Ability to Work and Employability of Patients in Opioid Substitution Treatment Programs in Slovenia

Abstract

Aim

To assess the ability to work and employability of individuals taking part in opioid substitution treatment programs (OSTP).

Methods

The study was composed of two surveys. In the first survey, 237 of 480 patients enrolled in OSTP responded to the questionnaire about their employment status, opinion about employment, and perception of assignments before and during OSTP. In the second survey, 66 of 100 employers responded to the questionnaire on the occurrence, perception, and management of addiction problems in their companies.

Results

Unemployment rate in individuals enrolled in OSTP was 43.5% and decreased during OSTP by 10.5% (P = 0.027). Irregular use of OSTP medications was the most important factor for unemployment (odds ratio, 2.44; P = 0.016). OSTP was highly effective in achieving a positive change in patients’ perception of different kinds of assignments previously perceived as beyond their abilities. Thus, perception of mentally demanding assignments (P < 0.001), working at unfavorable hours (P < 0.001), and forced work pace (P < 0.001) represented much lower burden after entering OSTP. Only 6.6% of employers reported illicit drugs as being a problem at their companies and 79.1% believed they would not recognize a person under the influence of illicit drugs. In 93.0% of the cases, applicants for a job would have had lower chances if they had been drug users; the percentage was slightly higher for those taking part in OSTP (94.7%).

Conclusion

OSTP in Slovenia was effective in increasing both employability and OSTP patients’ ability to work. To facilitate complete rehabilitation, particularly in obtaining employment for the patients, the process must involve the society as a whole.

Psychoactive substance use, including illicit drugs use, represents a significant threat to the human health (1). It is one of the major public health problems worldwide (2), especially in the Americas and Europe (1-4).

Opioid substitution treatment program (OSTP) is one of the main approaches in drug addiction treatment and harm reduction programs for opioid illicit drugs users. The main goals of OSTP are reducing drug use, improving personal and social functioning, and improving public health (eg, by diminishing the risk of HIV infection and hepatitis and by preventing and reducing drug-related mortality and criminal behavior) (5-8). Through OSTP programs, opioid users can contact health services for assistance and treatment and gain access to other treatment programs, from low-threshold to abstinence-oriented ones. Since these programs are more effective when there is community participation, employment and working environment are of the utmost importance. Moreover, employment is a very important long-term outcome of treatment of drug dependence (9).

The employability of OSTP patients, especially younger ones theoretically able to work, is a serious problem in most environments. This is understandable to the certain extent, since working environment is one of the areas where use of illicit drugs can result in significant human and material damage. Employees under the influence of psychoactive substances are less productive and the quality of their work is decreased (10,11). They are frequently involved in workplace accidents that can result in material damage and personal injury (12-14). Psychoactive substance abuse before or during work presents a potential risk not only to the proper execution of assignment, but also to the well-being and safety of the user and his or her coworkers.

In Slovenia, the problem of illicit drugs use has become even more pronounced in the last 15 years, since the beginning of the transition process (15). To address this problem, the Ministry of Health of the Republic of Slovenia established in 1995 a public health network of Centers for the Prevention and Treatment of Drug Addiction in nine Slovenian urban areas. Before that, Koper and Ljubljana had been the only two cities offering OSTP (Koper since 1991 and Ljubljana since 1992) (15). Currently, treatment of drug users is provided in 18 Centers and two outpatient clinics staffed with trained personnel. Methadone substitution treatment program is one of the basic treatment programs offered in these centers. Substitution treatment with buprenorphine and slow-released morphine (16-18) was introduced in 2005 and treatment with Suboxone (buprenorphine + naloxon combination) in the summer of 2007 (19). Additionally, drug prevention and rehabilitation centers provide counseling services for addicts, their relatives, and educators; individual, group, and family therapy; preparation for hospital treatment; and help in rehabilitation and social reintegration (20). Drug-dependent persons must meet with their counselor at least once a week and/or receive one of the forms of psychosocial therapy (20).

