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Employment interventions

This page refers to the current evidence on the effectiveness of the available employment interventions for improving the employability of drug users. Information on the methodology used and the definition of terms can be found on the methodology page.

Date of last update: 12.2016    Next update: 04.2017

Available evidence for employment interventions

Summary: Employee assistance programmes help people to improve work performance, while supported employment interventions may assist substance users with co-occurring mental illness to enter competitive employment.

Beneficial

Employee assistance programmes to improve work performance

Employee assistance programmes were found to be effective in one RCT (n = 498; Jordan et al., 2008, cited in EMCDDA, 2012 - Online appendix):

  • with 30–60 days’ treatment
    • reported absence decreased from 58.5 % at admission to 26.9 %;
    • lateness for work decreased from 37.3 % to 20.4 %;
    • less productivity decreased from 19.7 % to 14.9 %;
    • less conflict decreased from 18.1 % to 11.8 %;
  • similar decreases were reported at 61+ days with 66 % reduction in absenteeism; and
  • 70 % of patients had improved workplace performance after 1 month of treatment.

Likely to be beneficial

Supported employment for substance users with a co-occurring mental illness

Supported employment interventions showed to be effective in one UCBA (n = 113; Biegel et al., 2009, cited in EMCDDA, 2012 - Online appendix):

  • 46.9 % entered competitive employment during the 12-month study period — 66 % of these individuals entered employment within the first 3 months;
  • the average length of employment was 4.3 months; however, 43 % were employed for 2 months or less;
  • non-white, higher consumer empowerment, higher supported employment service use and lower financial status predicted employment entry.

Trade-off between benefits and harms

No interventions met the criteria for this category.

Unknown effectiveness

Psycho-social treatment (including contingency management) to improve crack-cocaine users employment conditions

A narrative review (Fischer et al., 2015), without meta-analysis, concluded that there is

  • mixed evidence, thus not conclusive, on the effectiveness in relation to social outcomes, eg, housing and employment.

Occupation-based interventions to improve recovery outcomes

Occupation-based interventions are those programmes in which an occupation is performed, and occupations are defined as those activities a person engages in to structure time and create meaning in their life. In the addiction field, occupation-based interventions are typically in the areas of work, leisure, and social participation. Those interventions were found in a systematic review without meta-analysis (Wasmuth et al., 2016, 26 studies) to have no significant effect in:

  • improving recovery short and long-term recovery outcomes (ASI scores)

Evidence of ineffectiveness

No interventions met the criteria for this category.

References and definitions

List of references

Explanation of terms used

Below you can find definitions and further explanation for some of the terms used in this section of the Best practice portal. A more general glossary for the best practice portal is also available.

Affective-focused prevention intervention

A type of prevention intervention which aims to they aim to modify inner qualities (personality traits such as self-esteem and self-efficacy, and motivational aspects such as the intention to use drugs).

BA

Before-after (BA) study design

BAL

Blood alcohol level (BAL)

Beneficial

Interventions for which precise measures of the effects in favour of the type of intervention were found in systematic reviews of relevant studies. An intervention ranked as ‘beneficial’ is suitable for most patients/contexts. See the relevant module methodology page for further information.

CBA

Controlled before-after (CBA) study design. UCBA stands for Uncontrolled before-after study design.

CBT

Cognitive behavioral therapy is an individual based intervention occurring in three stages. Phase 1 is aimed at determining and prioritizing the patient’s problems and constructing the treatment contract. Phase 2 is aimed at increasing coping competence and reducing risky behaviors. Phase 3 focuses on relapse prevention. Each session is administered once per week over a period of 4-6 months with 60- to 90-minute sessions (Beck AT, Wright FW, Newman CF, Liese B. Cognitive Therapy of substance abuse. New York: Guilford Press, 1993).

CCT

Controlled clinical trials (CCT)

Cohort study

A cohort study is a type of observational study that follows a group of people (i.e. a cohort) over time. In a prospective cohort study, the cohort is formed and then followed over time. In a retrospective cohort study, data is gathered for a cohort that was formed sometime in the past.

