 So it's five past 12 and we started this new EFCDDA webinar. This time we will talk about drug use and working place. The chair of this webinar will be Ines Hasselberg, our colleague. And I immediately give her the floor to start. Ines, the floor is yours. Thank you, Marika. Now, before giving the floor to our speakers, I would like to say a few words about the context of the seminar. Alek, can you put the slides? Perhaps the next one I will introduce the speakers afterwards. It might be easier. Okay, so earlier this year we have launched a mini guide on health and social responses to drug related problems in the workplace. And it is this mini guide that is the backdrop of the seminar. Now the speakers we invited here today will provide you with a general overview of the main issues and of the future challenges. But they will also share their experience and knowledge on some specific cases. So I'm not really going to attempt here to summarize the contents of our mini guide, but just to tell you a little bit about it. Next one. Thank you. So the mini guide is part of a larger sets of mini guides that together form the health and social responses to drug problems, a European guide. This is a free resource, fully digital, and you can find it very easily on our website, and it's very easy to navigate between the different components of the guide. Now this guide, what it does is that it looks at key public health challenges in the drugs field today. And then we try to provide practical advice for practitioners and policymakers who are in the process of designing and targeting and implementing responses to these problems. The guide is composed of four sets of mini guides that you see here patterns of drug use vulnerable groups, etc. Looking from a different perspective to the problems. Yes. So an important factor that can influence drug use the problems that may be associated with drug use and the selection of appropriate responses is the setting in which you use of course, of course, we have launched five mini guides addressing different settings so local communities, prisons, schools, recreational settings, and of course, the workplace. Now why is workplace an important setting. The workplace is an important setting to consider and this is why we've included it in the guide for several reasons. So perhaps the most obvious that we always think about is safety so bus drivers or people operating have a machinery, etc. may pose a risk to themselves or to others if they are intoxicated while working. But accidents and injuries apart drug use may also increase absenteeism or inappropriate behavior at workplace. It can impose an economic burden on employees, the government and society. It is also important to consider workplaces because it might be the actual circumstances of the work that are leading to drug use. And this could be because of very tough working conditions or low satisfaction of work or irregular work hours or coping with shift work, etc. We also need to remember that workplaces provide an opportunity for health education and promotion about alcohol and drug use. And they also provide an opportunity to identify individuals who have problems with alcohol and drug use, or who have family members dealing with these problems. Again here it's important to remember that employees, employers have a duty under health and safety laws to protect the health, safety and welfare of their employees. Finally, the workplace also has a potential role in supporting the social integration of people with the history of drug problems. So, what can you find in this mini guide. In this mini guide, we provide an overview of what to consider when planning or delivering health and social responses to drug related problems in the workplace. We review the available interventions and what we know about their effectiveness, and we also talk about what we know it's happening in Europe. We consider some of the implications for policy and practice. We provide available data and graphics, which in this case are actually coming from EU OSHA and their survey. And we provide lists of other relevant resources. Now together with the workplace mini guide, we also launched a spotlight on performance and image enhancement drugs. So, these substances are substances that have the perceived potential to improve human traits and along with with other human enhancement drugs. They are becoming a challenge to drug use or to responding in responding to drug use in the workplace. The spotlights are a different product than the mini guide and we use these spotlights in the general guide when we want to look at issues that are cross cutting to the different components and the different elements of the guide. Now they're really awesome because they're very short text and they're very to the point. So in this one, for instance, we will tell you what our performance and image enhancement drugs, what is happening in Europe, what problems are associated with their use, how we can respond to them and what are the implications for the future. Now again here I'm not going to dwell on these substances as our colleagues from EU OSHA will be talking soon about these and other human enhancement drugs. So in short, we invite you to have a look at this mini guide and to our other resources which you can find very easily at our web page at www.emcdda.europa.com. If you are interested, you can also stay informed about updates and news by subscribing to our mailing list newsletter. I will put the link in the chat very soon because it's easier to then just click if you're interested. And with no further ado, I will introduce you to our speakers today. The first speakers we have that are going to talk it's William Cockburn and Annick Staden, both from EU OSHA that is the European Agency for Safety and Health at Work. William is currently the interim Executive Director of EU OSHA. He was in charge of the Prevention and Research Unit and was responsible for the first European survey of enterprises on new and emerging risks on which data we actually draw on for the mini guide. William also contributed to the development of this mini guide in his role as external reviewer through which we are very thankful. Annick is a project manager at EU OSHA's Prevention and Research Unit. She's responsible for the four side project, which if I'm not mistaken, has published a few articles on the use of human enhancement drugs. So we'll go to the, oh, sorry, I'm forgetting about the other speakers. I was just going to run into the next question. After William and Annick, we will hear from Johan Sorson, a researcher at the School of Culture and Society at Aarhus University in Denmark. Johan has worked extensively on substance use and risk management in different recreational settings. She has also worked and keeps on working in collaborative health IT development