Tackle substance abuse in the workplace with these preventive measures

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Imagine discovering that one of your employees has been stealing prescription drugs from work to support a substance abuse habit that you never even suspected. Sound unlikely? Think again.

"It's a humongous problem," says Sheila Dunn, DA, MT (ASCP), founder and president of Quality America, Inc., an Asheville, NC-based company that sells Occupational Safety and Health Administration manuals and training programs to medical facilities. The American Journal of Public Health estimates that one in 12 nurses in the United States has an alcohol or drug problem severe enough to affect his or her practice.

In fact, such addictions are higher for nurses than for the general population, she says. "We think that's because it's a very stressful job, and nurses have increased access to drugs."

However, substance abuse is not just limited to the nursing profession. One out of every 10 people in the United States has an alcohol problem, 68% of whom have full-time jobs, according to the Department of Labor.

Drug abuse in the workplace is a life-and-death matter that affects all healthcare employees and patients alike, and needs to be properly addressed.

Warning signs and symptoms

In order to properly confront the addiction, it's important for colleagues to know how to recognize the warning signs of an employee with a substance abuse problem. "With most substance abuse users, there are definitely clues," Dunn says.

Watch out for changes in work patterns, for example. "They get pretty sloppy, use poor judgment, and make more mistakes than most people on the job," she says. Relationships with coworkers also may change.

According to the U.S. Drug Enforcement Administration, other signs and symptoms of an addict include:

  • Depression
  • Anxiousness
  • Irritability
  • Frequent mood changes, especially after lunch or a break
  • Excessive absenteeism and missed work days
  • Inability to concentrate or remember to perform simple tasks

However, even with all of these signs and symptoms "don't expect [that] everybody with a substance abuse problem slurs their words and stumbles around," Dunn says. "Oftentimes, it's really difficult to recognize somebody who's abusing drugs." Sometimes it's very difficult to tell whether the person has a drug problem or is just having problems in his or her life, Dunn adds.


Before you approach an employee you suspect of drug use, you have to do a thorough investigation, Dunn says. Track his or her performance rules, and keep a copy of complaints against him or her. "In other words, spend about six months documenting them, unless you think that person could really harm someone," she says.

If you know somebody has a substance abuse problem, bring the employee to a private area to inquire about his or her behavior. "Don't do it alone," Dunn says. Have a supervisor or manager in the room who can serve as a reliable witness.

From there, explain to the employee your concerns, and stick to the facts as they affect his or her performance, Dunn says. Then explain your company's policy regarding performance. If your company has a drug-free policy, explain that as well. "You may want to ask them to submit to a drug screen. If you have that in your drug-free policy, then you're within your rights to ask them to do that," she says.

Consider helping the employee with treatment, rather than firing him or her. "Give them a list of resources in your community where they can go to get clean," says Dunn.

Also, "if the employee is high as a kite when you are speaking with them, you should offer to have them escorted home, rather than letting them drive home." Only if the employee's response warrants it, determine whether security and law enforcement need to be brought in. Above all, document everything that is said during the intervention. Everything has got to be in writing, because if you're wrong about your presumptions, or the employee misinterprets something that you've said, you could find yourself in legal hot water.

Case study

It may also be helpful to consult an attorney before approaching such a situation, says one practice administrator at a Washington, DC-based healthcare facility, who recently confronted an employee whom she suspected of using cocaine. "Because of the sensitive nature of the situation, it helped greatly to consult with the attorney and get assistance with how to approach the problem," says the administrator, who asked not to be named.

Recognizing the warning signs that the employee exhibited, the administrator says she repeatedly went to her HR department for guidance. "Basically, I wanted to know our options," she says.

"For some time I was advised that unless I or another employee actually saw the employee doing drugs, or the employee revealed to my self or another that she was doing drugs, there was nothing we could do," she says. "I was extremely frustrated and concerned-not just for the employee but also for our patients and our liability."

The situation came to a head after a coworker, who was also a close friend of the employee in question, stepped forward and informed the practice administrator that the employee had recently admitted to doing so much cocaine the night before that she had not had any sleep.

With this new information, the practice administrator approached HR once again. "They, in turn, consulted with our attorney, who provided us with guidelines," she says. The guidelines included a script to follow upon meeting with the employee.

With the HR director as a witness, the practice administrator told the employee about her concerns and informed her that another employee had stepped forward about the suspected drug use. "She expressed surprise and adamantly denied using any drugs. She further explained that she had been under a lot of stress due to relationship issues," says the administrator.

The administrator followed up the denial by asking the employee to consent to an immediate urine toxicology screen. Her options were to either consent to the urine test and be placed on leave pending the results or not take the test and face additional disciplinary action, she says.

"After a few minutes of silence, she let out a big sigh and stated that she had been using cocaine, and added the caveat 'but never at work,' " she says. With that, the administrator notified the employee that pending additional investigation, she would be sent home immediately.

