Prevention is the best treatment
The general attitude toward addictions has changed over the years, but the stigma of shame stays. Problems arising from the abuse of intoxicating substances and habit-forming drugs cause work disability, but in practice they are no longer classified as diseases. Prevention is the best treatment, and many workplaces already have programmes for dealing with the problem. But why aren’t the programmes always effective?
In western countries, addictions were initially seen as sinful and immoral. In the 20th century they were comparable with crimes in many countries. In Finland, addictions were first considered to be diseases only from the 1980s onwards, says Antti Maunu, PhD.
He has analysed the history of alcohol consumption in his recent study ‘Humalan tällä puolella – alkoholikeskustelun uudet suunnat’ (On this side of drunkenness – new directions in the dialogue on alcohol).
According to Maunu, alcoholism is no longer viewed as an actual disease. More and more people think that drinking is every individual’s own choice.
– Drinking alcohol is considered to be mainly an improper and unfortunate social problem. The traditional mental image of sin connects it with shame and makes drinking a kind of moral battle. It’s hard to be humble and admit that you are weak and helpless, Maunu says.
He compares drinking with burnout and depression.
– These are new problems that don’t have a moral history that goes back hundreds of years. That is why it’s easy to look at them as diseases, and it’s also easy to speak of them quite openly nowadays. Burnout is almost fashionable.
Problems due to substance abuse haven’t attained this status. They are embarrassing and awkward to deal with.
Working has sobered up
In the past few decades alcohol and working are further from each other than ever before.
– In the old days drinking alcohol during the work day wasn’t necessarily seen as a problem at the workplace, but was rather part of the work culture. Studies conducted in the 1970s show that in those days drinking was considerable at industrial and construction sites in comparison to the present day. Similarly, luncheon meetings where alcohol is served during working hours are extremely rare today.
Maunu believes that employers, employees as well as today’s rapid work pace are behind this change.
– Employers have started to look at alcohol as a source of problems. Work life has become so demanding that employees can’t afford to fool around any more.
Small-scale drinker, party drinker or boozer?
Alcohol tends to be used rather as compensation for the pressures and stress of work life. According to Maunu, this change started already in the 1980s, so it can’t be explained simply by the fear of the massive present-day lay-offs.
– The total consumption of alcohol has increased, and drinking is more prevalent during the week-ends and free time.
Maunu divides the typical drinking trends into three categories: small-scale drinking, party drinking, and boozing or getting drunk.
Finns are typically small-scale drinkers during the week-ends, usually with their spouse. The goal is purely relaxation and enjoyment.
Maunu describes party drinking as controlled loosening up. People distance themselves from their daily routines, usually outside of their home.
Boozing is farthest from one’s daily routines, and boozers often drink very heavily with the aim of getting drunk.
”Even small-scale drinking can ruin your life, even if you never get really drunk.”
Bad, but also something good
Maunu emphasizes that all types of drinking habits have positive as well as negative sides.
– The recreational use of alcohol is usually considered less harmful than injecting drugs in shady alleys. But also small-scale drinking can ruin a person’s life, even if they never get really drunk. On the other hand, strong experiences of drunkenness may have meaningful social and emotional implications that are remembered for the rest of one’s life. New human relationships are formed and babies may be born nine months later.
Maunu suggests that the counselling and advice regarding the misuse of substances should include not only their hazards but also their benefits.
– People are well aware of the dangers of alcohol and drugs. It’s easy to speak about them, but that is precisely why it’s easy to shut them out of one’s own experience. After all, no one drinks in order to get into trouble.
Maunu reminds that the use of intoxicating substances is not rational. It is more about controlling and regulating one’s emotions, as well as seeking social experiences. According to him, the best kind of counselling is to offer people alternative ways of regulating their feelings and of interacting with other people.
Good working conditions that don’t have to be compensated by intoxicants are the best kind of prevention.
Advice for adult life
Maunu wonders whether enough information about the problems of substance abuse at workplaces is given in connection with vocational training.
