heart, the immune system, the brain and the nerves. It elevates the risk of certain cancer types and psychiatric disorders. As addiction builds up, the sudden withdrawal of drink may cause severe attacks (seizure, delirium).^[4][5]

Small doses of cannabis can have effects like alcohol (euphoria, relief of anxiety, sedation and drowsiness) and alike impairs the individual's driving capacity. It is claimed that chronic use can also lead to anxiety, depression, or even psychosis, personality change, loss of motivation, cognitive impairment.^[6] It may be conducive to drug addiction. It poses the same health risks as tobacco when smoked.

Stimulant and hallucinogenic effects can be varyingly attributed to the different compounds of amphetamines, ecstasy and hallucinogens. The stimulation of the nervous system suppresses fatigue, elevates blood pressure, heart rate and body temperature, which can be even lethal. There can be an increase of self-confidence and sociability. Most of the substances may change perception and alter the mood/thinking up to "lucid awareness". Stimulant users can feel irritable, restless, anxious, exhausted, depressed and lethargic afterwards. Hallucinogens can cause panic reaction and psychosis. Chronic use produces memory deficit, decreased decision-making and verbal reasoning, and even symptoms resembling to paranoid schizophrenia.

Cocaine – otherwise used as a medical topic anaesthetic – is a strong psychomotor stimulant producing euphoria, high blood pressure and heart rate with suppressed appetite. The above physiological effects of cocaine can induce a stroke. Psychological addiction builds up remarkably fast and thus affects behaviour.

The main effect of opioids (morphine, heroine) is analgesia (many are used as medicines for patients with severe pains) together with euphoria and a sense of detachment. Furthermore, it slows down several bodily functions like body temperature, breathing and digestion, and causes nausea and drowsiness. Acute overdose is a common source of death. Physical addiction is substantial, which is accompanied by augmenting doses; sudden quitting can cause withdrawal symptoms. Most common health impairments due to chronic use are infections (hepatitis, HIV) because usually they are taken intravenous.^[7] A complete overview on the profiles of illicit drugs is available at EMCDDA.^[8]

The substance misuse situation in Europe

Europe is consistently the top consumer of alcohol^[9]. In the EU 5% to 20% of the working population is estimated to be either addicted to alcohol or to be at risk of becoming addicted.^[10] Based on current population and employment data this can mean tens of million employees having such problems. Alcohol is the third highest out of 26 risk factors for ill health in the European Union.^[11]The most popular illicit substance in Europe is cannabis, especially among young males. Its consumption appears relatively stable with an estimated 1% of the adult population using it on a daily basis. Opioids and injecting drug use represent the greater part of problem drug use in Europe. However, amphetamines or cocaine are important substances in some countries. European drug associated morbidity, mortality and harm can be still heavily attributed to heroin and cocaine.^[12] According to data from the United States of America, 65% of substance user adults were employed full or part time in 2011.^[13] There are certain sectors where alcohol and drug consumption is particularly relevant (construction, farming, HORECA, transport). Concerning occupational categories, alcohol is more typically used among blue-collar workers, while cocaine among professionals in the information and communication technology and the financial services.^[14]

The EU Drug strategy (2005-2012) focused on two policy fields: demand reduction and supply reduction.^[15] In 2006 the European Commission issued the Communication that briefly addressed workplaces too.^[16] The European Workplace and Alcohol project (EWA) set two important target groups:

• the young who are entering the labour market, because they are most vulnerable, and run much greater risks of unemployment; and
• the older middle age because they are the age group at the greatest risk of an alcohol-related death, while they posses valuable work experience.^[17]

The Report from the European Commission on the implementation of the Council Recommendation on the prevention and reduction of health-related harm associated with drug dependence in 2007 concluded that workplace substance misuse should be addressed in the Strategy on Safety and Health at Work.^[18]