projects. And most importantly for this webinar, Johan has conducted research on doctors' use of drugs and alcohol in the work environment. And then last but not least, we will hear from Elisabeth Santus. Elisabeth is a clinical psychologist. She has worked for over a decade at the Portuguese National Agency for Drugs and Drugs Addiction, and currently she works in the healthcare unit of a large Portuguese company. She has been very involved in the development of a workplace drug and alcohol prevention program, of which she will tell us more during the webinar. Yes, so question number one for William and Annick. What are the most pressing challenges right now in Europe? And what are the implications for policy and practice? Okay. And yes, thank you. Thank you for the introduction. And it's really a great opportunity. I think I'll speak for William and me to be here and put this topic on the spotlight. We've been working on it and it's really, really great to make the link, to make the bridge between the topic of the use of drug and substances and to put this in the context of the working place. So yes, occupational safety and health, safety, health, workplace health promotion and trends and challenges. These are the four perspectives for which we would like to look at this topic of drug use. So I will start with the safety and health perspective and then I really will take over and continue with the workplace health promotion and the ongoing interesting trends and challenges that we have in this field. So next slide please. Safety. Yes, you told us already a bit in your introduction. The use of drugs is being an old, quite conventional problem, alcohol drugs, in especially safety critical occupations. So if you think of drugs in the workplace, yeah, you don't want to have a bus driver or pilot. I think we even have stories or narratives like this in the past of people who were in their work position and may or did use drugs and so got into a critical incident. That's what we have. There's also in the high risk in the high risk industry. You see, it's very, very important. And here I think it's more normal to see also drug testing in the most structural way. This should be to the second point, drug testing, drug testing of workers. Well, I think here in Europe we have a more restrictive approach, compared to it, for example, in the, in the US. And here you see mostly that if there's drug testing in one place that's because something already has happened in the past, so there is already kind of a biased world. So, random testings and still there are a lot of issues going on and it's very different as you also describe in, in, in your overview between countries. And there are some issues open, for example, related to occupational injury compensation. What happens if somebody is involved in an accident that work and there, and it goes wrong. Then we have all these societal attitudes that differ between sector between working places and role social partners in advance what's the awareness what is the, what is the mindset regarding this issue this can really change between sectors, companies and countries. And there are guidance and workplaces in place with what does help what does not help there's a very little evidence related to interventions. And, and that was what you're already aiming at, I think that's really interesting that's the growing and a different type of drugs and substances use in the workplace for that in our full site study we already published two articles on performance enhancing drugs what's the prevalence, if you can say anything about it, and how can you manage it. And the next slide please. For example, how you see this broad range of substances for announcements and micro doses on LSD for creativity. And that is specially used in more in the creative industry for example in software development or in game development. Next slide please. The next slide. Yes, so. Yes, that's a really interesting development that you that brings me to the topic of help, because of course this help perspective is very interesting to to take into account here and preventing it. For example, exposure to combinations of substance senses. What, how does it increase maybe our influence sensibility when it's used together with the carcinogens skin sensitize as much as, or, yeah, other other symptoms and substances that already used for headbasses, musicians, farmers builders, and then healthcare workers. So what's the impact on the use of PPE is on personal protective equipment related to performance enhancement. You see now as an example, Stalina alertness. That's it used for so you see cocaine and vitamins. You see used by long distance drivers and financial tracers and then you see the four performance enhancement, the memory and the concentration activators for example the little in for that. That's quite normal to use for the students populations like the mother female for the ADHD support. And we have the imagination creators the inspiration creators like LSD micro dosing. That is what you mostly see on designers and programs. That's kind of an overview of what we see that is happening more and more. And what is the issue is there's no data there's really minimal minimal data. Little understanding of long term health effects, and then related to social attitudes you see it's getting more and more normal because you have this availability of internet pharmacist. You have the use of the smart drugs really really seen in the media as if it's like really normal. And then the acceptance of recreational use we can see that when recreational use of drugs is is normal then also the step to drugs in the workplace. The drugs in the workplace is is seen as more normal and normal, also among supervisors. There's some first proof. So, when you are trying to improve your mental function it seems like that is okay. Well there's some little known about the side effects. So, it's really hard to to get this mindset to get a change because it feels okay and I think and we think this normalization of the issue is really an issue. And it's interesting to look at this working context and where are the trigger factors in this working context to get this normalization, not so normal anymore. So now I would like to give over the floor to William. Another example of the type of tricks it's now going and going. Thanks, and hi everyone. Maybe we can move to the next slide and I'll say a few words about workplace health promotion. There's a lot of surveillance in the workplace the role of occupational doctors, as well as the workplace being a fantastic opportunity a venue for for promoting health benefiting behaviors and this is this is picked up in your in your guidelines. Very well so the workplace is a setting for for changing behavior in terms of health. Occupational health is also able to provide a link to to