Summer 2023

A Moment of Clarity: Alcohol’s Impact Across Workers and Medical Management

Fast Focus

As part of our continuing Social Determinants of Health article series, we are examining the negative impacts of substance use or abuse on injury and recovery. In this article, we look specifically at alcohol use as a complicating factor in the workplace and as a detractor from injured worker outcomes.

The health effects of alcohol have been well-researched for decades, but they have done little to slow down excessive drinking, with an estimated 1 in 6 Americans regularly engaging in binge drinking,1 and approximately 14.5 million suffering from alcohol use disorder (AUD), representing nearly 6% of the U.S. population 18 years of age or older.2 Unfortunately, this is no surprise, considering how omnipresent alcohol has been in human history.

The earliest evidence of alcohol can be traced to 7,000 BC China in ancient rice wine.3 The Egyptians brewed beer as early as 3,400 BC,4 and alcoholic distillation is theorized to have begun in 3,000 BC in India.5 Virtually every culture has developed some unique alcoholic beverage, often rich with history and pride.

  • 1 in 6 Americans – or 38 million people – binge drink1
  • 14.5 million Americans have alcohol use disorder (AUD)2
  • Excessive drinking is responsible for 1 in 5 deaths among adults aged 20-496

Drinking culture is unlikely to disappear anytime soon, and while alcohol can be enjoyed responsibly, far too often it is not. The sheer pervasiveness of alcohol in the world can often blind people to the real-world impacts it can have, and workers’ comp is no exception to these impacts.

Alcohol can increase the likelihood of workplace injury and create problems in the workplace. It can also cause a wide range of health consequences that can impact claims management and injured worker recovery, and it can interfere with various medications prescribed in workers’ comp, further complicating recovery.

Alcohol Use in Worker Populations

Five Fast Facts

Industries with the highest rates of heavy alcohol use include mining, construction, and food service7


Alcohol use disorder contributes to over 232 million missed workdays annually8


Workers with alcohol problems are 2.7x more likely to have injury-related absences9


Excessive alcohol use is responsible for a $179 billion loss in workplace productivity10


Excessive alcohol use is responsible for $28 billion in healthcare spending10

The Pandemic Doubled Down on Alcohol Use

Problematic alcohol use is by no means a new problem, but the COVID-19 pandemic increased the U.S. population’s use of alcohol as a response to severe stress, isolation, and uncertainty.

Pandemic Driven Increases to Alcohol Use

Now more than ever, it is incredibly important to understand the impact alcohol has on the work environment, the health considerations across workers’ comp claims, and how alcohol can interfere with pharmacy management.

How Alcohol Creates Workplace Concerns

Employees with problematic alcohol use can cause several different types of issues within the workplace, including issues of workplace safety, liability, and performance and productivity losses.

What Qualifies as Problematic Alcohol Use?

When it comes to understanding what amount of alcohol use is problematic, there are two different forms of over-consumption.

Binge Drinking

Five or more drinks in a single day for men6

Four or more drinks in a single day for women6

The average person consumes eight drinks when binge drinking1

Over 90% of excessive drinkers are binge drinkers1

Most people who binge drink are not alcohol dependent or alcoholics1

Heavy Drinking6

15 or more drinks per week for men

8 or more drinks per week for women

Workplace Safety

First and foremost, working while under the influence of alcohol is problematic, as drops in coordination and reaction time lead to a greater likelihood of accidents and workplace injury.

  • Substance abusers, including heavy alcohol users, are 3-4x more likely to be involved in workplace accidents14
  • Alcohol abusers are 5x as likely to file a workers’ comp claim14
  • Workers with alcohol problems are 2.7x more likely to have injury-related absences9
  • Chronic alcohol use decreases bone density and increases risk of fractures15

However, even when employees with problematic drinking are not inebriated on the job, there are still potential safety risks tied to hangovers. Hangovers negatively affect cognitive function, working memory, and psychomotor speed.16 This can still be the case when individuals no longer have alcohol in their system but are still experiencing a hangover.

Absenteeism and Productivity

Problematic alcohol use among employee populations can create financial strain for employers, stemming from missed workdays, drops in productivity and greater healthcare costs.