Understanding the underlying reasons for drug use

Regular substance misuse is often a coping strategy with an uncomfortable or problematic situation. These can have work-related reasons and/or social/personal reasons. The background or origin of work related reasons can be the physical working environment (e.g. working in cold), the work organisation and psychosocial work environment (e.g. low satisfaction, irregular working time, low social support at work, mobbing and work-related stress).High job pressure, job insecurity, working far from home are also risk factors for alcohol and drug problems. Social factors range from consumption-prone cultural patterns and tolerance towards alcohol/drug consumption, and the accessibility of these substances. Certain types of personality and the family background are the main personal factors. Tolerance to or misuse of alcohol or drug by the friend / partner, frequent or binge drinking, start to drink at early ages, having dependence in family history, mental problems, depression are further identifiable risk factors.^[19][20]

Substance misuse at work can be the sign of an unhealthy workplace. Such reasons can be dealt with more effectively by the company (and its OSH and related services) than the non-work-related reasons.

Impact at workplace

Alcohol and drug consumption can cause serious problems at the workplace. It is practically irrelevant whether the consumption takes place at work or outside, the following consequences are observable:

• Health disorders;
• Elevated sick leave/short-term absenteeism rate;
• Reduced performance and presenteeism;
• Conflicts at workplace and unsettled working environment;
• Work accidents, safety and other risks;
• Damage to company reputation, equipment or products.^[21][22][23]

Data on alcohol at work is more available then on illicit drugs. The World Health Organisation (WHO) emphasises the serious consequences of alcohol on health in their report: absenteeism and decreased productivity and the intoxicated people negatively affecting co-workers. The hazardous and harmful use of alcohol has impact on workers’ productivity too.^[24] Absenteeism, unemployment and lost working years through premature death was estimated to cause from 39 to 102 billion Euro worth of lost productivity, which was almost the half of the tangible costs of alcohol to the European Union in 2003.Only light drinking is linked with a slightly reduced absenteeism. Higher alcohol use increases injury also to others at work.^[25] US data showed that alcohol use and alcoholism caused up to 40% of fatal and 47% of non-fatal accidents at work.^[26] Alcohol or drug abuser employees are 3.5 times more likely to be involved in a workplace accident, than the employees, who have no problem with substances.^[27]

Legal principles and the issue of testing

While legislative measures are essential to prohibit or control substance use in the workplace (especially in safety-sensitive jobs and sectors), the preventive approach can help in containing the problem.^[28] The respective legislations of the Member States differ considerably, influenced by the national culture, the relevance of the issue at the given country or the quality of social dialogue. Substance use at work is dealt either by the labour codes or by specific occupational safety and health legislation, certain countries rank it among matters of social dialogue.

The issue of testing is a very delicate one. On one hand there are safety and productivity demands by the employer and the society, on the other hand the employees' rights to privacy.^[29]

There may be specific regulations on alcohol at work or the process may be left at the employer’s discretion. In cases where the result of a breathalyser is positive, a blood analysis may be required to confirm the result. For drug detection, oral swabs, eye, urine or blood tests are typically used, though the latter are considered intrusive and thus not often recommended.^[30]

Due to the substantial differences in the legislation between Member States, the employer is advised to carefully study the legislation in force of the given country when addressing testing in the company alcohol and drug policy. In certain cases the employer may have no choice in the applicable conduct when a worker is found positive (e.g. reporting to the police in case of an accident at work, drink driving, etc.).

The best corporate approach

It is unquestionably very important, that the company has to have a good corporate approach and activity to handle the substance use problem in the workplace. There are three beneficiaries of these activities: the workplace, the employee, the society.

• The workplace: Spending on prevention and early intervention is not an expense, but an investment. This investment prevents the high cost of absenteeism, loss of productivity, disciplinary suspension, poor co-worker relation, company moral and increased possibility of accidents related to unsuppressed substance use.
• The employee: work has a central role in employees' life: maintaining income, social status and prestige. Substance use problems can seriously threaten or ruin these values. Taking part in prevention or early intervention helps people with such problems to keep the advantages of being employed.
• The society: On the basis of European studies, the approximately 59 billion Euros productivity loss contributed 47% of the total cost of alcohol to Europe.^[31]