primary care. And, and this is about treating a drug problem, as you would any other health problem, avoiding stigmatization and a lot of this comes across in the ILO key principles. So you would then establish links with with the general practitioner and then advise the employer on appropriate adaptations in the organization of work for example in the tasks and duties. There's a strong link, of course, between drug use and psychosocial risks and psychosocial health mental health. On the one hand, if you're a drug user you're more likely to develop mental health problems have psychological problems, but on the other hand, drug use itself is an important red flag it's an important signal to an employer. And there may well be issues at work that are prompting the use of drugs as a as a coping mechanism, whether that's for adverse relationships to deal with the stress of a high workload work intensity. And so this is something that needs to be to be addressed from an occupational organizational perspective. There's a link between occupational injury and drug use and a recent survey in Canada by the Institute for Work and Health where cannabis has been legalized in 2018. They saw that the injury rate was doubled for those who used drugs at the workplace. At the same time, they also found that 16% of those who use cannabis in the workplace are doing so to manage the pain from a from a work related injury or illness. And if you like it's a two way, two way street. Just as an anecdote, I think in the US, there's a strong link between the opioid epidemic and working conditions there, many people were prescribed opioid painkillers to deal with injuries that they'd got in heavy industry. And that introduction then not only made the the injured person more likely to to develop an addiction but also family members in the household who had easier access to those drugs so so there's a strong occupational link. If we can move to the next slide. I can mention the survey that we carried out interviewing those responsible for health and safety and around 50,000 enterprises in Europe and we asked them about whether they provide health promotion interventions on on addiction to alcohol and and drugs. And we can see here in this map, the distribution. There's, I should say that we carried out this survey in 2014 and 19 and we'll do so again in 24, and there's been not much change year on year. And that is from 58% of enterprises in Finland to 21% in Estonia so big variations across Europe, larger enterprises are much more likely to have these interventions in place. And also those enterprises that are in education in health or the social care services. So, so so quite, quite different from one from one area to to another. If we go to the next slide. Just summarize some of the trends and challenges that we see from from our perspective. One is the extent of drug use in the working population. What will be the impact of legislation, the study I mentioned in Canada, indicated that the prevalence of drug use in the workplace did not change it stayed constant at around. Around 12%. What there was was a very big increase in the proportion of workplaces that had a policy on on drug and alcohol use in place it changed from 63 to 79%. So quite a quite a positive impact in that sense. And also the Canadian Standards Association is working to develop a standard on measuring impairment in the workplace which is a very big challenge when trying to control drug use in the workplace. I've mentioned psychosocial risks from our research we see that these are an ever increasing problem. So that will raise the issue of whether drugs are increasingly used to cope with those psychosocial risks, or whether increasing drug use will lead to more psychosocial risks. And this is an area that employers find especially difficult to to to manage so there's a there's a need here for for practical guidelines like the ones that you have issued at EMCDDA. The meaning of the working population is also a factor that we think needs to be taken into account. Just because drug use currently is amongst younger age cohorts does that mean that people leave and change their habits as they get older or will they be carrying their habits as a generation as they get older. Perhaps as we get older, people will be turning to performance enhancing drugs to compensate for for the deficiencies that inevitably come with getting with getting older. The research we're doing at EU OSHA also highlights challenges from digitalization we're seeing artificial intelligence used more and more for managing workers monitoring workers. We're seeing greater automation. These are changing the demands on workers, perhaps here again it'll be a driver or perhaps even reducing drug use in the workplace. Again, lots of changes happening. And it's essential that we keep these collaborations going and the information and research carried out so that we know how best to respond. And the next slide is just to thank you for your attention and to thank EMCDDA for inviting us to this workshop and giving us the opportunity to comment on the excellent guidelines. Thank you. And Anik, this was a wonderful presentation and I think it gave a very good overview of the issues at hand. I would like to say to everyone attending that we will have a question and answer sessions at the end of the presentations. In the meantime, feel free to put in your questions at the question and answers button. This is right next in the bottom line right next to the chat button. And I will now give the floor to Johanna for answering our question. What do we know about substance use in the workplace. And I believe she is going to present us with a case study from Denmark based on her own research. Johanna. Yes, thank you very much for the invitation to speak here today. It's a great pleasure to to be here and thank you for the nice introduction also. And I'm going to tell you a little bit about my research on substance use disorders in physician workplaces in Denmark. And I use the ICD 10 definitions of substance use disorders and dependency syndromes. Please change slide. So these are the outputs of my survey among 4000 Danish physicians in 2014. And we had a response rate of 48%. Please change slide. Thank you just a few findings from the study. And the quantitative articles show that 19% of the physicians had a problematic consumption of alcohol and only 23% of these physicians actually recognize that they had a problematic alcohol consumption. And more of the men than women had a problematic consumption of alcohol and only 3% of the whole population in the study thought that there was an openness about substance use disorders at the workplaces. Please change. Yes, and this is an article, also from the same study but this is a qualitative article. And please change slide and I will tell a little. The title