Regarding employability of patients enrolled in OSTP, employers in Slovenia have the obligation to ensure the safety and well-being of their employees according to the Occupational Health and Safety Act, including patients in OSTP. On the other hand, the general attitude of Slovenian society toward OSTP patients is negative and rejection and stigma of drug users is especially strong (20). It is the reflection of ignorance and simplification of the problem and our inability to distinguish between different types of drugs and their consequences.

The aim of our study was to determine the status, options, and chances of employment of drug users currently or previously treated in OSTP in Slovenia. We investigated the attitude of drug users in OSTP toward their employment status and work in general and the attitude of employers toward current employees and future job seekers with drug problems or treated in OSTP.

Methods

OSTP participants

A total of 480 individuals enrolled in OSTP at the Center for the Prevention and Treatment of Drug Addiction of the Community Health Center Ljubljana at the time of the survey were approached to participate in the study. The Ljubljana Center covers the largest health region in Slovenia (15). Of 480 individuals in OSTP, 239 agreed to answer the questionnaire (response rate, 49.8%). The rest refused to participate and were excluded from the study. Of 239 questionnaires, 237 were fully or almost fully completed (in 11 questionnaires some answers were missing) and thus were eligible for the analysis, while in 2 of them more than a half of answers were missing. The mean age (±standard deviation) of participants was 27.4 ± 6.1, and more than half were men (Table 1). At the time of the study, 156 of 237 (65.8%) participants were taking only substitution medication (methadone or buprenorphine and no illicit drugs), while 81 participants (34.2%) were taking heroin, cocaine, or amphetamines in addition to substitution medication (Table 1).

Table 1.

Characteristics of unemployed individuals taking part in opioid substitution treatment programs (OSTP) in Slovenia in 2006

Characteristics	No. (%) of participants*	P†
Sex:
male	56/132 (42.4)	0.718
female	47/105 (44.8)
Age (years):
≤20	4/17 (23.5)	0.101
21-30	74/173 (42.8)
≥31	25/47 (53.2)
Education level:
primary	46/94 (48.9)	0.187
vocational	15/46 (32.6)
secondary or higher	42/96 (43.8)
Number of previous employments:
0	47/109 (43.1)	0.918
1	24/52 (46.2)
2	14/36 (38.9)
≥3	18/40 (45.09)
OSTP medication status:
only substitution medication	64/156 (41.0)	0.294
substitution medication and other substances	39/81 (48.1)
Years in OSTP:
≤5	65/170 (38.2)	0.027
6-10	23/43 (53.5)
≥11	15/24 (62.5)
Regular use of OSTP medication/drugs:
no	25/44 (56.8)	0.048
yes	78/193 (40.4)
Type of drugs used prior entering the OSTP:
only heroin	40/99 (40.4)	0.661
heroin and other substances	55/127 (43.3)
Years of drugs use prior entering the OSTP:
≤5	53/131 (40.5)	0.426
6-10	35/78 (44.9)
≥11	15/28 (53.6)
Sentenced due to use of drugs:
no	76/178 (42.7)	0.681
yes	27/59 (45.8)
Involved in petty thefts:
no	62/135 (45.9)	0.378
yes	41/102 (40.2)
Involved in criminal acts:
no	73/185 (39.5)	0.019
yes	30/52 (57.7)
Involved in drug dealing:
no	68/165 (41.2)	0.291
yes	35/72 (48.6)
Involved in begging:
no	79/191 (41.4)	0.184
yes	24/46 (52.2)
Involved in blackmailing of parents:
no	95/218 (43.6)	0.901
yes	8/19 (42.1)
Feel capable of performing any type of job:
no	40/71 (56.3)	0.009
yes	63/166 (38.0)
Feel positive change in attitude toward job after entering the OSTP:
no	61/123 (49.6)	0.048
yes	42/114 (36.8)

*The number of responses varies from 226 to 237 as participants did not answer all questions.