Editor's note: Some of the information cited in this article was extracted from Quality America's white paper What to Do About Substance Abuse in the Healthcare Workplace. For more information, go to, and click on White Papers.

Sample drug-free workplace policy


ABC Healthcare is firmly committed to a safe work environment and high standards of employee health and safety. The use of drugs or alcohol on the job impairs job performance and safety. ABC Healthcare is committed to having a workplace free from the influence of drugs and alcohol. The drug and/or alcohol screening outlined in this policy will help ABC Healthcare maintain a drug-free workplace, in accordance with the requirements of The Drug Free Work Place Act.

Statement of policy

ABC Healthcare strictly prohibits the use, sale, possession, or distribution of alcohol or controlled substances by its employees while on duty, in ABC Healthcare's vehicles, or on ABC Health care's premises. Off-duty alcohol or drug-related activities, with the exception of the use of prescribed medications used as prescribed, which impair an employee's attendance, efficiency, or quality of work, are also prohibited. Any employee who refuses to submit to or tests positive in any drug test required under this policy will be considered in violation of this policy and may be subject to discipline up to and including discharge.

ABC Healthcare's drug screening program is designed to maintain a drug-free workplace and provide assistance to those employees' chemical dependency problems. For the purpose of this policy, the term "employee" means all individuals actively employed by or a member of ABC Healthcare, including physicians. The policy has been developed in compliance with existing state and federal regulations designed to ensure the most accurate and reliable test results available. It also contains procedures designed to recognize and respect the dignity and privacy of all of our employees. More importantly, we recognize that our employees are our most valuable resource, and we will strive to assist any employee who feels that he or she may have a problem with chemical dependency or alcoholism. Accordingly, we have information available about, and access to, appropriate employee assistance programs designed to help those individuals who are desirous of treating such problems.

Substances tested

A. Controlled substances. Any drug test required by ABC Healthcare will analyze an individual's urine to test for the presence of "controlled substances," as defined by state and/or federal laws from time to time.

B. Alcohol testing. All breath alcohol samples are deemed positive if the alcohol concentration is equal to or greater than 0.04 g percent by weight of alcohol in the sample. Any employee with a positive alcohol result will be subject to disciplinary action up to and including dismissal.

C. Prescribed medication. An individual will have the opportunity to discuss the use of any prescribed medications with the medical review officer (MRO). The individual will be required to identify the physician prescribing the medication to authorize the MRO to communicate with that physician about the medication, its possible side effects, the condition requiring the taking of the medication, and their relationship to the individual's ability to safely perform his or her job. If the MRO determines that an employee is taking, or is under the influence of, a prescribed medication that will adversely affect the employee's ability to safely and adequately perform his or her job, and/or pose a significant risk of harm to the public or to other employees, the employee will be placed on medical leave of absence or in another position until the employee is no longer taking the medication.

Qualifications for employment and prohibited conduct

Any employee who refuses to submit to or tests positive in any drug test required under this policy will be considered in violation of this policy and may be subject to discipline up to and including discharge.

Required testing

A. Preemployment. Any applicant to whom ABC Healthcare has made a conditional offer of employment will be required to provide a urine and/or breath alcohol sample for testing and will be asked to sign a consent form.

B. Reasonable belief. ABC Healthcare will require a drug test for an employee when ABC Healthcare has a reasonable belief that the employee is impaired and may be in violation of this policy.

ABC Healthcare reserves the right to screen all employees within a division of ABC Healthcare, including but not limited to situations in which there is evidence of widespread drug/alcohol use, possession, selling, or paraphernalia. The employees must sign the consent form. Any employee who refuses to sign the consent form or provide urine and/or blood samples will be subject to appropriate disciplinary measures up to and including discharge. ABC Healthcare will strive to have the manager/supervisor verify the reasonable belief circumstances, when possible. Any reporting manager/supervisor will be required to complete a report of reasonable belief, which will be forwarded to the MRO for review and consideration with any positive test result. The employee will be discreetly escorted to the collection site by his or her manager/supervisor for testing. After appropriate samples are provided, arrangements will be made with a spouse, family member, or other individual to transport the employee to his or her home. If the employee refuses and attempts to operate his or her own vehicle, ABC Healthcare will take appropriate efforts to prevent him or her from doing so, up to and including contacting local law enforcement officials.

Pending ABC Healthcare's receipt of the results of the employee's drug/alcohol test, the employee will be suspended with pay. If the test results are negative, the employee will be reinstated (with no loss of seniority); if positive, the employee will be subject to disciplinary action, up to and including termination.

C. Postaccident. As soon as possible, ABC Healthcare will test each employee whose performance either contributed to an accident, as defined below, or cannot be completely discounted as a contributing factor to the accident. ABC Healthcare may decide not to conduct a postaccident drug test if the best information available immediately after the accident indicates that the employee's performance did not contribute to the accident, or it is not likely that a drug test would reveal whether the performance was affected by drug use.