was how physicians, a professional socialization and social technologies may affect colleagues in substance use disorders. The subject group here was physicians who had been treated for substance use disorders. And I was focused at their own outlook at the physician work culture. I researched on specific socio cultural factors in the physician work culture and interviewed these physicians about it and also had a literature study specifically focused at the development of substance use disorders and problematic substance use. And also at physicians management of their previous substance use challenges and problems. Please change. Yes. The interviews were surgeons medical doctors general practitioners and researchers and a short overview to you the women for four of the participants were women and one of them was a drug user one was a medicine user and non alcohol users actually eight were men in the study and five of these were alcohol users and no one drug users and three were medicine users and actually this fits quite well with the quantitative data it's it's often women are doing more medicine and other drugs and men a little more likely to do to use an alcohol. Alright, and so the general findings from the studies was that the durability of the substance use disorders were from six months up to 25 years, and the men were the ones who sought help at the latest time in their substance use disorders. The external help was initiated either because the substance users were identified at the workplaces doing drugs or doing alcohol at work, or and then sent to treatment by the health inspectors and others would seek help through colleagues and leaders but this was not very prevalent actually. So please change. Yes. And the key points of the study is that substance use disorders is not a lifestyle choice rather it's a loss of self control and the loss of self identification. So the physicians work culture and professional socialization can affect the development of professional problematic substance use. And the last thing is that the social technologies such as sanctions can actually affect problematic substance use in both intended, but also unintended ways. So the most disciplinary paradox that I will return to in a minute. Yes. So the cultural influence on the loss of self control seemed through the interviews to be a product of a combination of hierarchical pressure and emotional strains in critical clinical situations. Go me more into detail with it in a minute. But the thing is that performance enhancing self medication is is part of the problem here in this setting. It's to control emotional strains in critical clinical situations, but it's also often used initially only periodical on single days but then as the pressure while climbing the career letter, letter increases. And they also tend to to arise their performance pressures and their consumption of substances. So there is a work. It's a kind of work related coming strategy that then becomes a substance use a problem at a certain point. Yeah, the dependence syndrome seems to results from an unconditional loss of self control and self identification, please change. Yes. So which are then these work related strange. It may be the critical patient case, particularly cases of a strong identification. It may be if the position physician has a child himself himself that is of this equal age as a patient. Or if the long term relations to the patient somehow affects the physician some patients have been in contact with a specific physician for half a life or something like that. Also, organizational changes such as restructuration and financial cut downs, increased administrative pressure and efficiency improvements sometimes push towards extra substance uses to actually to put up with the job and all the tasks. And also, of course, fear of making mistakes professionally. And here, I would like to to give you an impression of a particular informant I interviewed. He was a surgeon and to me, he said, and no one of the physicians will admit that they are afraid of operating. It is a physician tossing syndrome. We've assistant can do everything. We are kind of made that Miguel and manic. You cannot have a shaking hand if you operate a patient. You need to somehow get control of it and it's quite easy, actually, you can take beta blockers combined with been so dear the pains and then you are kind of in control and your hand will not be shaking. And this is the, this is actually why he started he had to control his movements to an extreme extent in order to not cut in the wrong places of the bodies, he was operating on. So, so yeah so there was this was just to give you an impression of the material I have to please change now. So, but what do we do about a drug use at the workplace is we have the social technologies and sanctions to actually try to direct and redirect a professional conduct. And this may be, for instance, the physician law, and also an ethical conduct codex for physicians. And then like we have like a seven physician roles that kind of standardized the professional conduct for physicians and this is a way to assure quality standards. So, but then the sanctions are also part of this social technology, and then they are also meant to direct the conduct and redirect it. And these are the loss of authorization as a physician, the loss of prescription right. And then, of course, dependency syndrome treatment and urine controls, and then you can change again. So, social technologies by interpreted by the physicians and some of the positions actually know very little about the social technologies and then it creates fear of the sanctions fear of a total social derude. The loss of the job loss of prestige identity and the ability to provide for oneself and for relatives. This may lead into a catastrophe thinking that I've met when I've interviewed these systems. They fear engagement in treatment very much, and they prefer self treatment to hide the problem from colleagues and treatment systems. So, alcohol consumers will self treat with the Dysulfiram, and they may stay in their substance abuse substance use disorders for 20 to 25 years while they are working as physicians. And this is, this is quite serious it may have consequences for patients actually, or a scow it's in 2012 reported that 78% of the medical mistakes reported were related to physicians alcohol problems, please change again. So, yeah, and, and there is also in the physician work community a kind of covering up of physician colleagues who are in substance use disorders. And this leads to a kind of non intervention and I was looking at older studies in order to see where does this come from. And it seems that there is this ethical codex and arms from once pointed out that there is a kind of a brotherhood among physicians, and that in this brotherhood they tend