†χ²test.

Employers

A sample of 100 Slovenian companies was randomly selected from the Slovenian Labor Inspectorate at Ministry of Labor, Family, and Social affairs of the Republic of Slovenia Registry. Fifty companies with less than 50 employees (n = 93 913) and 50 companies with 50 or more employees (n = 1486) were selected. Within each group, companies were given serial numbers and were selected by a random number generator (Statistical Package for the Social Sciences for Windows, Version 13.0, SPSS Inc., Chicago, IL, USA).

The response rate from selected companies was 66.0% (66 companies). Among respondents, there were 31 (47.0%) companies with less than 50 employees and 35 (53.0%) companies with 50 or more employees. Thirty-six (54.5%) were manufacturing companies, followed by construction (n = 7; 10.6%) and retail companies (n = 4; 6.1%). In 37 (56.1%) of them, the employees had mainly vocational and in 17 (25.8%) mainly secondary education.

Method

The study was performed in May and June 2006. It was composed of two parts, one investigating the perception of individuals in OSTP on work and employment and the other investigating employers’ perception of addiction.

The OSTP participants were asked to fill out a questionnaire that consisted of 35 questions about the personal data, drug use before and during treatment, employment, and assessment of work ability (web extra 1). All questionnaires were filled out by participants in the presence of a therapist who provided explanation to each question in detail, as necessary.

A different questionnaire was distributed to the employers or occupational safety managers of the companies. This questionnaire was comprised of questions about company size, branch, and company regulations with regards to use of psychoactive substances, companies’ attitudes toward employed users of psychoactive substances, and employees and job seekers in OSTP (web extra 2).

The study was performed according to the guidelines of the National Medical Ethics Committee of the Republic of Slovenia. It was approved by the Ethics Committee of the Psychiatric Clinic Ljubljana in 2006.

Statistical analysis

In the analysis of perception of work and employment of patients in OSTP, descriptive and analytical statistical methods were used. As some of the questions in the survey were not answered by all respondents, the results are shown only for respondents answering the specific question. The differences in unemployment between different subgroups of patients in OSTP were analyzed univariately by χ² test. Unemployment as the main observed outcome was related to several independent variables including sex, age, education level, number of previous employments, OSTP medication status, number of years in OSTP, type of drugs used prior to OSTP, years of drug use before entering OSTP, drug-related sentencing, regular use of OSTP medication/drugs, drug-related thefts in the past, involvement in criminal acts in the past, involvement in drug dealing, involvement in begging, involvement in blackmailing of parents, perception of ability to perform a job, and attitude to working process after entering the OSTP. Multivariate analysis by using logistic regression was performed to relate unemployment to several independent variables simultaneously (21). The variables with P < 0.200 in univariate analysis entered the multivariate model (22). The dummy variables were created for all independent variables considered in the model. The simple method was applied. The group with the lowest frequency of observed outcome was assigned as the reference group (22). Characteristics of both unemployed and employed participants were statistically described. The differences in employment rate and perception of assignments to be beyond abilities of study participants between before and during OSTP were analyzed with McNemar test for dependent variables (21). P ≤ 0.05 was considered significant in all statistical tests. In the analysis of employers’ perception, only descriptive statistical methods were used. The SPSS 15.0 for Windows was used as a tool for analysis.

Results

Perceptions of individuals in OSTP on work and employment

Employment status was established in all 237 respondents. There were 134 (56.5%) employed participants, of whom 34 (14.3%) were employed full-time, 34 (14.3%) worked on contract, and 66 (27.8%) were undeclared workers. In the group of employed participants, 109 of 134 (81.3%) were employed before entering the OSTP, while 25 (18.7%) participants in the study became employed during OSTP (10.5% of all 237 participants). The employment rate increased from 46.0% to 56.5% (P = 0.027) during OSTP.