Confidence Interval (CI)

The Confidence Interval (CI) is a measure of the precision (or uncertainty) of study results. It is the interval that most likely includes the true value of the parameter we are calculating, where 'most likely' is taken by common usage to be a 95% probability. Thus the current expression of '95 % CI'. A wide CI indicates less precise estimates of effect and vice versa.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
CPS

Current population survey (CPS)

Cross-sectional study

A cross-sectional study is a study employing a single point of data collection for each participant or system being studied.They are usually conducted to estimate the prevalence of the outcome of interest for a given population at a given point in time.

Evidence of ineffectiveness

Interventions that gave negative results if compared with a standard intervention or no intervention, for example. See the relevant module methodology page for further information.

Additional information for prevention
For ethical reasons this category in prevention should be considered as interventions with negative and undesired (iatrogenic) effect.

IP

Individual psychotherapy is a standard individual treatment based on counseling and motivational interviewing and focused on substance use triggers and strategies for relapse prevention. It includes elements of cognitive-behavioral therapy (CBT).

IQR

Interquartile range (IQR) - also called the midspread or middle fifty - is a measure of statistical dispersion. It is a trimmed estimator, defined as the 25% trimmed mid-range, and is the most significant basic robust measure of scale.

ITS

Intermittent time series design (ITS)

Knowledge-focused prevention intervention

A type of prevention intervention which aims to to enhance knowledge of drugs, and drug effects, and consequences.

Likely to be beneficial

Interventions that were shown to have limited measures of effect, that are likely to be effective but for which evidence is limited. An intervention ranked as ‘likely to be beneficial’ is suitable for most contexts/patients, with some discretion. See the relevant module methodology page for further information.

Number Needed to Treat (NNT)

The Number Needed to Treat (NNT)indicates the number of patients that needs to be treated to obtain one respondent patient. Numerically the NNT is the reciprocal of the difference between the proportion of events in the experimental and the comparison group (absolute risk reduction). Taking into consideration that the ideal NNT would be 1 (the unreal situation in which every single patient succeeded) it is easily understood that a NNT value close to 3 or 4 would be very good.

Adjusted Odds Ratio (AOR)

The Adjusted Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups, yet they are calculated adjusting for or controlling for other possible contributions from other variables (tipically demographic variables) in the model. An AOR equal to 1 implies that the the event is equally probable in both groups. An AOR greater than 1 implies that the event is more likely in the first group. An AOR less than 1 implies that the event is less likely in the first group.

Odds Ratio (OR)

The Odds Ratio is a way of comparing whether the probability of a certain event is the same between two groups. Like the Relative Risk, an OR equal to 1 implies that the the event is equally probable in both groups. A OR greater than 1 implies that the event is more likely in the first group. A OR less than 1 implies that the event is less likely in the first group. In medical research, the odds ratio is commonly used for case-control studies, as odds, but not probabilities, are usually estimated. Relative risk is used in randomized controlled trials and cohort studies.

p value

A p-value is a measure of how much evidence we have against the null hypothesis. The null hypothesis represents the hypothesis of no change or no effect. The smaller the p-value, the more evidence we have against the null hypothesis thus it is more likely that our sample result is true. Traditionally, researchers will reject a null hypothesis if the p-value is less than 0.05.

RBS

Responsible beverage service (RBS)

RCT

Randomised controlled trial (RCT)

Relative Risk (RR)

The Relative Risk (RR) is used to compare the risk in the two different groups of people, i.e. treated and control groups to see if belonging to one group or another increases or decreases the risk of developing certain outcomes. This measure of effect will tell us the number of times an outcome is more likely (RR > 1) or less likely (RR < 1) to happen in the treatment group compared with the control group.

Practical interpretation

  • If the RR (the relative risk) = 1, or the CI (the confidence interval) = 1, then there is no significant difference between treatment and control groups
  • If the RR > 1, and the CI does not include 1, events are significantly more likely in the treatment than the control group
  • If the RR < 1, and the CI does not include 1, events are significantly less likely in the treatment than the control group
Trade-off between benefits and harms

Interventions that obtained measures of effects in favour of the intervention, but that showed some limitations or unintended effects that need to be assessed before providing them. See the relevant module methodology page for further information.

 
Unknown effectiveness

Interventions for which there are not enough studies or where available studies are of low quality (with few patients or with uncertain methodological rigour), making it difficult to assess if they are effective or not. Interventions for which more research should be undertaken are also grouped in this category.

Additional information for prevention
For prevention interventions,  this  is also known as 'zero effect'.