to protect each others from strange from for instance patients complaints. And this leads to the covering up towards the old outside, because they know that mistakes will happen at some point and it can happen for everyone. And this is actually in a way a good thing but it also leads to the non intervention. It's not the only thing and I will point to other things that that point in in the direction of non intervention. But it, yeah, and that is is actually the fact that it's seen as a private problem you probably know that already, because I think it's quite a general thing that we view the consumption of alcohol drugs, by and large, as a private problem. So it makes it difficult to intervene for workplaces actually, please change. So, yeah, my conclusion substance use disorders may be related to physician work culture and physician work is settings include some emotional strange from patients and critical conditions but also from work hierarchies performance pressure and competition among colleagues that might lead to a consumption of both alcohol drugs, and the reasons why alcohol drugs are used by these positions at least two full performance enhancement, but also for relaxation relaxation after stress stressful situations at the job. And, and yeah, this may then, as we have seen lead to the dependence syndrome and result in an unconditional loss of self control and self identification can you change again. Thank you. And, yeah, then I also wanted to return to the paradoxes. There is this paradox of the social technologies that are meant to standardize and assure quality. You may have this adverse effect, and in fact, actually make physician self treat and avoid formal treatment systems, and also, yeah, make it difficult for them to to access the treatment systems, because they really fear this total social derude as I pointed to. So, yeah, the physician community will cover up as we just saw and each other and they will do that both externally but also internally because they see it as a private problem and moral problem. And it's not really something that the workplace should salute. So, there is a tendency at the physician workplaces for non intervention to be the most prevalent thing. And it is quite risky actually both for the patients, the physicians themselves, because they may harm their mental and physical health but also for the patients safety of course, can you change. Yes. So, this leads me to come up with some recommendations. I would recommend an open dialogue at the workplaces at dialogue in which it was mentioned also that the sanctions are not definitive that it's possible to enter anonymous treatment. It's also for health professionals, and to make this very clear to everyone and also to to make sure that that physicians know that it's important to to intervene in these processes, and both for the patients and for the physicians. And also, it would be important to mention to them that it's actually possible to regain the loss of control, and that 80% of the first physicians who finalize treatment, return to work and stay there, at least five years after they have been in treatment and the results when they enter treatment are very good and we should actually stress this and stress also that it's possible to get reintegrated at job afterwards. So, and also, I recommend early intervention, and I recommend that it is mentioned as a collegial responsibility at workplace responsibility to intervene in these things. And that we really stress that openness about substance use disorders and that it can hit anyone, regardless of profession, and it's really important. Also, it's important at workplaces to have work, to have alcohol drug policies, and they should be very clear to everyone they should be mentioned every year, it's not something that should be hidden, hidden away. Yeah, I think this is actually all. And yeah, so I just want to say thank you for this opportunity to speak to you all. It's been a pleasure. So, yeah, thanks. Thank you, Johanna. That was really, really interesting. And I'm sure it will elicit some questions from the audience which again I will emphasize you have a question and answers button at the bottom of your screen and you may use that to include your questions that then we will address at the end of the presentations. So, the next question is for Elizabeth Santosh, and she'll be talking about what is being done to address the problems through a case study from Portugal. Hello, good morning. I would like to start by thanking the NTDDA for the invitation to share with you our experience in designing and implementing a substance use prevention program in the workplace. I will start by presenting you the focus and the principles of the program, as well as the aims that we have with our program, presenting you the healthcare team, and then sharing with you some of the design and implementation main questions. And I will finish by sharing some of the main challenges that we have faced throughout the process. So, starting by the beginning, the program is named PREVNIR, which in Portuguese means to prevent. And this is because that really is our focus. We want to prevent substance use problems and negative consequences. It is not our aim to catch people or to punish them for their substance use and substance use prevention programs should not be about punishing, but instead about preventing and providing the support needed for treatment and recovery. So, the focus, first of all, is on health, because we are a healthcare unit. But as we work with workers that deal with a safety sensitive industry, we also have a focus on performance and as well on safety. And the major principles we are following are the ones presented by the Pompidou group, which are responsibility, transparency along the process, respect for collective and individual freedoms, as well as the solidarity within working communities. As for the aims, well, they differ according to the substance use experience people have. So, to all workers, our aim is to improve their health performance and security and safety as well. For those at higher risk for substance misuse, the aim is to prevent substance misuse. And at last for those with substance use problems, the aim is to provide treatment of substance misuse and recovery. The healthcare team, well, then this program is under the umbrella of occupational health and safety department. So our team integrates occupational health physicians, occupational health nurses, clinical psychologists and psychiatrists. And they are the ones that provide treatment to workers with substance misuse. And now I would like to share some information about design and implementation. So we started by having an agreement within the company as for these issues. And then we have to have the agreement by the unions as they are the entities responsible for work with