There were 103 (43.5%) unemployed participants. Univariate analysis showed that unemployment was significantly higher in those who were longer in OSTP, who did not use OSTP medication/drugs regularly, who were involved in criminal acts, who did not feel capable of performing any type of job, and who did not feel a positive change in attitude toward working after entering the OSTP (Table 2). All data necessary to perform multivariate analysis were available for 236 (99.6%) participants. The logistic regression model was significant as a whole (P_Model = 0.003), and according to Hosmer and Lemeshow goodness-of-fit test, it was a reasonably good fit (P = 0.251). Detailed results showed that only regular use of OSTP medication/drugs played a significant role in unemployment (Table 2). The Nagelkerke R² indicated that 16.3% of unemployment of OSTP participants could be explained by variables in this model (R² = 0.163).

Table 2.

Results of logistic regression analysis of unemployment in 236 individuals in opioid substitution treatment programs (OSTP) in Slovenia in 2006

Independent variables	Odds ratio (95% confidence interval)	P
Age (years):
≤20	1.00
21-30	2.89 (0.84-9.95)	0.093
≥31	3.07 (0.72-13.13)	0.131
Education level:
vocational	1.00
primary	1.81 (0.81-4.07)	0.150
secondary or higher	1.70 (0.77-3.74)	0.189
Years in OSTP:
≤5	1.00
6-10	1.64 (0.79-3.44)	0.186
≥11	1.80 (0.59-5.51)	0.305
Regular use of OSTP medication/drugs:
yes	1.00
no	2.44 (1.18-5.05)	0.016
Involved in criminal acts:
no	1.00
yes	1.78 (0.90-3.52)	0.095
Involved in begging:
no	1.00
yes	1.80 (0.88-3.69)	0.106
Feel capable of performing any type of job:
yes	1.00
no	1.53 (0.79-2.97)	0.211
Feels positive change in attitude toward job after entering OSTP:
yes	1.00
no	1.70 (0.97-2.99)	0.064

Among 103 unemployed participants, 16 (15.5%) did not want to become employed and did not look for a job, 15 (14.6%) wanted to get a job but did not look for one, while 7 (6.8%) did not want to get a job but did look for one (Table 3). The remaining 65 (63.1%) wanted to get a job and did look for one. Of 60 participants, 26 (43.3%) responded that they would accept any type of job, 16 (26.7%) would accept only a well-enough paid job, 8 (13.3%) would accept only a job that would allow them to work independently, and 15 (25.0%) would accept only a job that would allow them sufficient creativity. Of 65 participants, 15 (23.1%) expressed a desire to get support while searching for a job (5 from relatives; 2 from a partner; 2 from friends; one from former coworkers; and 5 from former employer). In this group of OSTP participants, 22 of 65 (33.8%) wanted a job because of their rehabilitation, 44 (67.7%) because of the financial independence, and 41 (63.1%) to get their lives in order.

Table 3.

The most frequent reasons for unemployment in 63 of 103 unemployed individuals in opioid substitution treatment programs in Slovenia in 2006

The reasons for unemployment	No. (%) of participants
The salary was too low	23 (22.3)
They did not want to work due to the effects of drugs	11 (10.7)
They did not need a job	11 (10.7)
They were often ill	5 (4.9)
They were frequently in conflicts with the employer	5 (4.9)
They were unsuccessful at their job	4 (3.9)
They were unable to work due to effects of drugs	4 (3.9)

