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Methods Used by The Center for Integrated Behavioral Health Policy to Calculate Company-Specific Business Costs of Substance Use Disorders

Substance use disorders are among the most common and costly health conditions affecting Americans: over 21 million adults meet the diagnostic criteria for alcohol abuse or dependence or illicit drug abuse or dependence.1 Yet, despite widespread public awareness of its scope of substance use problems in U.S. society, research shows that business leaders and policymakers remain largely in the dark about its heavy economic costs. Many businesses have not examined the costs of undetected and untreated substance use disorders on their bottom lines.

To help sharpen understanding of the business cost of substance use disorders, The Center for Integrated Behavioral Health Policy, a research center based at The George Washington University Medical Center, devised a calculator that shows how substance use disorders generate avoidable health care costs and reduce workforce productivity. The Substance Use Disorder Cost Calculator provides concrete, industry-specific information, grounded in research, about the impact of substance abuse and dependence on employed populations. The Substance Use Disorder Cost Calculator, first released for public use in November, 2009, estimates the business impact of the continuum of substance use problems — categorized here as alcohol abuse or dependence, or illicit drug abuse or dependence in 13 different industry categories.2 Specifically, it shows:

  • how common substance use disorders are in each sector
  • how many work days are lost due to substance use disorders
  • the extent of substance use -related hospital and emergency room visits of employees and their families
  • the costs of missed work days and health care of employees and their families

This document describes in detail the methods that The Center for Integrated Behavioral Health Policy uses to derive these estimates.

Acronyms

  • BLS Bureau of Labor Statistics
  • NCQA National Committee on Quality Assurance
  • NHSDA National Household Survey on Drug Abuse
  • NSDUH National Survey on Drug Use and Health
  • SAMHSA Substance Abuse and Mental Health Services Administration
  • NIAAA National Institute on Alcohol Abuse and Alcoholism

Methods

Sources of Data

The Center for Integrated Behavioral Health Policy draws upon a large government-sponsored epidemiological survey, the National Survey on Drug Use and Health3 (NSDUH) 2004-2006 (prior to the 2002 survey, NSDUH was known as the National Household Survey on Drug Abuse [NHSDA]), to create a calculator that can provide company-specific estimates of the prevalence of substance -related problems among employees and their families. The Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services conducts the NSDUH annually. The survey generates detailed estimates of the prevalence, symptoms, and consequences of alcohol use, prescription pain abuse misuse, and illicit drug use in the civilian, non-institutionalized U.S. population. The NSDUH uses a representative national sample, surveying people in all 50 states and the District of Columbia. Since 1999, approximately 70,000 persons age 12 and older residing in households respond each year to questions for the annual NSDUH. SAMHSA produces publicly available data annually based on a representative subgroup of about 57,000 of the NSDUH respondents. For The Substance Use Disorder Cost Calculator, Ensuring Solutions analyzed the pooled 2004 -2006 NSDUH data. A total of 166,786 individuals were represented in the pooled 2004-2006 datasets. All respondents who met the following criteria were included in our analyses:

  • 18 years old or older
  • Employed full- or part-time
  • Reported being covered through private health insurance

Based on these criteria, a total of 56,010 individuals were included in analyses focusing on employed populations. A total of 110,766 were excluded because they were unemployed, retired, adolescents, students not in the workforce, homemakers, or without private health insurance at the time of the interview.

The Center for Integrated Behavioral Health Policy used SPSS statistical software, version 15.0 (SPSS Inc., Chicago, IL) as the primary software to analyze the NSDUH. Additional analyses were conducted with the Survey Documentation and Analysis (SDA, version 3.0) computer program.4 The computer-assisted Survey Methods Program at the University of California, Berkeley developed and maintains the SDA. The data and SDA are part of the Substance Abuse and Mental Health Data Archive maintained by the Inter-University Consortium for Political and Social Research at the University of Michigan.

Adjustments

The Center for Integrated Behavioral Health Policy computed state-level adjustments to reflect the substantial differences in substance use patterns from state to state. SAMHSA published state estimates of alcohol dependence and abuse and illicit drug dependence and abuse for 2005 and 2006 from the NSDUH for the general population.5 No state estimates were available for prescription pain medication abuse or dependence, and given the relatively low prevalence of this problem in employed populations no adjustments by state were performed. The state rates published by SAMHSA were used to calculate adjustment factors by dividing the rates reported in each state, by the national prevalence. For example, the adult alcohol abuse and dependence adjustment factor for the District of Columbia was calculated by dividing the state-specific rate of alcohol abuse and dependence for adults 18 and older (10.53%) by the national adult prevalence during that same time period (7.90%) for an alcohol adjustment factor of 1.33. A similar alcohol adjustment factor was calculated for dependants by dividing the prevalence rate reported for all persons age 12 and older in the District of Columbia (9.86%) by the national prevalence rate reported during that time period (7.1%) for a alcohol adjustment factor of 1.38. These adjustment factors were then applied to prevalence rates calculated with the 2004-2006 NSDUH data in order to more accurately reflect differences in substance abuse and dependence rates among workers in each state.