workers as well. And then we perform needs assessment in order to know what kind of activities and what kind of working conditions should be targets as well. So based on this needs assessment, we started to work on some working conditions and I will afterwards share with you some information about each one of the implementation activities. Then after making some improving in working conditions, we have developed a document for substance free activities. So it's a policy, a company policy for substance free workplace. And this document determines some activities, namely awareness activities, as well as training and education activities, and at last drug testing, counseling and treatment. And the last activity is evaluation of the program. So as for improved working conditions, I have two, I brought you two examples, one a more broad example. Can you please change for the next more broad example, which is vending machines with healthy snacks, healthier snacks. So it's a more broad example related with health improvement. And another one, more specific for substance use, which is taking out alcoholic beverages from the canteen so we don't have access to alcoholic beverages within the company. Well, about substance free company documents, the policy itself. It was based on national laws, as well as sectorial policies and contractual laws. And as well as on several international guidelines that we had to take into account, namely the ones from international labour organization, the Pompidou group, the MCDDA, the European workplace drug testing society so we had, we took into consideration all of these national guidelines when developing and designing the program. And as well as national guidelines from the data protection commission, the general directorate for intervention on addictive behaviors and dependencies, the Portuguese health authority and as well as the Portuguese authority for labour conditions. Well, now, the first, the first activities that we had really implemented was awareness activities. So we started implementing our program by delivering awareness activities. Within these activities, we have developed several materials that started to approach the subject on substance use as a health problem that has an impact on safety of everyone. And that's the reason why companies started to implement measures to prevent and to control as well as substance use within the workplace. So we also developed materials for each substance that were addressed within the company policy. You can give one click. That one is translated to English. So we provided several, I think useful information about the intended effects and the unintended effects of substance use and the negative consequences within familiar professional areas of workers life. We also provided some questions that people could use to self assess whether they have a problem or not with that substance in particular. And all of these materials were sending were sent to to all workers by email and disseminated in the company communication channels like Internet and they all were made available afterwards for people to be able to consult afterwards. So when we finished awareness information. We started with drug education and training, and we have developed two activities. The first one was a new learning activity that was considered mandatory to all supervisors and voluntary to all other employees. The purpose was to inform about the company's substance free policy and the workplace program, and as well as to provide information on some on substances and substance use. And we had several contents related with the company policy the workplace program the substance use were in science prevention and treatment as well. And the second activity was a non site training that was considered mandatory as well for supervisors managers directors and other kinds of people with responsibilities within the company. The purpose, the purpose was to work and abilities to make referrals to the health service the health services whenever needed, and we approach the contents such as stereotypes prevalence of substance using the workplace warning signs, the supervision, supervision is ruled and the referral to the health services. And it was only after training was completed that we started to undertake drug testing counseling and treatment. And I will share some information with you about the procedure so screening tests. We started to do after training, and it's a random screening tests, and whenever there is a negative result, the worker returns to duty, whenever there is a non negative result, there is a counter analysis that is made. And if the counter analysis negative, the worker returns to duty, but if the counter analysis is positive. They will get retested in another certified laboratory. If the result is negative, they will return to duty but if the result is positive, they will be sent to a medical review. And they will be considered and fit to duty, and they will integrate the program, the treatment, the treatment, the treatment program so whenever there is a positive result, workers getting the program, they can also getting the program to self referral, or if the worker considers that there is a problem with the performance and they are referral to the health services and screening test is done and it's positive. So, when these kind of situations arise, they get in the program, they are going to be assessed through one of the professionals, so a physician, a nurse, a psychologist, and a psychiatrist, and we perform a diagnosis. So if the diagnosis is of non problematic use, there is a therapeutic contract that is signed, and the worker is allowed to follow up for six months, and they have to perform several screening tests. If all the screening tests are negative, they will have a clinical discharge. If the diagnosis is for abuse or dependency, there is as well as therapeutic contract being signed, the person, the worker can choose the treatment is voluntary, and they can choose whether they have inpatient treatment or outpatient treatment, but they will always have the follow up, the monitoring with us, and after 24 months of negative tests, and the positive opinion of all the professionals, they will have a clinical discharge. So we get to evaluation. We perform two kinds of evaluation as suggested by the MCDDA. So we have a process evaluation, which is about implementation of the program, the quality and usefulness of the program, the reach and coverage, the acceptance, the implementation fidelity and the use of resources. So we also have an outcome evaluation that is about the effects of intervention, accomplishment with aims and the need to adapt or discard some activities. And I brought some examples for you. So as for the process, the number of workers, the worker satisfaction with training, the number of screening tests, the