In the group of 134 employed participants, 94 of 134 (70.1%) were satisfied because their job was paid well enough, 21 (15.7%) because their job allowed them sufficient creativity, 9 (6.7%) because their job was not demanding, 3 (2.2%) because they had full support from their employer, and one (0.7%) because he/she had not been discovered by the employer yet. Of 134 participants who managed to keep or find a job after entering OSTP, only 30 (22.4%) received help, mostly from their families (n = 14) or friends (n = 12). Twenty-six of 134 (19.4%) participants had a positive attitude change toward work and job after entering OSTP and believed that they were more concentrated; 24 (17.9%) believed that their attitude to work improved, 13 (9.7%) believed that their relationship with coworkers improved, and 14 (10.4%) believed that their relationship with their employer improved. In this group of participants, 30 of 134 (22.4%) believed that they were equally capable of doing their job, while 104 (77.6%) believed that they were more capable of doing their job than before entering OSTP. Of 134 employees, 112 also believed that methadone had influenced their ability to work. Also, 100 of 134 (74.6%) were prepared to undergo drug testing to keep their jobs. This percentage was almost the same in the employed (100 of 134; 74.6%) and unemployed participants (75 of 103; 72.8%; P = 0.753).

Participants had to asses whether the assignments offered were beyond their abilities before and during OSTP. Several assignments were perceived as significantly less difficult after OSTP. Such a shift was observed in mentally demanding assignments, physically demanding assignments, working at unfavorable hours or at a forced pace, and jobs requiring field work (Table 4). Concerning OSTP participants’ perception of society attitude toward them, 226 of 237 (95.4%) of participants reported that Slovenian society was not tolerant enough to provide employment for unemployed persons in OSTP or to enable them to keep their jobs. Also, 230 (97.0%) participants thought that it would be more difficult to a get new job if the employer knew that they were included in OSTP.

Table 4.

Individuals in opioid substitution treatment programs (OSTP) in Slovenia in 2006 believing the assignments are beyond their abilities before and during the program

Assignment	No. (%) of participants		Change from “yes” to “no” (%)	P*
	before OSTP (n = 237)	during OSTP (n = 237)
Mentally demanding assignments	54 (22.8)	5 (2.1)	21.5	<0.001
Physically demanding assignments	43 (18.1)	10 (4.2)	15.6	<0.001
Forced to work at unfavorable hours	55 (23.2)	10 (4.2)	19.8	<0.001
Forced pace of work	49 (20.7)	9 (3.8)	18.1	<0.001
Night shifts	3 (1.3)	1 (0.4)	0.8	0.500
Working overtime	11 (4.6)	4 (1.7)	3.8	0.065
Field work	17 (7.2)	2 (0.8)	7.2	0.001
Dangerous assignments (eg, work at heights)	19 (8.0)	0	8.0	NA†
All of the above	27 (11.4)	2 (0.8)	10.5	<0.001

*McNemar test.

†NA – not applicable.

Employers’ perception of addiction

Only 4 (6.6%) out of 61 company employers or safety managers answered positively to the question if the presence of drugs and psychoactive substances had been perceived as a problem in their companies. Out of 63 respondents, 59 (93.7%) believed that illicit drugs and psychoactive substances were not a problem at their workplace, 56 (90.3%) of 62 respondents had never had problems with such employees, and 50 (78.1%) of 64 respondents believed they lacked the expertise to recognize a person under the influence of illicit drugs or other psychoactive substances.

Concerning legal regulations of the companies, 53 (85.5%) of 62 respondents had no regulations on measures to be taken in the case of suspicion of psychoactive substance and drug use. Only 3 (4.8%) of 63 of employment contracts included a clause that required prospective employees to undergo drug and psychoactive substance testing. In 27 (42.9%) of 63 cases, such a testing was performed to ensure the safety of other employees and due to the difficulty of assignments in question.

According to employers’ answers, if job seekers had been treated for drug addiction in the past, their likelihood of getting a job would have been lower in 53 of 57 (93.0%) of cases; if they were taking part in OSTP at the time of job searching their chances would have been lower in 54 in 57 (94.7%) of cases; and if they were recreational drug users their chances would have been lower in 56/59 (94.9%) of cases.

Employers expressed a desire for professional instruction in the identification of individuals under the influence of illicit drugs in 16 of 64 (25.0%) of cases, on the effects of drugs and psychoactive substances in 13 (20.3%) cases, on testing methods in 11 (17.2%) cases, legal issues in 8 (12.5%) cases, on means of help for drug users in 6 (9.4%) cases, and on safe involvement of individuals who are or were in treatment for addiction in 5 (7.8%) cases.