Annual Losses Tied to Alcohol

232 million
missed workdays annually8
$179 billion
in worker productivity10
$179 billion
in worker productivity10
in employee costs per alcohol abuser14

Health Risks of Alcohol That Add Claims Complexity

When consumed, alcohol travels down the esophagus and into the stomach. At this point, some alcohol passes into the bloodstream via the lining of the stomach and then travels throughout the body, impacting the brain, kidneys, lung, and liver. Meanwhile another portion travels through the small intestine.

Along this journey, alcohol has the potential to disrupt a wide range of bodily functions. The list of health risks that come with excessive alcohol use is significant, and many of these risks can add an additional layer of complexity to workers’ comp claims.

However, it is important to recognize that problematic alcohol use can be divided into two specific forms: binge drinking and heavy drinking.

While binge drinking and heavy drinking share many risks, the nature of these drinking habits can manifest quite differently. Functional alcoholics who are heavy drinkers may not drink as vigorously as binge drinkers and may be more prone to long-term health conditions and alcohol use disorder, while binge drinkers may be more susceptible to the more immediate health risks from the sheer level of alcohol they consume in a single instance.

Immediate Health Risks of Excessive Alcohol Consumption

Alcohol poisoning
Motor vehicle accidents
Accidents and falls due to compromised motor function

Long-Term Health Risks of Heavy Alcohol Use

Considering the journey that alcohol makes throughout the body, excessive use over a chronic period of time creates a wide range of health risks, all of which can make managing a workers’ comp claim far more complex.

These health risks include but are not limited to:6, 15, 17

High blood pressure, stroke, and heart disease
Digestive problems
Alcohol hepatitis, fibrosis, or cirrhosis
Cancer of the liver, breast, mouth, throat, esophagus, voice box, colon, or rectum
Weakening of the immune system
Insomnia and other sleep concerns
Decreased bone density and increased risk of fractures
Muscle weakness and atrophy
Learning and memory problems, including dementia
Mental health concerns, including depression and anxiety
Social problems, including family problems, job-related problems, and unemployment
Alcohol use disorders and alcohol dependence

How Alcohol Creates Medication concerns

Alcohol can negatively interact with several medications, impacting how the body absorbs, metabolizes, distributes, and excretes them. This can exacerbate certain drug effects or lead to harmful interactions, increasing the likelihood of adverse events.

Some of the potential drug interactions that alcohol can have with medications prescribed in workers’ comp include but are not limited to:

WC Medications
Prescribed for
Conflict With Alcohol
Pain management

Mixing NSAIDs with alcohol can increase the risk of stomach bleeding and ulcers
NSAIDs make up 18% of Rx drug payments in workers’ comp18

Pain management

Mixing alcohol with opioids can cause excessive drowsiness, respiratory depression, and death
1 in 7 opioid-related deaths involved drinking alcohol within a few hours of opioid use19

Neuropathic pain management

Both gabapentinoids and alcohol cause CNS depression and respiratory depression, creating risk for therapeutic duplication. Additionally, mixing alcohol with gabapentinoids can increase risk of seizures

Gabapentinoids are among the top three drug classes prescribed in workers’ comp20

Pain Management

If the liver is breaking down alcohol, it cannot break down acetaminophen. This can lead to a buildup of acetaminophen, which can cause liver damage

Muscle relaxation,

Increased sedation, muscle fatigue, trouble balancing, intense confusion and paranoia, disinhibited actions, respiratory depression which can be fatal, suicidal thoughts

Alcohol was involved in 21% of benzodiazepine drug-related deaths21

Muscle relaxants
Reduce muscle

Depression and anxiety, confusion, dizziness and trouble balancing, impaired judgment, motor skill impairment, poor memory and difficulty concentrating, respiratory depression, overdose, and death

Blood pressure medications
For comorbid
treatment of hypertension

This drug interaction can cause dizziness, fainting, drowsiness, and a faster heartbeat

Anti-anxiety medications
For the treatment of anxiety

Alcohol can exacerbate the sedative effect of anti-anxiety medications, causing drowsiness or unconsciousness

For the treatment of depression

Mixing alcohol with antidepressants can affect judgment, coordination, motor skills, and reaction time. This can also cause drowsiness and confusion

Diabetes medications
For the treatment of comorbid diabetes

Combining alcohol with diabetes medications can lower blood sugar, create rapid changes in blood pressure, and increase heartbeat

Strategies for Detecting and Addressing Problematic Alcohol Use

Whether through wellness programs, employee assistance programs (EAPs), or benefits available through group insurance, there are treatments for problematic alcohol use that are effective when properly utilized.