number of workers under treatment, and for the outcomes, the durability, the number of dropouts, the number of clinical discharges, et cetera. And I have three real examples to share with you. So as for the e-learning, here you have the score accomplished by the end of the e-learning. And we have 93% of workers that finish their learning with a classification higher than 90%. So because they are assessed along the e-learning training, so I think it's a very good result. People really absorb the contents. As for the onset training, we have assessed in the beginning of the session the stereotypes that supervisors have on substance users. And we can see that 59% of supervisors had negative stereotypes of substance abusers. And at the end of the session, the number dropped to 12%. So 88% ended up the session with positive stereotypes about substance users. So we can conclude that, click, 47% of supervisors have changed their negative stereotypes on substance users. And at last, one result on counseling and treatment. So we have, under treatment, 10% at the moment, 72.9% of workers that completed treatment requirements and were clinical discharge, 13% that were dismissed, and 3% that deceased, unfortunately. So main challenges from our experience. As for, I wrote one for each of the activities. So as for the awareness and information, our main challenge was to access the information to give access to information by workers in remote locations. As for education training to motivate supervisors, managers and directors to enroll on site training. As for the screening test, the main challenge was to screen workers in night shifts and for counseling and treatment to motivate workers in denial for treatment. So you have my contact. Thank you very much for your attention. And I'm available to answer all your questions. Thank you. Thank you, Elizabeth. We already have some questions at the questions and answer and also in the chat. I would start actually with a question from Fleur to William and Anik. We, William had to leave earlier, so it will be for Anik. And Fleur is saying, are there are there any UI data on the links between bullying violence and in particular gendered violence and assaults related to substance use in the work settings. This would be especially interesting given the associations that have been finally getting more attention between alcohol and domestic violence in high competition social settings, like sports events. Yes, thank you. Well, it's not directly possible to make this link, but I think maybe at a higher level we could see some parallels in here, but I think for sure it's very useful to look at the situational aspects within a company, for example, where there's a lot of fragmented work or no direct supervisor available, and to see the link between the link between the prevention programs. So there could be an interesting link, but it's not directly available, unfortunately. But yeah, we can try to get as close as possible. Thank you. There has been some questions also about the testing and the testing programs. Someone has asked about who pays this tests and whether the workers are aware that they can be tested. So, and Fleur again was wondering if you could mention some key points about the use of substance use testing in programs to reduce use. I have a question that all three of the speakers can can answer, in a way, perhaps Elizabeth, would you like to to tell us something from Prevenid. So, the company pays the tests. Okay. And it's, it's regulated by law in Portugal. So the company should pay for the tests, the screening tests and the concert truth as well. And the next question was whether workers were aware of that they could be tested, and they are, they have to be. And that's why we started with awareness activities. We started to talk about the program and to communicate the kind of activities that were going to be undertaken. So people do know that they can be tested. And the policy document is available on the internet, so that all workers can access and read the documents. Thank you, Elizabeth, Johanna, Anik, is there something that you would like to add. Can I ask you also just because we're still on this point, Elizabeth, if you think that there has been if you notice that there, there is any correlation or causal effect between being aware that this can be made. And, and drug use for instance because the evidence has been pointing that, well, currently there is no evidence of such causal relationship so we were wondering as well how employees take, or what they think about the possibility of being tested. We have a really specific reality because we work with companies that is mandatory for them to test their workers. So, I think there is a general culture within the companies that people have to comply with drug testing. It's a matter of safety for them, as well as for the clients of the companies. And I can share with you that it was difficult for the companies to implement the program until, while it was not mandatory, because we are talking about a sensitive subject that has to do with individual freedom. And we had to think about the way we tested people in a way that we can accomplish with the requirements, okay, as well as to respect individual freedom. And I think we've managed to do that through the kind of tests we do, because we can use several kind of tests with different time detection windows. And so I think that within our reality, workers, they do comply with drug screening. Thank you, Elisabeth. I believe Marika compiled a few questions as well from the chat. Yes, so there is a question for Juan, saying that it is very important to recognize that being a medical doctor or physician can be a very stressful profession and not only in the workplace because quite often they are the reference point for also for families and friends. They are under continuous pressure. The question is, do you know if there are any self-help groups to manage stress in place, if these are experienced beyond using or not substance, it's just to manage the stress related to this profession. This is in Denmark, a network of physicians where they can come and speak anonymously to each other about work related to challenges. So it is a possibility to access a network both online but also in some cases in physical meetings. There is an offer for them, some sort of, but I think it's not all physicians that actually know about it. So there are still challenges in that sense of spreading it out and making it work. Also, the physicians have a special challenge because they know that colleagues might read their electronic patient documents. So that is also a strain and a pullback in relation to actually seeking treatment. So they really fear that if they enter into some kind of treatment but also maybe these networks, somebody may get to know and then it will spread