Prevalence of Substance Abuse or Substance Dependence

The NSDUH is constructed so that alcohol and other drug diagnoses can be derived from survey questions.6 Among employed adults with private health insurance, 3.2 percent have alcohol dependence disorder, and 5.0 percent meet the diagnostic criteria for an alcohol abuse disorder. A total of 8.2 percent of working adults have an alcohol use disorder. These estimates are somewhat higher than estimates from the 1992 National Longitudinal Alcohol Epidemiology Survey, which finds a 6.7 percent prevalence of alcohol abuse and/or dependence among all persons with private health insurance,7 and the 7.1 percent prevalence of alcohol dependence and/or alcohol abuse among working adults from the NCS.8

Among employed individuals with private health insurance, 1.3 percent meet the diagnostic criteria for dependence on illicit drugs, while another .6 percent met the criteria for illicit drug abuse. A total of 1.9 percent of working adults have an illicit drug disorder.
Among employed individuals with private health insurance, .3 percent meet the diagnostic criteria for prescription pain medication dependence, and another .1 percent meet the criteria for prescription pain medication abuse. A total of .4 percent of working adults have a prescription pain medication use disorder.

The Center for Integrated Behavioral Health Policy calculated the prevalence of substance use problems in the workforces of 13 industry sectors from the NSDUH coding of respondents’ places of primary employment, using the Department of Labor standard industry classifications. The number of respondents by industry sector in the 2004 through 2006 NSDUH pooled sample ranged from 1315 in agriculture, forestry, fishing and hunting to 15,358 in the education, health and social services sector.9 No industry adjustments were performed on the prescription pain medication estimates due to their substantially lower prevalence rates.

Lost Work Days Estimates

The NSDUH asked respondents to recall how often they missed work due to illness and injury or skipped work in the past 30 days. The responses to these two questions are summed to measure the total number of missed workdays per month, with the total number of lost workdays capped at a maximum of 20 days per month. Mean number of missed work days are generated by industry category and multiplied by 12 to produce an estimate of total number of missed days per year.

Rates of Health Care Use

NSDUH respondents were asked how many times they had gone to a hospital emergency room in the previous 12 months, whether they had been hospitalized overnight during the previous year, and the number of nights in the hospital if they had been admitted. Mean number of emergency department visits and days in hospital are stratified and compared by substance use disorder and industry sector.

Cost of Absenteeism Estimates

The costs to businesses of missed work days are derived from the Bureau of Labor Statistics (BLS) Current Employment Statistics.10 The most current average daily wages for salaried, nonsupervisory employees by industry as of July 2008 were extracted from BLS Current Employment Statistics. Where industry sectors have been combined due to limited sample size, wages were weighted according to the number of jobs in each sector and summed to derive the average wage for the combined industry sector. The cost of extra work days missed by employees with substance use disorders in each of the 13 industry sectors is computed by multiplying the estimated number of extra days missed (as computed above) by the BLS average daily wage. These cost estimates are undoubtedly conservative, since The Center for Integrated Behavioral Health Policy did not adjust for fringe benefits or for the higher salaries of supervisory and management employees.

Cost of Health Care Estimates

The Center for Integrated Behavioral Health Policy calculates the health care costs of substance-related problems from two sources. A per capita health care cost is derived from estimates of the economic costs of alcohol and illicit drug problems in the United States.11 In order to update these figures to reflect more current costs, these figures were adjusted to 2008 estimates using similar methodology as the original reports. In order to estimate the total economic costs for these two issues, the total costs for alcohol were added to the total costs for illicit drugs, and then discounted by a factor of 12% to reflect the estimated overlap in costs between these sets of conditions in the general population.

For its detailed analyses of the costs of substance use problems, The Center for Integrated Behavioral Health Policy extracts the following yearly direct health care costs related to alcohol and illicit drug use:

Table 1: Yearly Direct Health Care Costs
Treatment Yearly Cost
Treatment Costs $15.3 billion
Prevention and Early Intervention $1.7 billion
Treatment of Medical Consequences of Alcohol and Illicit Drug Consumption $36.5 billion
Medical Consequences of Fetal Alcohol Syndrome (Alcohol Only, Illicit Drug Estimate not Available) $5.6 billion
Insurance Administration $2.2 billion
Total: $61.3 billion

The total health care costs in 2008 are divided by the projected total U.S. population in 200812 to yield a per capita cost of $200. Since employers offering health insurance to their employees generally cover family members as well, the per capita health cost of alcohol and illicit drug related problems is multiplied by 2.61, the estimated average household size in the United States according to the US Census Bureau for an estimated total per-employee cost of $522.13

In addition, The Substance Use Disorder Cost Calculator estimates the costs of excess health care use. The estimated costs of extra hospital and emergency room use by persons with substance problems are computed by deriving the extra per capita rate of hospital and emergency room use for people with substance problems, and then multiplying the per capita rates by the industry-specific substance problem prevalence rates. The resulting number of extra hospital days and emergency room visits are then multiplied by the Healthcare Utilization Cost and Utilization Project estimates of average emergency room costs and daily hospital charges for patients with commercial health insurance.14

Additional Costs

Substance misuse is associated with a number of hazardous and costly social consequences including driving under the influence of alcohol or drugs, getting arrested, displaying violent behavior, and many others. The Substance Use Disorder Cost Calculator illustrates the social costs of problem substance use by comparing prevalence rates for workers and family members with substance use disorder to those without an substance use disorder. Prevalence rates are calculated as the percentage of respondents who had experienced an event or problem within a given time period prior to the survey (usually 12 months). The difference in prevalence rates by substance use disorder can then be applied to the number of individuals with a substance use problem to derive the increase or excess that is attributable to substance misuse.

