
D rug abuse has reached alarming levels in our society; and the problem is not unique to certain ethn ic groups, levels of income, or employment settings. Studies show that employees who use drugs have three to four times as many accidents as other employees (O'Donnell, 1988) . Because of decreased worker productivity and the high cost associated with employee related accidents, many companies are rapidly implementing drug screening programs in the workplace.
Health care employees who are in safety-sensitive positions may be the next group to be tested for drugs. It is clear that hospital employees, particularly physicians, nurses, and ancillary personnel who work in demanding, high stress positions, are candidates for drug abuse (Digiacomo-Geffers, 1985) . Working with impaired judgment may decrease professional practice and lead to liability for unsafe conditions. More importantly, use of drugs while working can lead to serious client and employee accidents and even client death.
Many sectors ofthe population support some type of drug testing program in the workplace. According to several opinion polls, most Americans support even random testing of employees in certain professions. In a 1987 Gallup poll conducted for Hospitals magazine, 69% of those polled favored mandatory testing, while 24% disagreed; others were neutral or did not know (O'Donnell, 1988) .
It is clear that drug abuse in the workplace can result in low worker pro-It is clear that drug abuse in the workplace can result in low worker productivity, danger to clients, and increased cost to the institution.
ductivity, danger to clients, and increased cost to the institution. According to a study released in 1984 by the Research Triangle Institute, abuse of illegal drugs cost the U.S. $60 billion in 1983, up from $46 billion documented in 1979. Notabl y, lost worker productivity in 1983 accounted for $33 billion. Some experts think the figure was much higher (Time 1986; 127(4), 48, 52-61) . While these are alarming figures, dollar signs cannot be attached to the cost of human lives lost as a result of drug related accidents. It is therefore imperative that hospitals establish drug awareness programs to prevent employee drug abuse. Although businesses have been quick to implement programs to combat drug abuse in the workplace, many hospitals have yet to address the problem. This may be because personnel in the helping professions sometimes think that they are immune to such problems. While unsafe practice and client related accidents due to drug abuse must not be tolerated in the health care setting, employers must balance the safe ty of the workplace against the invasion of privacy imposed by testing.
DRUG SCREENING PROGRAMS
Currently, the literature documents four different categories of drug screening programs used in employment settings: preemployment; inc ident related; probable cause; and, random testing. The preemployment program is perhaps the easiest to implement and the least threatening or objectionable. Testing before employment screens potential employees for illegal drug abuse. However, the employer must be careful to obtain consent before the testing.
Incident related testing in volves testing the employee when a question is raised about the employee's competency level. The employer may require testing when there is reasonable suspicion that the employee is impaired or under the influence of drugs while working. A reasonable suspicion policy means that to justify testing the employer must supervise the workforce. Blood and urine analysis are used as methods for drug screening.
Probable cause is similar to incident related testin g; however, reasonable suspicion is a lesser standard than probable cause. Probable cause involves testing the employee when the evidence suggests more than an inarticulate hunch that an employee is impaired (O'Donnell, 1988) .
By far, the most controversial category is random testing. The random screen is often questioned, since it involves no input from the employee and the company arbitrarily decides which employees will be tested. Random testing has been attacked as being violative of the Fourth Amendment search and seizure clause. Moreover, many employees have filed additional litigation with respect to invasion of privacy and violation of due process.
It should be noted that courts have permitted drug testing when the standards used to determine who should be tested were reasonable and nondiscriminatory. With respect to the Fourth Amendment, the United States Supreme Court has indicated that although probable cause and a warrant are normally required for a search to be reasonable, in certain limited circumstances neither is required (O'Connor v. Onego, 1987) .
In addition, federal circuits have upheld random testing of certain public employees in safety-sensitive or critical positions (O'Donnell, 1988) . The courts tend to support the individual's need for privacy when public safety is not a concern (Farrish, 1988).