Discussion

Our study showed that OSTP in Slovenia was effective both in employability of OSTP patients and in increasing their ability to work. According to the survey, the unemployment rate substantially decreased after OSTP, while ability to work substantially increased. Our results indicated that OSTP in Slovenia was effective in achieving that patients change their perception of ability to perform different types of assignments. Therefore, the perception about mentally demanding assignments, work at unfavorable hours, and forced pace of work represented lower burden for participants after entering the OSTP (Table 4). On the other hand, the employment rate of OSTP patients in Slovenia has been more or less the same over more than a decade. In this respect, our results are in accordance with the results obtained in 1995 and 1997 (20), indicating that Slovenian society did not substantially change during this period with respect to the employability of OSTP patients. However, it seems that the quality of employment has changed as in previous years, there were more OSTP patients employed on regular, contractual and part-time bases than in our study. Unfortunately, there were no data on undeclared employment in previous studies to compare them with the results of present study. These studies also differed in other aspects, so no other comparisons could have been performed.

In univariate analysis, unemployment was strongly related to duration of OSTP, regularity of the OSTP medication, involvement in criminal acts, perception of ability of performing a job, and perception of OSTP influence on OSTP patients’ attitude on the working process. However, multivariate analysis in which some potential confounders were included (eg, age and involvement in begging) showed that the most important factor was regular use of medication and consecutively stability of OSTP patients. This was one of the most important elements in restoring the status of individual OSTP patients in their social environment. The OSTP medication status did not play an important role in unemployment and neither did the type of drugs used prior entering the OSTP.

We found that the majority of employers in Slovenia had poor knowledge about illicit drugs use, since their companies did not have a legally binding document addressing drug use at work. Additionally, only 25% of interviewed companies expressed a need for professional help with drug abuse problems. Their attitude toward workers and job seekers with drug problems was extremely negative, even if they were in treatment, taking part in OSTP, or were recreational drug users. These results indicate that it is very difficult for current or former declared drug users to get a job in Slovenia. This phenomenon could be explained only by a generally negative opinion on drug users in Slovenian society and scarce information on drug problems and interventions to control them among employers (18). Due to the low familiarity with the subject or perhaps negative experiences with it, many employers were very reluctant to accept employment applications of individuals who were or had been treated for addiction. Patients in OSTP seemed to be aware of these difficulties, so those who were employed hid their drug problems from their employers. Full support of the employer was reported only by a very small percent of OSTP participants who were employed at the time of the survey. The unemployed mostly had no desire (in spite of their relative youth) to find a job, mostly because of low salaries. On the other hand, almost three-quarters of OSTP patients were prepared to accept surveillance on drug presence to keep their jobs, and this attitude was not related to employment status. This could mean that for most of OSTP patients, such surveillance would be welcome and desired, and not only acceptable, since it would be another stimulating intervention that could direct them on their way to social rehabilitation.

Detailed description of the group of unemployed OSTP patients revealed that almost two-thirds of them expressed a desire to find a job and they already searched for it. Almost a half of this group would accept any type of job, but all others stipulated conditions like creativity or independence. We suppose that these patients were not fully ready to accept social reintegration in spite of their intrinsic need for it. They were aware of general negative opinion of Slovenian society about them and they were afraid of being rejected by the society.

Results of our study are also in accordance with the results of other recent studies with the same subject abroad (23,24) and in Slovenia (25). In the last two decades, the awareness of psychoactive substance abuse at workplace and the problems it can cause has been increasing (23-25). Simultaneously, the awareness that the workplace is a place for the development of broad preventive partnership has been increasing as well (10,26). However, it is important to note that preventive policies can only take root if they are based on basic social units such as families, schools, labor organizations, and social services (27).