– Education plays a big role in helping young people to adjust to work life. The earlier that possible problems are discussed, the less secrecy and embarrassment they cause. At the same time young people learn the basics of how to act if they themselves or their workmate drinks so much that it hinders working.
Maunu believes that the communication culture at work plays a key role in how openly people are ready to talk about their problems, and whether they get support and help for them sufficiently early. He reminds that good working conditions that don’t have to be compensated by alcohol or drugs provide the best prevention. This includes a positive work climate and social conditions at the workplace.
A disease without motivating rehabilitation
Problems arising from substance abuse cause work disability, just like many other diseases, but the social insurance system does not consider them to be diseases, says Olavi Kaukonen, managing director of A-Clinic Foundation. According to him, the social security system that used to motivate substance abusers to seek rehabilitation has in practice been dismantled.
Kaukonen compares the present situation with the one twenty years ago. At that time the Social Insurance Institution of Finland (Kela) granted daily sickness insurance allowance for the duration of treatment at an institute offering rehabilitation for substance abuse. To get the daily allowance, a doctor’s referral was usually needed.
– According to the new policy of Kela, problems arising from substance abuse are not diseases to which the sickness insurance law and compensation practice can be applied. In the 1990s a rehabilitation compensation law was passed, the implementation of which took precedence in regard to the sickness insurance legislation.
Simultaneously, the criteria for granting money for the rehabilitation of substance abusers were tightened. As a result, the use of sickness insurance to cover the rehabilitation of substance abusers has decreased. The funding to support rehabilitation is now only marginal.
– So we are now dealing with a ”disease” which causes work disability, but to which social insurance is not applied systematically, Kaukonen summarizes.
He reminds that alcohol is still the real reason behind the work disability pension of many people, even though the decision to grant disability pension is often based on other diseases.
– If the social insurance system were to function as an incentive, it would motivate the clients, their families, employers as well as the providers of rehabilitation services to start treatment earlier than now. The rehabilitation would thus be easier, and work disability leading to premature retirement would not be as common as it is today, Kaukonen says.
“The general opinion is that everyone should be able to control their life in all kinds of situations. Even losing control should happen in a restrained manner.”
The word ‘addiction’ is neutral
Kaukonen is an expert on the substance abuse policy and service system. He has analysed the changes in the service system for substance abusers, for instance in regard to controlling substance abuse, client selection, and impact of the system. His doctoral thesis dealt with the Finnish welfare state from the viewpoint of services for substance abusers.
According to Kaukonen, the concept ‘addiction’ has helped to lessen the negative stigma related to substance abuse.
– Addiction is a neutral medical term which (in Finland) has replaced the concepts of substance dependency and behavioural dependency. The idea that people can develop a dependency to almost anything, from traditional substance misuse to gambling, video games, the Internet, physical exercise, sex or some other repeated behaviour has been strengthened, especially in the public discourse.
However, a condition of dependency is not seen as something to be wished for, because losing control causes problems. Especially drug abuse still has a strong negative stigma. And the attitude of particularly young people toward alcohol is more reserved than that of middle-aged people, according to Kaukonen.
– The general opinion is that everyone should be able to control their life in all kinds of situations. Even losing one’s control should happen in a ‘restrained’ manner, says Kaukonen.
A light follow-up is effective
Kaukonen believes that the models for promoting the well-being of employees are successful in enterprises if they include elements on substance use. He points out that if problems arising from substance abuse are dealt with early, a “light follow-up of the situation” is very cost-effective.
– The problem is that models promoting well-being are used selectively. Programmes that focus on overall well-being are useful in work communities, but they don’t necessarily address the drinking problem.
– For example, the model of early intervention is good, provided that it is applied to substance abusers throughout the entire work community. When the entire work community is committed to following the rules of the game, no one is blamed, and together people who have a common work culture look for solutions. This helps also those who have difficulties in assessing their own alcohol consumption realistically, Kaukonen points out.