The employee involved in any one of the above shall notify their immediate manager/supervisor at the first available opportunity after the accident. Any employee failing or refusing to provide a drug/alcohol sample or who has a verified positive test result after being involved in an accident will be subject to appropriate disciplinary measures up to and including discharge.

Specimen collection procedures

Any person required to undergo a drug/alcohol test will be required to provide a urine specimen or, in the case of alcohol testing, a breathalyzer at the following designated collection site: [address]

Laboratory testing/results

All urine and/or blood specimens to be tested for the presence of controlled substances will be analyzed by a certified laboratory.


The role of the MRO shall be to review and interpret laboratory results. This is called the MRO verification process, which renders the final MRO report. ABC Healthcare's current medical review officers are: [names]


Unless otherwise prescribed by applicable law, the following discipline will be taken in the event of a MRO report under any of the following circumstances:

A. Preemployment. Any prospective employee who has been given an offer of employment and has a verified positive or adulterated test as a result of a preemployment drug test will have the offer revoked and will be considered disqualified from employment for a period of twelve months.

B. Reasonable belief. Any employee who has a verified positive result or adulterated test as a result of a reasonable belief drug test and does not consent to an evaluation by a substance abuse professional will be discharged.

C. Postaccident. Any employee who has a verified positive result as a result of a drug/alcohol test taken after an accident and does not consent to an evaluation by a substance abuse professional will be subject to discharge.

D. Refusal to test. Any employee who refuses to drug test, refuses to sign a release and consent form, fails to properly cooperate with collection site personnel, or creates reason to believe a sample has been altered, substituted, or adulterated will be subject to discipline, up to and including discharge.

Employee assistance, training, education, benefits, and rehabilitation

The following describes generally the resources that are available and may be subject to change at the discretion of ABC Healthcare.

A. Education. ABC Healthcare provides education for its employees about the dangers of drug and alcohol abuse available from community resources, treatment, rehabilitation, and assistance providers:

1. Display and distribution of informational material

2. Display and distribution of information regarding employee assistance

3. Distribution of ABC Healthcare's drug-free workplace policy

B. Training: Any manager/supervisor responsible for determining whether an employee must be drug tested based on reasonable belief will complete a training program on the specific physical, behavioral, and performance indicators of probable drug/alcohol use.

C. Employee assistance program: ABC Healthcare also has available an employee assistance program. The HR department will aid in the coordination of services for employees who are confirmed by the MRO as having positive test results.

D. Insurance benefits: Treatment for drug and alcohol abuse is presently a covered benefit under ABC Healthcare's health insurance plan. Please refer to the summary plan description for further information about covered benefits.

E. Rehabilitation

1. Alcoholism and chemical dependency. Consistent with the Americans with Disabilities Act and the Family Medical Leave Act, ABC Healthcare is willing to recognize and provide assistance to those employees whose use of alcohol or controlled substances may be the result of problems such as alcoholism or chemical dependency. Any employee who comes forward and voluntarily requests assistance for chemical dependency prior to any request for a drug test under this policy and/or any employee who has a verified positive or adulterated test in any drug test under this policy will be provided the opportunity to undergo an approved drug/alcohol assessment by a qualified healthcare provider and to participate in any treatment program recommended by that provider. These services will be at the employee's expense, unless coverage is provided by an applicable health insurance plan.

2. Return to work and follow-up testing. Upon successful completion of the program, the employee will generally be reinstated to employment as if returning from medical leave of absence, providing he or she is qualified to return to work and upon successful completing of an additional drug and/or alcohol test. Further, the employee may be required to submit to additional random drug and/or alcohol testing at any time within 12 months from the date the employee returns to work. If the employee has a verified positive test or adulterated test result, then the employee has made himself or herself unfit for continued employment, resulting in termination of the employment relationship.

3. "Second chance" program: Any employee who comes forward and admits to renewed substance abuse problems, other than as a consequence of a positive test result, may be afforded the opportunity to take an additional medical leave of absence in order to readmit him- or herself into an appropriate treatment program. This "second chance" program will be available to anyone who has once gone through a rehabilitation program as a result of a verified positive or adulterated test, but only to those employees who voluntarily come forward and request readmission. The "second chance" program will not be available to any employee who desires to participate in treatment only after a verified positive or unadulterated drug test in a reasonable belief or accident drug screen.


Information regarding an individual's drug test results or rehabilitation will be released only upon the written consent of the employee. However, failure to authorize release of such results to ABC Healthcare may be an act of insubordination and subject to disciplinary action up to and including termination.

ABC Healthcare will not release employee information without first obtaining written authorization and consent from the tested individual unless compelled to do so by court order or applicable law.

Source: Unity Healthcare, LLC, Indianapolis. Reprinted with permission.