However, the initial step is identifying patients who need help and connecting them with resources that can help them. 14.5 million Americans have alcohol use disorder (AUD), but less than 10% of them receive treatment.2

Within the scope of workers’ comp, the larger conversation of gaining visibility into social and behavioral determinants of health has gained serious traction. With social and behavioral factors comprising upwards of 80% of modifiable factors impacting health outcomes,23 it stands to reason this is such a strong area of focus. Traditionally, identifying claims where one or more social or behavioral determinants are a negative contributing factor could be compared to finding a needle in a haystack – especially a factor such as AUD, which affects less than 6% of the U.S. adult population. But identifying these factors needn’t be so difficult. We have the clinical tools and technology to get us there today at lightning speed.

Take physical therapist (PT) notes as an example. As a provider who spends significant, quality time with the injured worker, a PT is well positioned to gain insight about the injured worker that can help identify social and behavioral barriers to recovery (see A Golden Opportunity: The Physical Therapist’s Role in Behavioral Health in this issue of RxInformer ). And this needn’t be a heavy lift for provider or patient. A study utilizing a questionnaire used by the Institute of Medicine designed to capture social and behavioral determinants of health took an average of 5 minutes for patients to complete and garnered an 80% participation rate in the first week of the study.24

By Healthesystems’ estimation, each PT episode of care generates, on average, more than 50 pages of PT notes.25

 Substance abuse, including alcohol abuse, was in 1 of 50, or 2.5% of claims.25

Healthesystems’ analysis confirmed alcohol abuse is associated with a 10-15% increase in the duration of PT episode of care, with additional impacts on number of visits and associated spend.25

By Healthesystems’ estimation, each PT episode of care generates, on average, more than 50 pages of PT notes. And these documents are rich with insights – including those of a social and behavioral nature. Here is where technology comes into play – helping to analyze data at scale, taking those individual, 1-on-1 PT interactions and aggregating them across a claims population. An analysis of evaluation and functional capacity forms from approximately 100,000 episodes of care conducted with natural language processing (NLP) technology revealed a SDoH documented in approximately 80% of claims.25

Keep in mind that this is just the tip of the iceberg. PT documents represent just one of many documented data sources present on a claim. And within this, evaluation and functional capacity forms represent just a fraction of PT documents.

So what did this targeted analysis reveal about AUD? Substance abuse, including alcohol abuse, was in 1 of 50, or 2.5% of claims. Perhaps most impactful is the timing aspect, with approximately 1 in 3 of these claims being identified within the first 30 days of injury through data captured at the initial evaluation, and 85% identified within 90 days of injury. Early identification provides earlier opportunity to intervene, a significant advantage in helping to address the downstream clinical complexity of a behavioral risk such as AUD, which is associated with extended treatment durations as well as a higher frequency of missed PT appointments.

Behavioral Treatments for Excessive Alcohol Use

Behavioral treatments that aim to change drinking habits through counseling have proven to be effective. Among many forms of therapy, this includes cognitive behavioral therapy, which helps identify feelings and situations that lead to heavy drinking, with the goal of changing these thought processes to develop skills necessary to cope with everyday situations that trigger drinking.23

Medication Assisted Therapy for Excessive Alcohol Use

In addition to therapy, there are three FDA-approved medications that can help stop or reduce drinking and prevent alcoholic relapse. They include:26

Naltrexone, which can help reduce alcohol-related cravings and euphoria

Acamprosate, which helps to stabilize chemical signaling in the brain that is normally disrupted by alcohol withdrawal

Disulfiram, which blocks the breakdown of alcohol in the body, causing unpleasant symptoms when alcohol is ingested. The triggering of these unpleasant effects is theorized to give individuals incentive not to drink alcohol

One key point to note is that if an injured worker is receiving medication-assisted therapy for alcohol abuse, there are potential pharmacy management issues that can arise from mixing any of these medications with other medications used to treat a work-related injury or illness.