The workplace has a considerable potential to prevent the substance misuse related problems, as the majority of adults at risk are employed. Workplace prevention programs reach a lot of people, which would be harder in any other setting. Workplace health promotion (WHP) strives to keep people in their carriers and productivity, so effective workplace prevention and early intervention save money and quality life.^[32]

The international and European background of best corporate approach

There are many efforts on international, European and national levels dealing with alcohol and drug use at work, as stakeholders understood the severity of the problem.^[33]

The International Labour Organisation offers an inspiring publication which includes a comprehensive description of drugs and problems; it outlines the paradigm shift to prevention and the programme to reach this goal.^[34] Several organisations provide useful information for implementing alcohol and drug policy in the workplace on a European Union scale:

• European Monitoring Centre for Drugs and Drug Addiction (EMCDDA),
• Pompidou Group,
• European Agency for Safety and Health at Work (EU-OSHA),
• European Alcohol and Health Forum.

The Commission report^[35], the European project European Workplace and Alcohol^[36], the EU strategy Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions, An EU strategy to support Member States in reducing alcohol related harm. Retrieved 18 March 2013, from: https://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:52006DC0625:EN:NOT and the EWCO Comparative study^[37] are further relevant sources.

The WHO EURO mentions the alcohol problem at workplace in the European action plan to reduce the harmful use of alcohol in 2012–2020. One of the main areas of policy options and measures to be considered are the community and workplace actions. Strategies that can reduce alcohol consumption are the promotion of alcohol-free workplaces, the reduction of stress and the increase of the rewarding system. Psychosocial trainings, brief advice and alcohol information programmes can be implemented. There is a risk of using resources inefficiently, because most of the workplace alcohol and drug programmes have never been evaluated. Thus the resources and assessment tools for workplace action on alcohol and drug should be developed, and the implementation should be evaluated.^[38] There are examples for certification system where funding is available only to certified programmes.^[39]

Corporate approaches

There are many ways to reduce substance use and abuse problem in the workplace. There are overlaps of these categories, or they can include each other. All they can be used to improve the situation at the workplace.

• Written drug and alcohol policy (including testing rules; implementing a drug-free workplace)
• Health promotion and prevention (including communication and education)
• Offering health benefit (including counselling, treatment and rehabilitation)
• Employee Assistance Programmes
• Reducing adverse work environment that increases the risk of alcohol and drug use

Best corporate approach and workplace health promotion

The special characteristic of alcohol and drug use at workplace accounts for having a special policy. The MEPMIS project^[40] gathered the basic principles for an alcohol and drug policy at work:

• a formal written document that contains a clear statement of intent,
• is consistent with other organisational policies,
• senior management support and commitment,
• accountability,
• applicable to all,
• communication,
• confidentiality issues are addressed,
• developed and agreed through consultation,
• the policy objectives are clearly stated,
• health and safety obligations are fulfilled,
• education and training form an integral component of the policy,
• data protection regulations,
• the policy is constantly monitored and reviewed,
• timing.

The companies are different, they have different problems, different attitudes, different other policies, so the alcohol and drug policy have to be tailored to it, nonetheless the basic principles have to apply. The alcohol and drug policy should be in written format, similarly to the other policies of the company. It has to include a clear statement of intent about the role in the issue of alcohol and drugs, concerning prevention, employee support, health, safety and welfare, procedures and improving the policy. The document has to be in line with other company policies and legislations, like the Health and Safety policy and regulations, data protection regulations. Not just the data protection is important, but the confidentiality is also a fundamental principle. The policy can be effective in case the senior management supports it, and it concerns every member of the company. The policy has to be developed through consultation, and monitored and evaluated during the implementation. It has to set clear roles for accountability.