Results

Prevalence of Substance Problems by Industry Sector

Based on the analysis of the merged 2004-2006 National Survey on Drug Use and Health (NSDUH) data, most people with substance problems work, and the majority are full-time employees. Among adults that currently have the disease of alcoholism, 75 percent work (59% work full-time and 16% work part-time). Even higher workforce participation rates are found among adults who meet the diagnostic criteria for alcohol abuse: 82% work (67% work full-time and 15% work part-time). By contrast, only 67% of adults with no alcohol problems are employed (55 percent full-time and 13 percent part-time). In fact, adults with a substance use disorder are significantly more likely to work than adults without a substance use disorder.15

Among adults that currently meet the diagnostic criteria for illicit drug dependence 65, percent work (48% work full-time and 17% work part-time). Even higher workforce participation rates are found among adults who meet the diagnostic criteria for illicit drug abuse: 74 percent work (55 % work full-time and 19% work part-time). By contrast, 68% of adults with no illicit drug problems are employed (55 percent full-time and 13 percent part-time).

Among adults that currently meet the diagnostic criteria for prescription pain medication dependence 61 percent work (50% work full-time and 11% work part-time). Even higher workforce participation rates are found among adults who meet the diagnostic criteria for prescription pain medication abuse: 77 percent work (58% work full-time and 19% work part-time). By contrast, 68% of adults with no illicit drug problems are employed (55 percent full-time and 13 percent part-time).

Male employees are approximately twice as likely to have a substance use disorder than female employees.16 Employees with a substance use disorder also tend to be younger, on average than the general workforce population.17

Rates of substance use problems vary greatly from industry to industry. Overall, substance use problems are most prevalent in the entertainment, arts and food service industries (15 percent) and lowest in the education, health and social services industries (5.8 percent). Industry-specific rates are not calculated for prescription pain dependence and abuse because of its relatively low prevalence rate.

Table 2: Prevalence (in percent) of Substance Problems by Industry Sector
Industry Sector Number of Respondents Alcohol Problems (%) Illicit Drug Problems (%) Prescription Pain Medication Problems (%) Alcohol, Illicit Drug, or Prescription Pain Medication Problem (%)
Agriculture, Forestry, Fishing, and Hunting (1) 772 6.8% 2.0% 7.3%
Arts, Entertain, Recreation, Accommodation, Food Svc. (11) 5687 13.3% 4.3% 15.0%
Education, Health & Social Services (10) 12035 5.1% 1.1% 5.8%
Finance, Insur, Real Estate, Rental & Leasing (8) 3913 8.9% 2.3% 9.8%
Information & Communication (5) 1332 8.7% 1.9% 9.9%
Manufacturing (3) 6140 8.2% 1.8% 9.2%
Mining/Construction (2) 4303 12.8% 3.0% 14.3%
Other Services (13) 2575 5.0% 1.3% 5.9%
Professional / Scientific / Management / Admin / Waste Mngmt (9) 5358 9.5% 1.9% 10.5%
Public Administration (12) 2704 5.7% 0.6% 5.9%
Retail Trade (7) 7134 9.1% 2.5% 10.3%
Transportation & Utilities (4) 2386 7.8% 1.5% 8.3%
Wholesale Trade (6) 1525 11.7% 2.3% 12.7%
Total (US Industry Average) 55864 8.2% 1.9% .4% 9.2%

Company-specific estimates of the number of employees who have a substance use disorder are computed by multiplying the NSDUH prevalence rates of substance use problems in a specified industry sector by the total number of a company's employees. When a company's state location is indicated, the company-specific estimates are adjusted for state prevalence rates of substance use disorders among workers and in the general population.

Example: For an automobile parts manufacturing company with 1,000 employees, the Calculator uses the manufacturing sector’s prevalence estimates of 8.2 percent with an alcohol problem to derive an estimate of 82 problem drinking employees. Using this same methodology, the Calculator will also estimate 18 employees with an illicit drug problem, 4 employees with a prescription pain medication problem, and 92 employees with any of thee problems. These estimates only apply to the national average; the Calculator also takes into account adjusters by state.

Company-specific estimates of the number of employees' family members who have a substance use disorder are computed by multiplying the NSDUH general population prevalence rates for substance use disorders by the total number of estimated dependants (number of employees * 2.61, which reflects the average number of dependants as projected from the U.S. Census). No industry sector adjustment is made for employees’ family members.

Example: For the automobile parts manufacturer with 1,000 employees, the general population prevalence of substance use disorders is estimated as 9.2 percent for the US population. This number is multiplied by 1610 (an estimate of the number of dependants for 1000 employees) to derive an estimate of 148 family members with a substance use problem. This estimate only applies for the national average; the Calculator also takes into account adjusters by state.