If you or anyone you know is struggling with alcohol abuse, SAMHSA’s National Helpline, 1-800-662-HELP (4357) is a free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders.26


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  2. Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health. Substance Abuse and Mental Health Services Administration. Sept 2020.
  3. McGovern PE. Ancient wine: the search for the origins of viniculture. 2003. Princeton University Press. ISBN 978-0-691-07080-3.
  4. Gately I. Drink: a cultural history of alcohol. 2009. Gotham Books. ISBN 978-1592404643.
  5. Dhawendra K. Genomics and health in the developing world. 2012. Oxford University Press. ISBN 9780199705474.
  6. Alcohol use and your health. Centers for Disease Control and Prevention. April 14, 2022.
  7. Bush DM, Lipari RN. Substance use and substance use disorder by industry. Substance Abuse and Mental Health Services Administration. April 15, 2015.
  8. Parsley IC, Dale AM, Fisher SL, et al. Association between workplace absenteeism and alcohol use disorder from the national survey on drug use and health, 2015-2019. JAMA Netw Open. 2022;5(3):e222954. doi:10.1001/jamanetworkopen.2022.2954.
  9. Drugs and alcohol in the workplace. National Council on Alcoholism and Drug Dependence. April 2015.
  10. The cost of excessive alcohol use. Centers for Disease Control and Prevention. Dec 30, 2019.
  11. Spencer MR, Curtin SE, Garnett MF. Alcohol-induced death rates in the United States, 2019-2020. NCHS Data Brief. Nov 2022.
  12. Julien J, Tapper CB, Down WN, et al. Effect of increased alcohol consumption during COVID-19 pandemic on alcohol-associated liver disease: a modeling study. Hepatology. Dec 8, 2021.
  13. Castaldelli-Maia JM, Seguar LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. Nov 2021.
  14. Drug and alcohol prevention. New York Department of Labor.
  15. What are the effects of alcohol on the body? Healthline. March 31, 2022.
  16. Scholey A, Benson S, Kaufman J, et al. Effects of alcohol hangover on cognitive performance: findings from a field/internet mixed methodology study. J Clin Med. 2019 Mar 30;8(4):440. doi: 10.3390/jcm8040440
  17. Alcohol’s effects on the body. National Institute of Alcohol Abuse and Alcoholism.
  18. Wang D, Thumula V, Liu TC. Interstate variations and trends in workers’ compensation drug payments: 2018Q1 to 2021Q1 – a WCRI FlashReport. Workers’ Compensation Research Institute. June 16, 2022.
  19. Geller AI, Dowell D, Lovegrove MC, et al. U.S. Emergency department visits resulting from nonmedical use of pharmaceuticals, 2016. Am J Prev Med 2019;56:639–647.
  20. Thumula V, Liu TC. Off-label uses of gabapentinoids for work-related injuries. Workers’ Compensation Research Institute. Aug 17, 2021. - 2021
  21. Jones, CM, Paulozzi LJ, Mack AK, et al. Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse–related emergency department visits and drug-related deaths — United States, 2010. Centers for Disease Control and Prevention. Oct 10, 2014.
  22. Employee assistance program (EAP) reduces depression and alcohol abuse, improves productivity. PR Newswire. Feb 27, 2019.
  23. National Academy of Medicine. Social Determinants of Health 101 for Health Care: Five Plus Five. October 2017.
  24. Guse NB, Koonce TY, Kusnoor SV, et al. Institute of Medicine measures of social and behavioral determinants of health. Am J Prev Med. 2017;52:199-206.
  25. Healthesystems analysis. Social & Behavioral Determinants and Functional Assessments in Physical Therapy. February 2023.
  26. Treatment for alcohol problems: finding and getting help. National Institute on Alcohol Abuse and Alcoholism. Last updated Oct 2022.


Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.