within the collegial community and then they are finalized as physicians. So they really feel this social derude. It's a big thing for the ones who have been in substance use disorders. Thank you. Thank you very much. There is another question. It was for William, but I understood they had to leave. So I asked this question to Nick and you mentioned two main reasons for using substances in the work environment. One is to manage stress and the other is to manage pain and fatigue. The question is, is there any pleasure component as it was for smoking cigarettes or having a glass of wine during food? Do you have any data about this and Nick's promotion? Well, we don't have such a specific data, but I think what was interesting with this stress effect was like bullying is the chicken and egg perspective that we also don't know if you are working in a fragile situation. It can be a trigger factor for using drugs, but on the other hand, if you're in an uncomfortable working situation at work, it can also be the drugs that is your kind of medicine you think to be able to perform as well. So it works like in two ways, but unfortunately there are no data available at that detail level. This is an invitation to build together. Maybe I can add here because I actually asked in the survey, I asked people why they were using substances. And I think the majority actually in the study was saying that it was to enjoy the taste of the alcohol or to be in a good mood and stuff like that. And so it of course is widespread also that this is an argument and this is a reason for consuming the substances and also relaxation as I mentioned in the presentation is a great thing and it's also kind of relaxation from stressful work and stuff like that. So there are indications of positive effects too. I moved to another question for Elizabeth and it is about you are also an expert in prevention overall. Can you do you highlight any difference main differences between prevention for example in school and prevention in the workplace. You are mute. I used to say that workplaces are for adults as schools are for children. And, well, I think the main difficulty and it's shared by schools and workplaces is to understand the poor efficacy of some strategies, namely the more informative ones, campaigns to share information on substances are proved to be ineffective. And I think that message is not really disseminated really disseminated and absorbed by schools and workplaces. So I think that there is a share difficulty across both contexts of intervention, but I think the workplaces are really really useful contexts to work with adults that otherwise we would miss. Thank you very much. There is still one other question from you and these about you mentioned some change between negative and positive stereotypes about drugs after your intervention about drugs use after your intervention. Could you make an example is there any statement or behavior that may have changed. Yeah, sure. So, we asked this was a free activity so we gave this paper to all of supervisors and asked them to write an opinion they have on substance abusers, and we had things like substance abusers are weak people. They are not productive. And we, we did the same at the end of the session. We gave them a piece of paper and asked them to write what they think about after the session about substance abusers, and they wrote things such as substance abusers have a chronic illness. And substance abusers are people that need treatment. So, that was the way we used to address stereotypes within supervisors. Okay, thank you for the, for the examples about people who use substances. There is another question asking I think this is more or less for everybody that is about drug testing, asking the timeframe. The question is about the fact that if someone uses substances in their spare time. And then they are tested. When the substance is seen stealing in the half life, it results positive but it's not positive while working. So, do you have any comments about this question. I thought, I thought that I talked about this question previously when I was saying that it's, we have to balance between workplaces companies right to check whether the workers are in the right condition to perform. And balance it with individual rights and freedom to do whatever workers want to do on their free time. And the way that we have managed to balance was through the kind of tests we use. So we can use different tests that give us information for different time frames. So if we test on hair, we will have a longer time frame depending on the, the length of the hair, but we don't use it. We use saliva, which is the, the tests that give us the smallest window. And the reason is exactly to show that we are not testing the day before or two days before or the weekend or the day off. We are testing that, that day. Yes, we could do. Thank you. Thank you for the answer. There is another but I think it's a comment, rather than a question that is about the fact that in some schools there is an environmental policy for the students but not also for the staff members. If I recall correctly, with the work with Gregor Burkart, who is our experts on prevention and with you also, when we talk about environmental policies, we talk about the entire environment. So whoever enters into the school, not only students or teachers. Can you confirm if I recall well. I take it as a yes. So I think we can go towards a conclusion if any of the speakers would like to add something. I'm not as good as our director to do to draw conclusions and they not even attend. I limit myself to to hear and to highlight something that you all said, and I think has also is in common with the environment in treatment, for example, where it is in the common interest to minimize the stigma around this behavior to mine with a neutral and open mindset in a way that people is is asking for help when they need and the respect of the dignity of individual is absolutely maintained. I heard this across all your presentations and I think is also in the recommendations that that that exists at the moment by several international organizations and mentioned in the in our mini guide. So after having said that, I would invite our audience to have a look at the mini guide to remain in contact with us. And also, I really thank you the speakers, my colleagues in ash for having chair this session and Sandra was so identified you as the speakers. And thank you, everybody, I will still launch a little poll for our audience to tell us if they liked it was too long to short etc etc. The next invitees can go you are not obliged to remain. I will keep the session open still for a while to give people time to reply to the poll and also because it's not never very nicely kicked off the webinar. Thank you everybody. See you at our next webinar. Thank you.