Communication, education, training are also important parts of the policy. At least three months should be left for the people to adapt to the new policy.^[41]

Basic principles of the corporate alcohol and drug policy

Taken into consideration the international and European recommendations, the best corporate approach to handle drug and alcohol at work is to implement an alcohol and drug policy that is embedded into workplace health promotion.
Source: ENWHP^[42] adapted by the authors The European Network for Workplace Health Promotion (ENWHP) worked out a toolbox that classifies workplace health promotion according to four aspects. The alcohol and drug issue belongs to workplace health promotion under the lifestyles issues. The manager who wants to implement an alcohol and drug programme can look for one with respect to the setting, the tool category, and the corporate health policy issues. (figure 1)

Offering health benefit, including counselling, treatment and rehabilitation

It is important that the employees with alcohol and drug problems should have access to help, counselling, treatment, rehabilitation and reintegration. Dependencies are treatable conditions, if the employee fully cooperates. Such help is fostered by the employer, and provided by independent experts or institutions. After the completion of successful treatment, the employee free from alcohol and drug problems should be employed or re-employed, which is true even for such demanding working environments like the maritime industry.^[43]

Of course, there are many points of view to be taken into consideration, like safety and security; privacy and confidentiality; finding good health care, help provider; providing an after care or relapse prevention; agreement with trade unions or workers and their representatives.^[44]

If there are no clear rules, confidentiality or offers for help, the chances are very high that the employees will hide their own and their colleagues' alcohol and drug problems, and it will turn out when it is too late. Peer education proved to be a valuable tool in primary prevention especially among populations of youth at risk.^[45][46][47]

Employee Assistance Programme (EAP)

Employee Assistance Programmes, which in Europe are practically understood as WHP measures, can also be used in the field of substance abuse in the workplace.

In this case the EAP is a program that provides a variety of support for the employees who have problems with alcohol and drug use. These are offered by the employer, aiming to reduce the drug and alcohol related problems, which might adversely affect the employees work performance. EAP should be established with the cooperation of workers and their representatives, because its important characteristic is the confidence. EAPs may provide help to the employee's family too. EAP can be a starting point for an initial assessment and referral to specialist caregivers.^[48]

EAPs have several benefits for the employer: it helps avoiding later absenteeism, reduced work performance or substance abuse related accidents. According to researches, the return of investment of the EAP is triple.^[49]

Reducing the adverse work environment that increases the risk of alcohol and drug use

There are two ways to guide the working environment to reducing alcohol and drug consumption. The first is to change the workplace characteristic that encourages or permits the undesirable drinking behaviour. It is not easy to change the alcohol related habits and informal rules of a given workplace. It is more a factor of the organisational structure, than an employee resistance. The best way to tackle this is the implementation of a corporate drug and alcohol policy that is thoroughly implemented and is in force for all employees, including managers.^[50]

The second approach is to reduce the work related stress that gives rise to alcohol or drug problems.

There are six key areas, which can cause stress in the workplace: demands (workload, environment), work control, support of work, relationships, understanding the work role, management of changes. These areas have to be addressed properly. Reducing work related stress helps diminish work-related substance abuse.^[51]

Identification and intervention programmes

Early identification and brief intervention programmes proved to be effective in alcohol-related harm reduction programmes in primary health care^[52], conducted by occupational physicians too, and targeting cannabis use as well^[53]. For example, the simple AUDIT questionnaire^[54], which is used in screening and brief intervention (SBI) enable identification of affected persons. Short, confidential meetings, where roles and to-dos are clearly set, can help in the reduction of consumption, abstinence, or seek for higher level professional help. The tool is ideally used by health care professionals.

Actors and actions in the workplace alcohol and drug area

Mainstreaming alcohol and drug prevention into workplace health promotion

As the workplace alcohol and drug issue belongs to workplace health promotion, WHP tools, like health circles, are applicable with modifications. The concept of health circles^[56] can be a very effective tool improving the drug and alcohol situation also in the workplace. In this case it can be called an alcohol and drug policy circle, and the participants are the employees' representative, the manager, the middle manager, the occupational physician (and nurse), the safety representative, the alcohol and drug program manager and the potentially invited drug and alcohol expert (figure 2).

