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Thursday, January 3, 2019

Creating recovery-friendly workplaces

If you can’t stop picking your skin, you may have a very common condition called skin picking disorder (SPD). We all pick at a scab or a bump from time to time, but for those with SPD, it can be nearly impossible to control those urges. Apart from the cosmetic impact of recurrent skin lesions and scarring, SPD can lead to serious infections, shame, depression, and anxiety.

You may be feeling alone or embarrassed, but you should know that this condition affects at least five million Americans. A diagnosis of SPD, also known as excoriation disorder, is made when there are repeated attempts to stop picking, and the skin picking is either distressing or interfering with social or work functioning. SPD is one of a group of disorders that is related to obsessive-compulsive disorder (OCD).

You already know that it is not a matter of will — trying to stop is the equivalent of telling one not to have high blood pressure. The good news is that therapy, medication, and dermatologic treatments can help. For most, though, no one treatment will be curative, and you will experience remission and recurrence.

Having realistic expectations and arming yourself with a variety of skills for skin picking flares will make this condition much more manageable. Here are four tips that can help you tackle your picking.
1. Know your triggers

You may be tempted to pick for a variety of reasons, from boredom, itch, or negative emotions, to blemishes or simply looking at or feeling your skin. You may even find the experience of picking itself pleasurable. Understanding your triggers can be a first step in deciding which treatments to pursue. For example, if your picking is triggered by a skin condition such as acne or itch, you might be best served by first seeing a dermatologist. If, however, your picking is triggered by depression, anxiety, or more of an urge, you should consult with a mental health professional with expertise in skin picking.
2. Make it harder to pick

One simple strategy to reduce picking, called stimulus control, involves changing your environment to make it harder to pick. Examples of this technique include keeping your nails short, wearing gloves at times when you are most likely to pick, and making the skin more difficult to access by wearing tight-fitting clothing or long-sleeve shirts. You can also try distracting your hands with any number of items including silly putty, stress balls, fidgets, and tangle toys. Once you have found an item that works for you, make sure to have one everywhere you spend time such as work, home, and your bag, so you are fully covered.
3. Get therapy

Cognitive behavioral therapy (CBT) is a structured type of psychotherapy that aims to produce healthier behaviors and beliefs by identifying unhelpful thoughts and behaviors. A specialized type of CBT has been developed for SPD. This type of CBT includes more of the stimulus control techniques described above, as well as habit reversal training, in which individuals are taught to engage in a harmless motor behavior (like clenching one’s fists) for one minute when triggered to pick. Clinical trials have demonstrated that skin-picking for CBT can be extremely effective. But because it is different than other types of CBT, it will be important to work with a therapist who is trained in treating SPD. You can find skin-picking experts at the TLC Foundation for Body-Focused Repetitive Behaviors.
4. Consider medication with your providers

While no medication has been formally approved by the FDA to treat SPD, there is evidence to suggest that selective serotonin reuptake inhibitor (SSRI) antidepressants and N-acetylcysteine (NAC), an antioxidant supplement, can be helpful. Owing to the limited and evolving research on medication treatments for SPD, you may find that your provider is not up to date on current skin picking treatments. If you or your provider would like more information about these medication treatments and others, you can look here.

Please be aware that even over-the-counter, well-tolerated supplements like NAC should always be taken under the supervision of a medical professional for guidance on dosing, duration of treatment, drug interactions, and side effects.
Our country’s ongoing opioid crisis has many faces, from teenagers on Cape Cod to middle-aged parents in West Virginia. A recent report from the Massachusetts Department of Public Health provides another demographic affected by opioids: people who work in the trade industries, namely construction. The report broke down overdose deaths by industry, and construction workers were involved in almost a quarter of overdose deaths recorded in the state over five years. Farming, forestry, and hunting, along with fishing, are the next most dangerous industries. And there are relatively high overdose death rates for women working within health care support and food services.

This research supports what we have seen in our own work treating patients for substance use disorders who work in manual labor jobs. On-the-job hazards and related injuries are common, and pain medications of all kinds tend to be readily available as workers informally share and sell them on worksites.
The need for recovery-friendly workplaces

A recent National Safety Council report found that 70% of surveyed employers have been impacted by prescription drug misuse, but fewer than 20% feel extremely prepared to deal with it. The financial cost to employers in lost productivity is significant: in Massachusetts alone, opioid addiction cost businesses $2.5 billion annually from employees who aren’t functioning at full capacity, and $5.9 billion in lost productivity from people who can’t join the workforce due to addiction. Opioid use disorder has kept nearly 33,000 people in Massachusetts from participating in the labor force each year, on average, over the past five years.

But what could a recovery-friendly workplace look like? Drawing inspiration from models like Supported Employment, an evidence-based intervention for individuals with serious mental illness, and recovery high schools, we describe five key features of a recovery-friendly workplace:

Available counseling for scheduled and on-demand recovery support. Manual labor workers with varying schedules often have trouble making appointments in traditional healthcare settings, which tend to be offered only during normal business hours. Missed work equals lost income, which is harmful to workers and employers alike. An onsite counselor for large worksites or availability of remote telehealth counseling on-demand during work breaks could encourage participation in these programs.

Peer support groups built into the daily schedule. Like individual appointments, therapy groups often occur during the business day. Open and safe discussions with crewmates who are also in recovery can help build a culture of mutual support. Onsite peer support by recovery coaches in the industry might be particularly impactful.

A supervisor who understands the challenges and needs of people in recovery. Slip-ups are part of the recovery process, and a positive drug test should signal the need for more counseling support and closer monitoring, not automatic termination of employment.

Support for medication-assisted treatment. We’ve heard anecdotally about certain union health insurance plans that deny coverage of buprenorphine (Suboxone), a medication for opioid use disorder that calms cravings and halves the risk of overdose death. This kind of discrimination is a federal crime, and for good reason — imagine employer-based health insurance refusing to pay for insulin for workers who have diabetes. Unfortunately, stigma and fear of retribution may keep union workers from speaking out to claim their rights.

Onsite drug testing (where appropriate) and telepsychiatry. Regular drug testing could help make construction sites safer and indicate when people need more support. Crews often share transportation to and from worksites, making it hard for an individual to leave in the middle of the day for a medication appointment or to provide required toxicology testing for their program. Telepsychiatry visits in a secure room on a worksite could allow people to get assessed more regularly and prevent missed doses of recovery medications like buprenorphine.
Recovery-friendly workplaces may lower healthcare costs

Employers in all kinds of industries should consider how establishing recovery-friendly workplaces may help them access an underutilized workforce while addressing a vital social need. People in recovery from opioid use disorder commonly describe their core recovery goals as needing to keep busy, to achieve financial self-sufficiency, and to recapture the dignity of being a working member of society. Our clinical work can go only so far in supporting our patients’ recovery, but with the right kinds of partnership across sectors, we can make great strides together.

Given the high prevalence of substance use disorders in certain sectors, investing in supported employment with recovery support and medication-assisted treatment might reduce costs associated with missed work as well as employee hiring and retraining, improving overall work quality while also lowering overall healthcare costs. Finally, substance use is rampant on construction and manual labor worksites, so investing in recovery support and treatment might improve the relationship of workers with management and unions and reduce risk for accidental injuries in the future.

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