Regarding complete rehabilitation of substance users, our research confirmed that employment itself, especially full-time one, is an important factor that can help drug users and those in OSTP achieve successful rehabilitation since it gives greater social security and safety. Everybody, from therapists to employers, and society as a whole, should therefore give more attention to active employment of individuals who are, or used to be, drug users. A job in which they are able to find themselves is without any doubt an important factor in their rehabilitation process. From this point of view, OSTPs are far from being only clinical activities, they are also primarily (or should be seen as) public health activities. Additional multidisciplinary research in this direction is needed on both national and international level.

Our study has some limitations and some advantages. The main limitation in both parts of the study is the response rate, which was 66.0% among the employers and 49.8% among the individuals taking part in OSTP, although the latter was very similar to 1995 survey (51%) (20). Sampling scheme among the employers could be another limitation. In our sample, the ratio of companies with less than 50 employees to companies with 50 or more employees was 1:1, while the real ratio in Slovenia is about 63:1. The rationale for our decision was the fact that 1.6% of companies employ about 55% of employed population (28). Additionally, in this part of the study, in most of the returned questionnaires one or more answers were missing, indicating that most of the questioned individuals were not familiar with the subject. However, most of the respondents were aware of their poor knowledge of the subject and expressed a desire for professional assistance.

This study is extremely valuable, since we got insight into the current situation of employability in Slovenia and the rehabilitation of OSTP patients. It could be seen as a pilot study for establishing a tool for evaluation of OSTP from the perspective of (re)socialization of OSTP patients. The results could be also applicable to the countries in South-Eastern Europe with a similar political situation. One could argue that the study did not address the costs and problems that arise from employment of the drug abusers. This study was not intended to explore this aspect and, therefore, the issues were not raised in this direction. Also, the study could be seen as the feasibility study for a further in-depth exploration of the problem.

Concerning cost-effectiveness or cost-benefit studies, so far the emphasis has been on evaluating costs of the OSTP (8) and not on evaluating the costs of employers. In the future, the research should also address this issue and compare it with OSTP costs and benefits of OSTP patients and those of the society. This could offer important information to policy makers for preparation of good and feasible policies in this field. Today, international experience confirms that the existence of proper psychoactive substance policies and their enforcement within the company benefits employees as well as employers (29). Employers can greatly encourage the development of environments and relationships that will enable employees to choose a life without psychoactive substances. Companies with developed psychoactive substance policies report a significantly lower number of current psychoactive substance users and employees with drinking problems (30,31).

Regular employment is an important motivation factor for the effectiveness of OSTP. Individuals with regular employment are more motivated and adhere to the rules of treatment programs much more than the unemployed patients (9). On the other hand, employers find that employees, their representatives, and other parties are all in favor of such programs, and also that employment seekers who are currently using psychoactive substances prefer to look for work elsewhere (32). It is no doubt that the part on employers’ perception of our study gives very limited information, but it could be used by the existing intervention programs, like “Fit for Work” intervention program of the Clinical Center Ljubljana, Clinical Institute for Occupational, Traffic, and Sports Medicine (33). This program is aimed at informing workers as well as employers on healthy lifestyle at work, and on the creation of health-promoting working conditions, including health-promoting working conditions for vulnerable population groups. The results of our study show that problem of unemployment in OSTP patients has not diminished over the last 10 years. OSTP programs in Slovenia are still often perceived as mainly clinical programs, while basically they should be comprehensive and cross-sectorial. This problem is impossible to tackle only through the health sector. Cross-sectorality will be in the short term rather difficult to achieve, because our society is still dominated by biomedical model of health, while programs as OSTP need to be seen in a context of a biopsychosocial model of health. Maybe the best start would be to encourage employers to adopt principles of an ongoing health promotion program “Fit for Work” (33).

The results of our study could be used in the establishment of comprehensive preventive policies on psychoactive substances in companies, including employees’ education about psychoactive substance, which are extremely needed in Slovenia. It would enable companies to provide a safe, healthy environment for their employees.