They meet twice a month in average for a couple of months. The meeting lasts one and half hours during work time. They identify the alcohol and drug situation in the workplace, build up strategies and aims for improvement, identify the resources, write the alcohol and drug policy of the company, plan the communication and implementation for the changes. After the announcement of the policy there is at least a three month adaptation period, and after the following three-six months the circle meet again for the evaluation of the effectiveness of the policy and its implementation. There is a continuous need for cooperation between the above mentioned actors. Initially they co-operate to formulate the policy, and during the implementation and revision they also have to feed in their knowledge and experience. The actors can be different, by different sectors. For example, in the maritime industry, the following players have responsibility in the workplace drug and alcohol problem: ship-owners, charterers, ship managers, manning agents, insurers, shipping communities and shipping organisations, ship masters, officers and seafarers. Even the maritime training institutions have responsibilities giving correct and clear message concerning drug and alcohol use and their abuse.^[57]

There are several players who have roles in the issue of alcohol and drugs in the workplace (Table 1).They all share the common tasks to foster prevention, to help those in need (at risk or misusing) getting access to appropriate help (within or outside the company) and to always act in a frank, constructive and confidential way.

Source: Overview by the authors

Necessary knowledge, skills and competencies to create and implement an alcohol and drug policy in the workplace

Health promotion practitioners' competencies

The different players need to have different knowledge, skills and competencies to fulfil their task. The CompHP project^[58] defined the core competencies (the essential knowledge, abilities, skills and values) for all health promotion roles and activities, including the issue of alcohol and drugs in the workplace.

The knowledge and ethical values underpin the core competencies, without these there is no health promotion. The Handbook of CompHP states that: "Ethical values and principles for health promotion include a belief in equity and social justice, respect for the autonomy and choice of both individuals and groups, and collaborative and consultative ways of working. The core competencies require that a health promotion practitioner draws on a multidisciplinary knowledge base of the core concepts, principles, theory and research of health promotion and its application in practice."^[59]

To practice health promotion the following competencies are necessary:

• enable people, group of people, organisations including workplaces to improve health
• advocate to improve health
• mediate across sectors, disciplines, work collaboratively with partners
• communication capacities
• leadership for health promotion action
• assessment of the situation and resources
• planning, implementation and evaluation of the health promotion action

Managerial knowledge, skills and competencies

Alcohol use and even misuse happens more often in relation with work than is thought. Thus the managers have to understand and recognise the signs and symptoms of problematic and inappropriate use of alcohol and drugs.

As dealing with drug and alcohol problem is not an inborn knowledge, it is important to improve these skills, especially of people who are responsible handling these problems. Proper training has to be given to the managers, line managers, supervisors and also for those employees who have to (or would like to) do something to improve the alcohol and drug situation at the company. The training should include:^[60][61]

• the role and the attitude of the supervisor;
• understanding and talking about the drug and alcohol problem and its affect on work;
• legal obligations and background, rules and policies;
• recognition of signs, symptoms and the problems with its all implications (who are at risk, the issue of confidence);
• acting in a constructive way;
• referral and reintegration;
• handling crisis situations;
• putting knowledge into practice.

Signs and symptoms

The symptoms of alcohol or drug misuse and addiction: absenteeism, lateness, decreasing work performance, increasing accident level, failure of duties, changes in mood, behaviour, irritability, problems in work and personal relations. Furthermore, various physical effects can appear: temporary blackouts or memory loss, headache, anxiety, insomnia, nausea, flushed skin and broken capillaries on the face; a husky voice; trembling hands; bloody or black/tarry stools or vomiting blood, chronic diarrhoea. Note these symptoms separately can be a consequence of many other problems.^[62][63]

Supportive way of handling the alcohol and drug problem

The MEPMIS project details the supportive way of handling the alcohol and drug problem in the workplace. There is a set of guidelines available for an informal, supportive interview when the manager thinks that the time has come when he/she has to intervene. This interview has to be in a quiet place with no interruption. The manager plans the interview, the questions, prepare the performance documentation. With the focus on performance and attendance the manager explains clearly the expectation. The style of the communication is objective, concrete, specific, non-confrontational, non-judgemental, fair and consistent. If it is appropriate, the manager may offer help to the employee from the company expert (occupational health specialist) or from outside (addiction centre).The supportive interview has three stages: exploration, understanding, and action.