Workplace Absenteeism

Employees with substance use problems skip and miss substantially more workdays per month than other employees. Employees with a substance use disorder miss an average of .98 days per month, while employees with no substance use disorder missed an average of .63 days per month.18

These differences are significant and over time, add up to become quite costly as demonstrated below.

Table 3: Excess Workdays Missed Monthly (per 1000 employees)
Industry Sector Alcohol Problems Illicit Drug Problems Prescription Pain Medication Problems Any of These Problems
Agriculture, Forestry, Fishing, and Hunting (1) 85 77 85
Arts, Entertain, Recreation, Accommodation, Food Svc. (11) 20 25 38
Education, Health & Social Services (10) 15 6 19
Finance, Insur, Real Estate, Rental & Leasing (8) 8 4 12
Information & Communication (5) 14 6 14
Manufacturing (3) 18 29 31
Mining/Construction (2) 28 47 66
Other Services (13) 23 4 27
Professional / Scientific / Management / Admin/ Waste Mngmt (9) 28 3 29
Public Administration (12) 12 11 13
Retail Trade (7) 35 18 48
Transportation & Utilities (4) 20 5 20
Wholesale Trade (6) 40 57 79
Total 22 16 6 31

Company-specific estimates of the number of extra work days missed are computed by calculating the average difference in number of workdays missed per month for employees with a substance use disorder versus those without a substance use disorder. The resulting number is the total number of excess workdays that can be attributed to substance use disorders.

Example: To continue the example of an auto parts manufacturing company with 1,000 employees, the average number of extra missed days of employees with a substance use disorder (.34) times the prevalence of the disorder in the manufacturing sector (9.2%) yields an estimate of 31 days lost each month, or 375 days per year.

Health Care Utilization

Hospital use: Company-specific estimates of the number of excess hospital nights are computed by multiplying the percentage of persons with substance use problems who reported any overnight hospital stay by the average number of nights for those who spent at least one night. The average per capita hospital use rate for adults with no substance use problems is then subtracted from the rates for adults with substance use problems.

Example: In the example of the auto parts manufacturer, the number of hospital days for persons with a substance use disorder (4.1 days) is multiplied by the percentage who reported an overnight stay in the hospital (6.4 percent) to generate rates of hospital days per person with a substance use problem. The number of expected hospital days in an employed population without a substance use problem is then calculated by multiplying the percentage of those without a substance use problem reporting an overnight stay in the hospital (7.1 percent) with the average number of nights (3.7 nights) spent by patients who were hospitalized. This rate of hospital days for persons with no substance use problem is subtracted from the rates for substance use disorders. The difference is multiplied by the number of people with substance use disorders in the workforce to generate the estimate of the number of excess hospital days. The excess number of hospital days for family members is calculated following the same method using the prevalence rates for the entire population. The resulting estimate is .5 fewer hospital days for an employee with a substance use disorder.

Note Concerning Hospital Utilization for Employees with an Alcohol Use Disorder: It is important to note that the calculator estimates that employees with alcohol use disorders (abuse or dependence) have lower rates of hospitalization than employees without an alcohol use disorder. However, it is important to note that there are significant differences in both utilization and cost within this population. Employees that meet the diagnostic criteria for alcohol dependence (alcoholism) are significantly more likely to report visiting the hospital in the past year than other individuals (7.8% versus 7.1%). They are also more likely to report longer stays. Dependant employees also report significantly longer stays than other workers (4.6 days versus 3.8). Workers that meet the diagnostic criteria for alcohol abuse are less likely to report any hospitalization (4.8% versus 7.1%) and report shorter stays (3.2 versus 3.8).

These results may be partially explained by recent research that suggests that moderate alcohol use may be inversely related to both cardiovascular risk and overall mortality. That is, individuals who meet the diagnostic criteria for alcohol abuse may actually benefit from some of the protective effects of moderate alcohol use. However, research has also consistently demonstrated that excess alcohol consumption (usually defined as four drinks per day for males, and two drinks per day for females) is associated with increased risk of disease and higher rates of mortality. Individuals who meet the diagnostic criteria for alcohol dependence are likely to routinely exceed these drinking guidelines. Their higher hospital use may reflect the fact that they are experiencing significant health problems as a result of their excess use.

While the fact that employees with alcohol problems report less frequent hospitalizations than employees without an alcohol use disorder may seem counter-intuitive, it is important to remember that those with the most serious alcohol problems do show significantly higher hospitalization rates compared to individuals without an alcohol use disorder. It is also important to remember that costs associated with hospitalization are only part of the total healthcare costs incurred by individuals with substance use disorders, and that estimates that include a wider variety of health care costs suggest that alcohol use disorder is responsible for an additional yearly cost of $161 per capita.