He reminds that recognizing substance abuse is relatively easy, but that there are no precise limit values that can be applied to the use of intoxicating substances.
– The use of intoxicants can be measured, but their problem use is determined by the person him- or herself, or by their closest persons: family, friends or work community. For instance, alcohol may be a problem in the opinion of close persons, regardless of whether the limit values of the AUDIT scale are exceeded.
The use of tax revenues to remedy injurious effects
Kaukonen proposes that the authorities should assume special responsibility for financing and implementing systematic information campaigns to prevent substance abuse.
– Ideally, revenue from the alcohol tax might be used to remedy the injurious effects of alcohol. This means that a part of the revenue would be allocated to the prevention of alcohol abuse and treatment of problem users. Now there is no such practice, and the tax revenue is channelled into the state treasury.
– Informing people is not effective by itself, but if it is linked with systematic restrictive alcohol policy, then it is effective. Research evidence on drug abuse shows that the use of extreme warning examples may even encourage some individuals to experiment with drugs and to start using them.
Kaukonen is concerned by the present trend that the different ways of using alcohol and the resulting problems already divide the population into different social statuses.
– Those who consume large quantities of alcohol are more likely than others to fall outside of education, work life, production, and other life-supporting social relationships. Alcohol also kills relatively more people in the lower social classes than in the higher classes.
The employer, supervisors as well as employees’ trustees at workplaces must be committed to create a supportive atmosphere and define ways of dealing with drinking and drugs.
A support person for substance abusers at the workplace
The central labour market organisations urge workplaces to look for early signs of substance abuse. Kari Haring, medical specialist from the Central Organisation of Finnish Trade Unions (SAK), emphasizes that if problems are tackled only in the addictive stage, it is much too late. The target group of substance abuse programmes includes also persons whose substance misuse has become evident, but who are not yet addicted.
– The starting point at workplaces is to recognize and face problems actively. The personnel are first informed about the introduction of a new treatment programme. The employer, supervisors as well as employees’ trustees at workplaces must be committed to create a supportive atmosphere and define ways of implementing the programme.
Anyone at all can bring up substance abuse with their work mate if they notice early signs. However, Haring believes that naming a person at the workplace as a coordinator of substance abuse issues is a good alternative.
– The threshold to talk about a problem with the coordinator is lower than going to the supervisor or the employees’ trustee.
Acknowledging the problem is a good start
The new recommendation emphasizes the role of the occupational health service providers. Health professionals recognize the signs of substance abuse. They should also bring up the matter with the individual in question.
– Talking about the problem face-to-face has been found to lessen the use of intoxicants. When a health professional asks an employee directly whether his or her use of alcohol, drugs or medication is under control, the response can be denial or a burst of anger. However, during my work as an occupational health physician I noticed that many people are actually pleased and relieved that the issue can be discussed openly and honestly, Haring says.
He reminds that it is not just a question of hang-over days, or risks related to being drunk at work, or lowered work capacity. An addiction affects a person’s whole life.
– A person may come to see a doctor for some other ailment when they don’t want to acknowledge the real reason in the background. For instance, the abundant use of alcohol predisposes to hypertension and many other diseases. In addition, it is a significant cause of work disability.
– A person can be stopped by the police for drunken driving during their leisure time, or get into an accident under the influence of alcohol. Sometimes family members contact the workplace and tell about problems that are not yet known at the workplace, Haring says.
AUDIT questionnaires and drinking diaries
The AUDIT questionnaire was developed to chart the risks of alcohol abuse. Haring knows that it is a reliable basic test for anybody. Usually people answer the questions quite honestly, so it reveals alcohol abuse rather well.
Another effective measure is the drinking diary. A six-week follow-up of drinking habits often reveals a surprising truth.
– Many people believe that they drink much less than the actual facts shown by the diary. That motivates a person to think seriously about their own alcohol use, Haring says.
Where to find help?
Help in recognizing a possible problem, and finding advice and guidance on seeking professional help for substance abuse is available for example from the following websites: