The Science of Addiction and Why it Matters to Employers

More than 107,000 Americans died of drug overdoses in 2021 according to the CDC’s National Center for Health Statistics. This marks the first time in history that U.S. drug overdose deaths have surpassed 100,000, and drug overdose is now the leading cause of accidental death in the U.S., with opioids as the most common drug of abuse.

‍Why it matters to employers

When it comes to substance use disorder (SUD), also known as addiction, the first thoughts and images that often come to mind are people experiencing homelessness injecting drugs on the street or partygoers snorting cocaine in swanky, urban nightclubs. Unfortunately, these are due to our implicit bias as a society regarding drug use, and these memes only represent a small portion of the real-life problem.

The truth is that 70% of the 40 million Americans living with a substance use disorder are in today’s workforce. This astonishing number—published by the National Council on Alcoholism and Drug Dependence in 2020—is a wake-up call about the importance of addressing and destigmatizing substance use in order to provide care and support to those living and working among us battling substance use on their own.

It could be John the office secretary, who instead of milk, puts Baileys in his morning cup of joe; or it could be Donna the manager who always wears long sleeves, even in the scorching hot summer, to cover up the track marks on her arms. Sadly, fewer than 10% of these people are being treated for their substance use disorder. In my experience as an internist and an employee health specialist, I have seen too many employees with substance use issues afraid to seek help because of societal stigma or fear of losing one’s job.

I remember vividly a 40-year-old construction worker who came to my clinic a few years ago. David was working at a 40-floor-high skyscraper. Because of his work in construction, he had sustained a lot of wear and tear to his body, so he self-medicated with street opioids to treat his pain and continue working. On the day that changed his life and brought him into my clinic, he snorted a crushed perc-30—a highly potent opioid—in the elevator on his way up to the top floor. He was high by the time the elevator door opened.

David’s job that day was to install the huge window frames on the 40th floor. He walked over to the edge of the building and was just about to get his tools out when his manager, Jason, grabbed his shoulder, pulled him back and yelled, “David, what are you doing? Your safety was not on…you almost walked off the edge of the building! You could’ve died if I hadn’t seen and grabbed you.” David was speechless.

“David, I know you have issues with drugs,” said Jason. “Take the day off, go get help, get cleaned up, then come back.”

That was the last sentence Jason said before David left the worksite. That’s when David realized he had hit rock bottom and decided no matter how hard it would be, he was going to come into my clinic and get help.

This is a true story, and sadly not the only true story. I can tell you about the other patient I had that fell off the subway platform and was almost run over by a train because he was high after work, or that patient who was drunk while working as a medical secretary and entered the wrong surgical information on patients. These are the real faces of addiction, part of the 70% of 40 million Americans suffering from an SUD issue in silence.

Why does this matter to employers? Because these intoxications are happening both remotely and at worksites, causing errors, damaging careers, and reducing work productivity. Impaired judgment due to substance use can even endanger the employee’s life or public safety, and this is a particularly serious issue in safety-sensitive positions and industries. Workers with an SUD miss nearly 50 percent more days than their peers, averaging nearly three weeks (at 14.8 days/year) of unscheduled leave. Workers with pain medication use disorders are absent nearly three times as much—about six weeks (or 29 workdays). Conversely, the typical worker with no SUDs only misses about two weeks (10.5 days) of work annually for illness, injury, or reasons other than vacation and holidays.

What makes these substances so powerful, dangerous, costly, and even deadly? Addiction

Addiction is a chronic disease

The science of addiction is complex, and in order to talk effectively about addiction, we need to define and understand the term. According to the American Society of Addiction Medicine, addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction ingest substances or engage in behaviors that become compulsive and often continue despite harmful consequences. As we’ve seen with David’s story and countless others, stigma adds another level of complexity. However, prevention efforts and treatment approaches for addiction can be as successful as those for other chronic diseases.

It’s important to understand what the latest research is telling us, which is that addiction is actually a chronic disease with deep physiological changes not unlike type II diabetes, cancer, or cardiovascular disease. People don’t choose to have an addiction any more than they choose to have heart disease.

Evolutionary roots and the science of addiction

A recent article in the Journal of Mental Health and Clinical Psychology points out that addiction has exceedingly deep evolutionary roots. The authors suggest that the roots of addiction are found in fundamental biological mechanisms for learning and motivation (i.e., survival) dating back hundreds of millions of years.

It’s only natural to want to keep our bodies alive and reproducing. From an evolutionary perspective, we humans can get a false sense of gain—including increased fitness and viability—from drug addiction, which in turn drives behavior. If we found delicious food or had sex, our brains would produce chemicals (neurotransmitters) that make one feel good. One of those neurotransmitters, dopamine, is released in response to pleasurable experiences, including the “high” from alcohol or opioids—so our brains want to repeat the action, even if the “gain” is only temporary.

‍Research shows that while the pleasure and reward derived from early drug use can play a substantial part in continued use of the drug, it is only one small part of the neurophysiological cycle of addiction. The intense reward sensation of drug intoxication creates a strong and rapid learning response in the brain. This association leads to ever-increasing drug use in order to experience the pleasure of the reward response more often, leading users to take risks at work and elsewhere to reinforce the reward.

Addictive substances such as nicotine and opioids act quickly and trick the human brain into thinking the reward was even better than it really was. The measure of a drug’s addictiveness is not only about how much pleasure it produces, but how quickly it reinforces it. Connections related to impulsive behavioral and emotional responses get stronger, while impulses such as those used in decision making get weaker. Certain people are more or less susceptible to developing addictions, depending on genetics.

Nicotine: a gateway substance

Nicotine has long been known to play a role as a “gateway” substance because it tends to precede the initiation of other drugs. Cigarette use may also act as a “primer” for multiple or polysubstance addictions. Research published in the New England Journal of Medicine reveals that nicotine works to prime animals to self-administer cocaine, for example, whereas the reverse is not the case—cocaine does not act as a gateway to self-administering nicotine.

Tobacco shares a number of close associations with the use and misuse of other drugs. The nicotine in any form of tobacco product is quickly absorbed into the bloodstream. Nicotine immediately causes adrenal glands to release the hormone epinephrine (adrenaline), which then stimulates the central nervous system and increases blood pressure, breathing, and heart rate. As with cocaine and heroin, nicotine activates the brain’s reward center and also increases levels of dopamine, which reinforces rewarding behaviors. Studies suggest that other chemicals in tobacco smoke, such as acetaldehyde, may also enhance nicotine’s effects on the brain.

In addition to tobacco being the leading cause of death and disability in the United States, the National Institute on Drug Abuse (NIDA) says numerous studies have shown that people who start using tobacco and alcohol products earlier in life are more likely to develop additional issues with substance use, including alcohol, marijuana, cocaine, heroin, and other illicit drugs.

Although people can’t get high on nicotine, the activity is repeated so often with so many other activities that it powerfully enhances the pleasure and motivation associated with smoking. Smokers’ brains have learned to smoke, and just like unlearning to ride a bike, it is incredibly hard to unlearn that simple, mildly rewarding behavior of lighting up a cigarette.

Opioids, on the other side of the spectrum, do result in a “high’ that can leave users addicted after just a few interactions, craving the rapid reward of intense pleasure despite its dangers. Even withdrawal can be dangerous, with symptoms including breathing difficulty, irregular heart rate, and seizures.

The road to recovery and cost savings

Addiction and substance use disorders are costly from a societal, personal, and business perspective. For companies, the combined toll of addiction on physical health, pharmacy spend, and behavioral health makes it a top 5 driver of healthcare spend, in line with other traditional high-cost areas such as diabetes, musculoskeletal health, and mental health. For individuals such as David, John, and Donna, the toll on physical and mental health can be crushing and life-endangering.

The good news is we now have effective, evidence-based, ways to treat substance use in an outpatient setting. By utilizing clinically validated medication assisted treatment (MAT) programs, we can support employees in their recovery with FDA-approved medications combined with counseling and social support while keeping the employees in the workforce without losing productivity. Getting people to engage in treatment for their SUD’s through destigmatization, clinically validated MAT programs, and increased access to quality care translates into significant cost savings for companies and health plans.

Workers in recovery miss nearly 14 fewer days each year than workers with untreated SUD and almost 4 days less than employees that have never had an SUD. Research published in the Journal of Occupational and Environmental Medicine shows how getting employees proper treatment can also lower costs—by an average of $536 per year per employee—increase productivity, and reduce turnover.

The science of addiction is complex, but the opportunity to address these complexities with compassion, understanding, and advanced medical care is greater than ever. With a detailed claims analysis conducted by consultants, health plans, or substance use disorder providers, employers can have a direct impact on their bottom line as well as the health of their employees and communities.

For more information on how your workplace benefits or health plan team can reduce the impact of SUDs on your business operations through accessible, high quality substance use care, visit our resources page or contact a solutions expert today.