Emergency room use: Employees with substance use disorders reported greater emergency service use in the past year than workers without substance use disorders (.49 ER visits per employee with a substance use disorder versus .39 visits per employee without a substance use disorder).19 Perhaps one reason for this higher use of emergency rooms is that adult employees with substance use disorders are much more likely to drive while under the influence of alcohol or drugs. Three-quarters of employees with a substance use disorder (75%) report driving under the influence of alcohol or drugs during the past year, compared to 7% of employees without a substance use disorder.20

Table 4: Number and Cost of Excess Emergency Room Visits Annually (per 1000 employees) – Substance Use Disorders
Industry Sector Excess ER Visits- Employee and Family Cost of Excess ER Visits
Agriculture, Forestry, Fishing, and Hunting (1) 18.7 $22,227.26
Arts, Entertain, Recreation, Accommodation, Food Svc. (11) 33.8 $40,283.18
Education, Health & Social Services (10) 23.6 $28,126.72
Finance, Insur, Real Estate, Rental & Leasing (8) 10.4 $12,347.15
Information & Communication (5) 15.3 $18,234.69
Manufacturing (3) 29.0 $34,562.49
Mining/Construction (2) 37.2 $44,275.74
Other Services (13) 27.3 $32,548.33
Professional / Scientific / Management / Admin / Waste Mngmt (9) 16.4 $19,486.09
Public Administration (12) 16.7 $19,843.64
Retail Trade (7) 23.6 $28,079.04
Transportation & Utilities (4) 27.6 $32,870.12
Wholesale Trade (6) 30.8 $36,660.08
Total (US Industry Average) 23.5 $27,983.70

Company-specific estimates of the number of excess emergency room visits are computed by subtracting the average number of emergency room visits for persons without a substance use disorder from the average number for persons with a substance use disorder. This number, which reflects the average excess number of visits attributable to substance use disorders, is then multiplied by the estimated number of employees with a substance use disorder. The average number of emergency room visits are generated by industry sector. A similar calculation is performed for employees’ families, and the two numbers are summed.

Example: Following the same procedure used for to estimate excess hospital use, the number of excess emergency department visits for the parts manufacturing company with 1,000 employees estimates 15 visits that are attributable to substance use disorders.

Costs of Substance Use Disorders to Business

Cost of missed work: Industry absorbs substantial costs because employees with substance use problems miss more work than workers with no substance use problems. The table below illustrates the estimated costs of missed days per 1,000 employees for the 13 sectors. Costs are based on the prevalence of substance use problems in each sector and the sector-specific average number of excess missed days by employees with substance use problems. The actual costs of missed days experienced by any specific company will vary from these estimates due to differences in wages, sick day reimbursement policies and employee replacement costs.21

Table 5: Cost of Missed Workdays Annually (per 1000 employees)
Industry Sector Cost of Missed Workdays
Agriculture, Forestry, Fishing, and Hunting (1) $90,235.01
Arts, Entertain, Recreation, Accommodation, Food Svc. (11) $38,844.00
Education, Health & Social Services (10) $34,617.37
Finance, Insur, Real Estate, Rental & Leasing (8) $24,374.25
Information & Communication (5) $33,011.19
Manufacturing (3) $53,241.06
Mining/Construction (2) $143,979.26
Other Services (13) $40,372.99
Professional / Scientific / Management / Admin / Waste Mngmt (9) $59,439.74
Public Administration (12) $27,575.75
Retail Trade (7) $60,183.31
Transportation & Utilities (4) $31,056.08
Wholesale Trade (6) $152,919.38
Total (US Industry Average) $54,201.98

Company-specific estimates of the cost of workdays missed by employees with substance use problems are computed by multiplying the company’s likely number of missed days per year by the average daily wage for that sector. Where state information is provided by the user, the company-specific costs include a state-level substance use disorder prevalence adjustment.

Example: For the auto parts manufacturer, the previous estimate of 375 missed days is multiplied by $141.84 to generate a total of $53,2418 lost annually.

Cost of alcohol and illicit drug -related health care use: Applying the average annual per capita alcohol and illicit drug related health care cost of $200.6522 to a workforce of 1,000 adds $200,650 for employees, and $323,046 for families and dependents of employees. This sum represents expenditures such as treatment of illnesses and injuries associated with alcohol and illicit drug use, treatment and prevention of alcohol and illicit drug problems, and insurance administration. Since these estimates do not include costs that are specific to prescription pain medication, these numbers almost certainly underestimate the total costs that are attributable to substance use disorders.

Company-specific estimates of the annual cost of health care services associated with substance use disorders are computed by multiplying the number of employees and their family members by the per capita cost of alcohol and illicit drug-related health care use. No industry sector adjustments are made.

Example: For the auto parts manufacturer, the number of employees and family members is multiplied by the average per capita health care cost of $200.65, yielding an estimated cost of approximately $525,000 annually.

Cost of excess hospital days and emergency department visits: The Calculator also includes estimates of the costs of extra hospital days and emergency room visits associated with substance use disorders by employees and their families. Cost estimates are computed by multiplying the industry-specific rates of extra hospital and emergency room use by employees with substance use disorders and the general population use rates for employees' families times the average hospital day and ER visit costs. These costs are components of the overall health care costs for the treatment of illnesses and injuries associated with substance use, figured above.