Because drug abuse is a national health problem and legal and right to privacy issues surround random and probable cause drug screening programs, emphasis should be placed on creating a policy that focuses on drug awareness and prevention. Concern for employees' health and rehabilitation should be the major focus of employee health programs.
DRUG AWARENESS/ PREVENTION PROGRAM
Hospital authorities must establish responsible programs that will combat drug abuse and promote a drug free environment in the employment setting. Administrators should be proactive, not reactive , to the drug crisis in society and to the potential problem of drug related incidents in the employment setting. Initiating a drug awareness/preven tion program Hospital authorities must establish responsible programs that will combat drug abuse and promote a drug free environment in the employment setting.
as part of a comprehensive policy aimed at protecting employees' health, as well as the hosp ital and its clients, can be one of the most effective forms of drug abuse prevention. An ideal drug awareness/prevention program should include policies that focus on: protection of individual rights; confidentiality; employee education ; steps to follow when reporting drug abuse cases; and drug screening programs. It should be noted that preservation of employee rights must be given the utmost consideration. The employee should be informed and given a thorough explanation of the drug awareness/prevention program to be implemented.
Ifdrug screening is to be part of the program, then the employee must first be told which type of drug screening will be used and, second , sign an informed consent. To preserve the employee's due process rights, all tested employees should be informed about their rights and how the information will be used with respect to their employment.
The employee's need for security and maintenance of confidentiality must also be recognized. Since use of certain nonprescription drugs is illegal in the U.S., many employees will be uncertain and hesitant about disclosing information that may have criminal ramifications. Once personal information is obtained, confidentiality must be maintained at all times. Additionally, employers must guard against gossiping and sharing confidential information about employees with other hospital personnel and outside agencies.
A major focus of the drug awareness program should be employee education designed to increase the employee's awareness regarding the danger of using drugs and the possibility of client related accidents that result from working while impaired. It should be noted that education can have a significant influence in reducing the number of individuals reporting to work under the influence of drugs.
Employees should also be caught to recognize behaviors of coworkers who may be abusing drugs, such as erratic behavior, decreased efficiency, deterioration in performance, change in quality and quantity of work, carelessness, change in personal appearance, increased absenteeism, high error rate, and bad judgments (Assareh , 1987) . Employees should be encouraged to report such behaviors without feeling that they are "blowing the whistle" or being disloyal. Education can help employees realize that reporting a fellow worker can be a caring response.
A drug screening program mayor may not be part of a drug awareness/ prevention program. However, if it is part of the program, criteria should be established for screening. The two most widely used methods are blood analysis and urinalysis. By far the least invasive is the urinalysis test. Urine testing is preferred over blood testing for most detection except for alcohol (Assareh, 1987) .
However, certain information should be considered when the hospital chooses a laboratory to do urine testing for substance abuse . First, most drug testing laboratories acknowledge a margin of error of 2% to 3% (Assareh, 1987) . Second, tampering is a real possibility during processing. Lastl y, if positive results are obtained , the laboratory should have some method of retesting the sample to ensure accuracy of results .
If the major focus of the drug awareness program is to assist employees to be drug free, then the program must be coordinated by a person who does not serve in a management position or otherwise pose a threat to employees. A counselor who has a collaborative relationship with both management and employees is perhaps the best person to implement this type of program. It should be noted that many companies are moving toward implementing Employee Assistance Programs. These programs are designed to promote employee well being and to assist employees with drug related and personal problems; however, they are not used as a substitute for disciplinary action.
For a drug awareness/prevention program to be effective, a non-threatening environment must be created; employees must feel that they can seek help and reveal personal, perhaps even damaging information without fear of job loss or retribution from management. The counselor must possess good interpersonal skills and be knowledgeable about the problem of drug abuse, ethical and legal issues, and how to identify and help employees who may be exhibiting signs of drug abuse.
The major role of the counselor is to establish guidelines for the drug awareness/prevention program. Other roles that the counselor must assume are those of facilitator and communicator. The counselor should also serve as a mediator to ensure that the employer-employee relationship is maintained at all times.

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