1. In the exploration stage the manager helps to explore the problem. Required skills: giving attention, active listening, reflection, open questioning, brief summarising.
2. In the understanding stage the manager helps the employee to see how he/she can improve the work performance. Required skills: positively confronting, focus on the essence of the issue, linking the alcohol or drug use and the performance.
3. In the action stage the manager helps the employee to find the best ways to improve his/her performance. Required skills: target setting, leaving the control at employee, work out the monitoring process.

If it turns out that the situation is more serious than it seemed to be, the manager has to explain and indicate a later formal interview. The referral can be voluntary, non-disciplinary, or disciplinary. The referral agencies can be for example: occupational medical service, general practitioner, employee assistance program, addiction expert and psychologist.^[64]

Criteria of successful workplace health promotion

The ENWHP worked out an evaluation system that is also applicable for alcohol and drug issues. The success of actions is based on the position of workplace health promotion, which includes alcohol and drug issues, in relation to the following areas:

• Corporate Policy: workplace health promotion can be successful if it is perceived as a managerial responsibility, and is included in the existing systems.
• Human Resources and Work Organization: The involvement of the employees into the planning and implementation of the workplace health promotion is also a crucial factor.
• Planning and Implementing: Workplace health promotion is successful if it is based on a well communicated clear concept that is reviewed, improved from time to time on the basis of measured indicators.^[65]

The WHO also worked out a set of criteria on conducting workplace health promotion programs that includes alcohol and drug policy:

1. Be cost-effective and may not be expensive.
2. Acknowledge and support workplace health and safety.
3. Be managed by the workplace.
4. Include an assessment of needs to identify health problems/concerns in the workplace.
5. Require voluntary participation.
6. Include training in health promotion principles.
7. Be sustainable.
8. Acknowledge social justice principles.
9. Include evaluation processes.
10. Use mixed strategies as appropriate.
11. Involve family members (where appropriate).
12. Consider the structures, cultures, laws and policies of the workplace.

The participation (all staff), good project management, integration to the company's regular management and include individual and environmental directed measures are also the key factors to the successful workplace health promotion programs.^[66]

3.3 Reintegration

The workplace may be an appropriate setting for rehabilitation, reintegration and secondary prevention as well. It should be kept in mind that there are many substance users working and creating values, without companies recognising the situation.^[67] Work is beneficial in the sense of treatment: together with other activities that foster a sense of inclusion and provide opportunities for social contact, it can help in the prevention of lapse and relapse.^[68] Surveys confirmed that individuals in employment showed lesser use of alcohol and drugs than those that were unemployed.^[69] One of the key elements in the social reintegration of drug users is improving the person’s employability.^[70] Employment is an important part of the reintegration of the ex-users or even for the users. If the company is open to help the reintegration programs, there are well developed forms: intermediate labour market (ILM), simulated work and contingency management, supported employment and also employment assistance programs.^[71]

The period of the employee's treatment and the return to work require special consideration. Treatment period can be handled as sick leave, annual leave or leave without payment, depending on the workplace rules and the actual situation. The company alcohol and drug policy may contain which approach is taken. These solutions have the benefit of staying in employment, which is a protective factor. After returning to work, it is recommended to have designated persons who help this process, for example personnel from the human resources department, peers, supervisors, staff members from the treatment program, counsellors or employees’ representatives. Usually there is some follow-up care, which can be from the workplace (employee assistance programme - EAP) or from the outside (rehabilitation program). Well designed follow-up is also important for continued sobriety.^[72]

Prevention measures are part of the workplace health promotion programme; there can be dedicated rehabilitation programmes for employees or former drug and alcohol addicted workers. These employees may be actively involved to help current users in quitting.

The EMCDDA report on 2012 noted that although programmes might enhance employability skills, drug users still had to compete on the labour market with other applicants at a time of high unemployment in many countries. Entry, re-entry into the labour market and the ability to retain employment are all risked by substance misuse.^[73]