Social Costs

Serious Psychological Distress

The NSDUH assesses whether respondents have had serious psychological distress, formerly referred to as serious mental illness (SMI) in versions of the NSDUH prior to 2004. Nonspecific serious psychological distress is determined using a six item scale that measures how frequently respondents experienced distress symptoms during the one month in the past year when they were at their worst emotionally. The symptoms of distress include the following: feeling hopeless, feeling nervous, feeling restless or fidgety, feeling sad or depressed, feeling everything was an effort, and feeling worthless. Workers with substance use disorders are approximately two and one-half times as likely to have had serious psychological distress at some point in the previous year (21.2 percent vs. 7.6 percent). To estimate the number of workers who are likely to have had serious psychological distress, the Calculator multiplies the expected number of workers with substance use problems by the difference between the rate of serious psychological distress among workers with substance use disorders and the rate of serious psychological distress among workers with no substance use disorders. To estimate the number of family members with serious psychological distress and a substance use disorder, the Calculator multiplies the expected number of family members with substance use problems by the difference in the general population rates of serious psychological distress of those who have substance use problems and those who do not have substance use problems (21.7 percent versus 7.6 percent). The Center for Integrated Behavioral Health Policy then summed the estimated excess number of workers who have psychological distress and the excess number of family members who have psychological distress.

Much of the serious psychological distress found among working people and their families is due to depression. Workers and family members with substance use disorders were twice as likely to report a co-occurring major depressive episode in the previous 12 months. Among workers, 14.6 percent of those with a substance use disorder had a co-occurring depressive disorder, and 5.5 percent of workers with no substance use disorder had major depression. The rates were similar among family members: among those with a substance use disorder, the prevalence of co-occurring depression was 15.4 percent; among those with no substance use disorder, the prevalence was 5.5 percent.

Anxiety

The NSDUH assesses whether respondents have experienced anxiety. Workers with substance abuse problems are more likely to report experiencing anxiety in the past year (8 percent) than workers without substance use disorders (3 percent). To estimate the number of workers who are likely to experience anxiety and also have a substance use disorder, the Calculator multiplies the expected number of workers with substance use disorders by the difference between the rates of workers who have reported experiencing anxiety among those with substance use disorders compared to those without substance use disorders. To estimate the number of family members that have experienced anxiety in the past year, the Calculator multiplies the expected number of family members with substance use disorders by the difference in the general population anxiety rates of those who have substance use disorders and those who do not have substance use disorders (7% vs. 3 %). The Center for Integrated Behavioral Health Policy then summed the estimated number of workers who experienced anxiety and the estimated number of family members who have experienced anxiety.

Smoking

The NSDUH assesses whether respondents have been addicted to nicotine within the past month. Workers with substance use problems are about twice as likely to have nicotine dependency (18.4 percent vs. 8.3 percent). To estimate the number of workers who are likely to have a nicotine dependence (smoking) problem, the Calculator multiples the expected number of workers with substance use problems (previously calculated by the Calculator) by the difference between the rate of nicotine dependence of workers with substance use disorders and the rate of nicotine dependence of workers without substance use disorders. To estimate the number of family members with a co-occurring nicotine and substance use problem, the Calculator multiplies the expected number of family members with substance use problems by the difference in the general population heavy smoking rates of those who have alcohol problems and those who do not have substance use problems (17.9 percent vs. 7.1 percent). The Center for Integrated Behavioral Health Policy then summed the estimated number of workers who have nicotine dependence and the estimated number of family members who have nicotine dependence.

Problems with Law Enforcement

The NSDUH assesses whether respondents have been arrested and booked in the previous year. Workers with substance use disorders are 2 and one-half times as likely to have been arrested and booked in the past year (36.3 percent vs. 13.7 percent). To estimate the number of workers who are likely to have a problem with law enforcement in the previous year, the Calculator multiples the expected number of workers with substance use problems by the difference between the rate of recent arrests of workers with substance use disorders and the rate of arrests in the previous year of workers without substance use disorders. To estimate the number of family members with a recent history of problems with law enforcement, the Calculator multiplies the expected number of family members with substance use problems by the difference in the general population arrest rates of those who have substance use problems and those who do not have substance use problems (34.3 percent vs. 11.1 percent). The Center for Integrated Behavioral Health Policy then summed the estimated number of workers who have previous year arrest records and the estimated number of family members who have previous year arrest records.

Driving Under the Influence of Alcohol and/or Illicit Drugs

The NSDUH assesses whether respondents have driven under the influence of alcohol or other drugs in the previous year. Workers with substance use disorders are over five times more likely to have driven under the influence in the past year (72.7 percent vs. 13.1 percent). To estimate the number of workers who are likely to have a problem with driving under the influence of alcohol or drugs within the previous year, the Calculator multiples the expected number of workers with substance use problems by the difference between the rate of driving under the influence of alcohol or drugs of workers with substance use disorders and the rate of DUI of workers without substance use disorders. To estimate the number of family members with a recent history of driving under the influence of alcohol or drugs, the Calculator multiplies the expected number of family members with substance use problems by the difference in the DUI rates between those in the general population who have substance use problems and those who do not have substance use problems (67.7 percent vs. 10.0 percent). The Center for Integrated Behavioral Health Policy then summed the estimated number of workers who have recently driven under the influence of alcohol or drugs and the estimated number of family members who have recently driven under the influence of alcohol or drugs.