Skill-focused prevention intervention

A type of prevention intervention which aims to enhance students’ abilities in generic skills, refusal skills and safety skills.

Standardised Mean Difference (SMD)

The Standardised Mean Difference (SMD) is the difference in means divided by a standard deviation. Note that it is not the standard error of the difference in means (a common confusion). The standardized mean difference has the important property that its value does not depend on the measurement scale. It may be useful if there are several trials assessing the same outcome, but using different scales.

z score (Standard Score)

The z-score (aka, a standard score) indicates how many standard deviations an element is from the mean of the population.

 

Definition

Although problematic drug users can in theory access the employment market through traditional means (e.g. individual job search, mainstream employment services), in practice there are significant barriers that prevent them from securing employment in this way.
Employment interventions can provide support for those who have found a job as well as employment opportunities for those who are struggling to secure work in the open labour market, and thereby also address other potential barriers such as low confidence.

Barriers to social inclusion

Personal level:
limited or no qualifications, including low levels of literacy and numeracy; poor employment histories; criminal records precluding certain careers (e.g. police, teaching, working with children, financial institutions); chronic mental and physical ill health; insecure housing circumstances; limited interpersonal skills; complex personal needs; lack of confidence; chaotic lifestyles (e.g. poor timekeeping); family problems; low expectations of themselves and of life in general.

Structural level:
requirement to attend treatment on a daily basis; inadequate opening hours of treatment services that are incompatible with working hours; lack of interagency coordination; stigmatising and discriminative views, actions and procedures; inability to open a bank account to receive wages; increased likelihood of temporary or insecure work; shortage of suitable employment opportunities; perceived ‘benefit trap’ whereby an (incorrect) belief is held that the loss of welfare benefits as a consequence of employment will result in a reduction in income that is not compensated by the salary; criminal record checks required by employers.

Interventions

Intermediate labour market

The intermediate labour market is a supportive system targeted at disadvantaged individuals to bridge the gap between (long-term) unemployment and the open labour market. It is characterised by offering paid work on a temporary contract, together with training, personal development and job search activities (Marshall and Macfarlane, 2000).

Simulated work and contingency management

This type of intervention is similar to contingency management under general drug treatment, but the reinforcer or the contingency behaviour is employment specific (e.g. the reinforcer is a salary, the contingent behaviour is work performance). Benefits are usually conditional on provision of negative urine toxicology, but the client must also demonstrate satisfactory employment performance before the reward (employment, salary) is received. The ‘workplace’ is usually a simulated environment set in a treatment centre or university. Although this approach has been designed to promote abstention (thus effectiveness is usually reported with respect to clinical outcomes, particularly initiation or maintenance of drug abstention, rather than employment outcomes), it has been included here as it can also improve job skills and subsequent employability. It should be noted that these interventions are more prevalent in the USA than in European countries.

Supported employment

Supported employment is paid work that takes place in normal work settings (on the open competitive employment market) with provision for ongoing support services. Ancillary services may include job coaches, role ‘shadowing’ and mentoring schemes.

Employee assistance programmes

Employee assistance programmes for problematic drug users are programmes that allow employers to address substance use among employees once they have secured employment. Substance use needs may be pre-existing or develop during the period of employment. These strategies often constitute screening, assessment, counselling and referrals to more specialist care and aim to provide opportunities for managers to forestall discipline or dismissal of employees with personal problems contingent upon their ability to constructively address personal issues that negatively affect job performance ( ). Employees may refer themselves or be referred by their peers, employer or line manager.

Note that the ILO (1996) code of practice of alcohol- and drug-related issues in the workplace states, ‘It should be recognized that the employer has authority to discipline workers for employment-related misconduct associated with alcohol and drugs. However, counselling, treatment and rehabilitation should be preferred to disciplinary action. Should a worker fail to cooperate fully with the treatment programme, the employer may take disciplinary action as considered appropriate’ (ILO, 1996: vii).

Outcomes

The main outcomes considered as proxy of social reintegration were employment-related outcomes.

Primary outcomes

  • Employment rate
  • Employment attendance
  • Average income

About the EMCDDA

The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is the reference point on drugs and drug addiction information in Europe. Inaugurated in Lisbon in 1995, it is one of the EU's decentralised agencies. Read more >>

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Page last updated: Friday, 16 December 2016