Violence

The NSDUH assesses whether respondents have been violent by attacking someone with the intent to cause serious bodily harm in the previous year. Workers with substance use disorders are much more likely also to report that they have attacked someone (4.5 percent) than workers without substance use disorders (.6 percent).To estimate the number of workers who are likely to have displayed violent behavior and who also have a substance use disorder, the Calculator multiplies the expected number of workers with substance use problems by the difference between the rates of workers who have reported attacking someone among those with substance disorders compared to those without substance use disorders. To estimate the number of family members who have both a substance use disorder and who have displayed violent behavior, the Calculator multiplies the expected number of family members with substance use disorders by the difference in the general population rates of causing violence of those who have substance use disorders and those who do not have substance use disorders (4.7 percent vs. .6 percent). The Center for Integrated Behavioral Health Policy then summed the excess number of workers and family members who have substance use problems as well as exhibit violent behavior.

Co-Occurring Disorders

The NSDUH results can also be used to assess the degree to which individuals with one substance use disorder meet the diagnostic criteria for another substance use disorder. Workers who currently meet the diagnostic criteria for an alcohol abuse or dependence disorder are significantly more likely to meet the diagnostic criteria for illicit drug abuse or dependence (11.8 percent) than employees that workers without an alcohol problem (1.0 percent). Likewise, employees who abuse or are dependant on prescription pain medication are more likely to meet the diagnostic criteria for alcohol abuse or dependence (50.6 percent) than other employees (7.4 percent).

Domestic Violence

Past versions of the NSDUH have asked respondents to report whether they have hit, or attempted to hit, their spouse or partner in the past 12 months. Data from the last year that this question was included in the study, 2002, were used to estimate the prevalence of domestic violence cases among workers and families with and without substance use disorders. These rates were then applied to 2004-2006 substance use prevalence rates to estimate the excess cases of domestic violence that can be attributed to substance use disorders.

To estimate the number of workers who are likely to have committed an act of domestic violence in the previous year, the Calculator multiples the expected number of workers with substance use problems by the difference between the rates of domestic violence in workers with (14.2 percent) and without (4.3 percent) a substance use disorder. To estimate the excess number of family members that have committed an act of domestic violence in the past 12 months the Calculator multiplies the expected number of family members with substance use problems by the difference in the general population domestic violence rates of those who have substance use problems and those who do not have substance use problems (12.2 percent vs. 3.5 percent). The Center for Integrated Behavioral Health Policy then summed the estimated number of workers who report having committed an act of domestic violence and the estimated number of family members who report committing an act of domestic violence.

Prevalence Rates of Social Problems

The following table summarizes the prevalence of the social problems described above based on the presence of substance use disorders.


Table 6: Prevalence of Social Problems
WORKER With Substance Use Disorder (percent) No Substance Use Disorder (percent) Difference (percent)
Serious Psychological Distress (past year) 21.2% 7.6% 13.6%
Major Depressive Disorder (past year) 14.6% 5.5% 9.1%
Anxiety (past year) 7.5% 3.3% 4.2%
Arrested and Booked 36.3% 13.7% 22.6%
DUI (past year) 72.7% 13.1% 59.6%
Nicotine Dependence 18.4% 8.3% 10.1%
Committed an Act of Domestic Violence 14.2% 4.3% 9.9%
FAMILY With Substance Use Disorder (percent) No Substance Use Disorder (percent) Difference (percent)
Serious Psychological Distress (past year) 21.7% 7.6% 14.1%
Major Depressive Disorder (past year) 15.4% 5.5% 9.9%
Anxiety (past year) 7.4% 3.3% 4.1%
Arrested and Booked 34.3% 11.1% 23.2%
DUI (past year) 67.7% 10.0% 57.7%
Nicotine Dependence 17.9% 7.1% 10.8%
Committed an Act of Domestic Violence 12.2% 3.5% 8.7%

Conclusion

The Substance Use Disorder Cost Calculator gives a simple estimate of the financial toll faced by individual businesses, illuminating an area with significant potential for cost reduction and improved productivity. The Center for Integrated Behavioral Health Policy has found that given the high costs imposed by substance use disorders, most employers can identify opportunities for health and productivity savings while also improving the health of employees and their families by improving access to treatment for the full spectrum of substance-related problems.
The Center for Integrated Behavioral Health Policy, November, 2009

Footnotes:

  1. U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. NATIONAL SURVEY ON DRUG USE AND HEALTH dataset. Research Triangle Park, NC: Research Triangle Institute. Ann Arbor, MI: Inter-university Consortium for Political and Social Research. [Back to Reference]
  2. Throughout this paper and The Substance Use Disorder Cost Calculator, the terms “substance use disorder” and “substance problems” are used interchangeably to refer to persons who meet the diagnostic criteria specified in the latest edition of the Diagnostic and Statistical Manual 4th Edition for alcohol dependence disorder , alcohol abuse disorder, illicit drug dependence disorder, illicit drug abuse disorder, prescription opiod dependence disorder, or opiod abuse disorder. [Back to Reference]
  3. U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, NATIONAL SURVEY ON DRUG USE AND HEALTH, Combined 2004-2006 dataset. Research Triangle Park, NC. Research Triangle Institute,. Ann Arbor, MI: Inter-university Consortium for Political and Social Research. [Back to Reference]
  4. Substance Abuse and Mental Health Data Archive. Available from the World Wide Web: http://sda.berkeley.edu/ [Back to Reference]
  5. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. State Estimates of Substance Use from the 2045-2006 National Surveys on Drug Use and Health. OAS Series #H-33, DHHS Publication No. (SMA) 08-4311, Rockville, MD, 2008. http://www.oas.samhsa.gov/2k6state/TOC.cfm [Back to Reference]
  6. The NSDUH includes a common set of questions about substance use that are sufficient to construct DSM IV diagnoses of substance dependence disorders and substance abuse disorders during the year prior to the interview. [Back to Reference]
  7. Brant, B. 1995. Variations in the Prevalence of Alcohol Use Disorder and Treatment by Insurance status. Frontlines, June 1995. The 1992 National Longitudinal Alcohol Epidemiology Survey sample consisted of 42,862 adults, 18 years of age and older, and was designed to provide detailed information about alcohol use and related disorders in the general population. In addition to diagnostic questions, the NLAES asked a broad range of background demographic questions, including work history and health care use. [Back to Reference]
  8. The NCS diagnoses were based on a modified version of the Composite International Diagnostic Interview (the UM-CIDI). The ll NCS diagnoses use DSM III-R criteria, the predecessor to the DSM-IV, which is used by the NSDUH to diagnose alcohol use disorders. The narrow DSM III-R diagnostic categories used by the NCS produced estimates of alcohol dependence disorder among working adults of 4.5 percent and of alcohol abuse disorder of 2.6 percent. The NCS is a national stratified random sample of 8098 respondents 15 to 54 years of age who were administered a detailed diagnostic interview between 2001 and 2003. [Back to Reference]
  9. Detailed tables of the prevalence of problem substance use, by industry, broken out by age and sex, are available from the author. [Back to Reference]
  10. Average hourly earnings of production or non-supervisory employees on private nonfarm payrolls by major industry. Available from the World Wide Web: ftp://ftp.bls.gov/pub/suppl/empsit.ceseeb16.txt
    Average Hourly Wage
    Agriculture, Forestry, Fishing, and Hunting $11.10
    Arts, Entertain, Recreation, Accommodation, Food Svc. ( $10.79
    Education, Health & Social Services $18.84
    Finance, Insur, Real Estate, Rental & Leasing $21.59
    Information & Communication $24.81
    Manufacturing $17.73
    Mining/Construction $22.80
    Other Services $15.84
    Professional/Scientific/Management/Admin/Waste Mngmt $21.06
    Public Administration $22.13
    Retail Trade $12.95
    Transportation & Utilities $16.24
    Wholesale Trade $20.23
    TOTAL (US INDUSTRY AVERAGE) $18.05
    [Back to Reference]
  11. Harwood, HJ, 2000. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States. National Institute on Alcohol Abuse and Alcoholism. Available from the World Wide Web: http://pubs.niaaa.nih.gov/publications/economic-2000/. See author's note on the calculation of updates. [Back to Reference]
  12. The estimated US population used by the calculator is: 305,500,000. [Back to Reference]
  13. The estimated average number of dependants for a family is 1.60. http://factfinder.census.gov/servlet/ACSSAFFFacts?_sse=on. [Back to Reference]
  14. The average daily hospital charge was estimated with data from HCUPnet. Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov/HCUPnet.jsp. [Back to Reference]
  15. Adults who worked full or part time were more likely to meet the diagnostic criteria for alcohol abuse or dependence, illicit drug abuse or dependence, or prescription pain medication abuse or dependence, (10.4%) than adults not in the workforce (6.8%), p <.000. [Back to Reference]
  16. 7.2% of employed females meet the diagnostic criteria for a substance use disorder (alcohol abuse, alcohol dependence, illicit drug abuse, illicit drug dependence, prescription pain medication abuse, or prescription pain medication dependence). 13.2 of employed males meet the diagnostic criteria for a substance use disorder. This difference is statistically significant, p <.000. [Back to Reference]
  17. 59 percent of workers with a substance use disorder were under 35 years of age. Only 32 percent of adults without a substance use disorder were under thirty-five years of age. This difference was significant, p <.000. [Back to Reference]
  18. 2004-2006 respondents who were employed full or part time in an industry sector, by primary place of employment. This difference was statistically significant, p<.000. [Back to Reference]
  19. 2004-2006 respondents who were employed full or part time in an industry sector, by primary place of employment. This difference was statistically significant, p<.000. [Back to Reference]
  20. 2004-2006 respondents who were employed full or part time in an industry sector, by primary place of employment. This difference was statistically significant, p<.000. [Back to Reference]
  21. These estimates are likely to err on the low side because fringe benefits, turnover and replacement costs, disability and workers' compensation costs are not included. Since the BLS average wage estimates cover only salaried, nonsupervisory and non-management employees, actual costs to companies of missed days are likely to be higher when the salaries of managers with alcohol problems are included. [Back to Reference]
  22. This number was calculated by dividing the total health care costs attributed to alcohol and illicit drug use by the total U.S. population estimated by the U.S. Census. Total health care spending of 61.3 billion by the US population estimate of 305,000,000 for an estimate of $200.65 per person. This is surely an underestimate of the actual costs associated with substance use disorder as it only accounts for costs associated with alcohol and illicit drugs. For a more detailed explanation of how this estimate was calculated, see our paper on the subject here. [Back to Reference]