Hi everybody, thank you so much for coming to this session. I know that you have a lot of different options during this time period. My name's Dr. Arielle Gerard. I'm a preventive medicine, public health, and addiction medicine physician. First, I just wanted to say thank you so much to AOHC for having me here again this year. I was presenting a poster last year on house staff rights, occupational rights for residents and fellows, because they don't have a lot of control over their workspace, and there's more work that we need to do there. And while I was here last year, I made a connection with Dr. Hartenbaum, who is on the planning committee, and she was so lovely in being willing to let me present this last year, and I'm very grateful to be here. This is like my first real conference with a first real talk, and so I just wanted to say thank you to the American College of Occupational and Environmental Medicine. So this is gonna be a talk on advocating to I'm sorry, advocating to prohibit pre-employment and random toxicology screening for non-safety sensitive positions in the public and private sectors. And this is a lecture grounded in advocacy journalism, so this isn't like a book that I wrote, it's not a paper that I published. What I really think is important about advocacy journalism is that in medicine, we often think that we need to be fully unbiased, fully objective about the things that we discuss. And not only is it almost impossible to be fully, not only is it almost impossible to be fully objective about the things that we do in our work, but it's not even necessarily necessary. What I learned a lot in my background, I got a distinction in advocacy during medical school, did a lot of training in legislative advocacy and drug policy. I got a master's degree in bioethics, and the thing about my degree in bioethics that was the most important is that if we have a shared language to discuss these ethical dilemmas, that at the end of the day, if there is a question, if there's a clinical consult, two different people might have a completely different argumentation, they might land on completely different sides of the decision that we should take. So as long as you can discuss in that shared language of ethics, it really just matters that you are bringing the best points that you can for the point that you're trying to make, and at the end of the day, if you are subjective, that's okay as long as your points kind of make sense. And so I think that's the most important part about this. I'm sorry, we're supposed to be seeing something here too. It doesn't show up there, sorry, it's just here. So financial disclosures, no financial disclosures, but ideological disclosures, of course. I'm a preventive medicine, public health and addiction medicine physician who believes in harm reduction and supporting the health and the rights of substance users. I have a decade long history of advocacy, ethics and journalistic work in cannabis substance use policy, and I'm a volunteer board member of Doctors for Cannabis Regulation, which is the first and only National U.S. Physicians Association dedicated to the legalization and regulation of cannabis for adults. And these opinions obviously don't reflect anybody I've worked with or will work with in the future because a lot of the stuff I tend to talk about is relatively controversial, but very important that we are continuing to have a nuanced and a broad discussion on what it means to protect people's rights, especially those who are discriminated against for a variety of different reasons. So session description, and so because I'm nervous, I'm probably just gonna read off my two wordy slides, which I will work on in the future, but the most important thing I think is that the message gets across. So upon increasingly widespread acceptance that the Nixon Reagan era initiated war on drugs has been a devastating policy failure, a paradigm shift in how we view substance use is reemerging. Harm reduction and informed substance use education are replacing the just say no model to support a safer population that recognizes that users of both legal and illegal substances hold the same fundamental rights and addresses demonstrated substance use disorders with a rehabilitative rather than punitive approach. According to Healthy People 2030, occupation is a social determinant of health, therefore reasonable access to steady employment for salary and purpose is a positive right. The negative right to bodily integrity and autonomy is also a protected domain. Efforts to infringe upon these rights with pre-employment or random toxicology screening must therefore provide clear and convincing evidence that they ensure or preclude safety and productivity issues in non-safety sensitive work, which does not exist, which I will be discussing. This presentation is an advocacy focused lecture recommending the universal elimination of pre-employment and random toxicology testing for non-safety sensitive positions in both the public and private sectors of employment in the United States at the federal level. And of course, this is a little controversial to discuss in a conference where some people's livelihoods is very much tied to the interpretation of toxicology testing. This does not mean that toxicology testing is gonna go away, but in these contexts, I advocate that it's not necessary and actually detrimental if we're actually trying to protect the public health. So there's a shifting landscape right now. Obviously, as cannabis becomes increasingly legal for medicinal and for adult use, different states are deciding to, on a state-by-state basis, change the way that they allow workers to not necessarily be tested for cannabis use in the workplace. It depends, there's a lot of caveats within this, but it's a state-by-state dependent process right now. And in general, I tend to advocate for universal changes so that there aren't individual states, individual employers who can still choose to kind of go against a larger top-down policy. And so while this is great, and we're really moving in the right direction with this, because we really should be looking at cannabis, especially more like tobacco and alcohol than we do other substances. But at the end of the day, as you'll see at the end of my lecture, I really do argue for the decriminalization and legalization of substances across the board. And if that were the case, then what would be the point of our toxicology testing in, again, specifically the pre-employment and the random contexts? So this is changing state-by-state right now. So educational gaps, or at least things I'll be addressing. What is the goal of pre-employment and random toxicology testing? Is this goal realized by testing? What assumptions do we make when we base employment eligibility or continuation on negative pre-employment and random drug screening, toxicology testing, better way to say that? Is there clear and convincing evidence that these assumptions are true? Are these reasons valid enough to limit civil liberties? And if not, what is the solution? So learning objective one is, upon completion, the participant will be able to explain the intentions and assumptions of pre-employment and random toxicology testing and consider whether or not they are valid. Because at this point, we really just do this because we've been told that this is what the normal thing is to do. Many other countries do not do toxicology testing in the way that we do it. And so it's important that we really think critically about the things that we think are important merely because they are a norm and not necessarily the ethical or the moral way to continue our practice. So bringing this from the American College of Occupational and Environmental Medicine, guidance and position statements on the ethical aspects of drug testing. So number two, the reason for any requirement for the drug testing program should be clearly documented. Reasons might involve safety for the individual, other employees, or the public, security needs or requirements related to job performance. So toxicology testing is usually something that we do for patients and not to patients. And so one of my questions and what you'll be seeing here is there's a lot of questions and not definitive answers because that's really what advocacy work is about so that we can continue a discussion and not just have black and white answers and considerations about things. So why should this precedent change in the employment context? And some people might have good answers for that, but that's my question for now. So a subgroup of interest is the pre-employment and random testing. Again, this is not advocating to remove toxicology testing entirely before pre-placement exams and for random testing. Here it says safety and security sensitive positions, but I've definitely seen random testing done for non-safety sensitive positions as well. And so this is what I really wanna kind of hone in on here because this is a really big discussion. And if we talked about all of this, we would never get out of here. And at the end of the day, these are different sorts of things to consider post-accident. That's a different context when it really is important to consider more about was substance use related because then accountability for the individual is something that we have to discuss. But this is what I'm talking about here is just pre-employment and random testing. So the history of drug testing. In 1986, the President's Commission on Organized Crime Report was released, which first kind of brought up the idea that possibly toxicology testing could be a good idea, not necessarily supported by any evidence, but ideologically. Executive order 12,564 made a mandatory toxicology testing for federal employees. And then that the public sector testing expanded to private and essentially what this order stated is that government and private sector employers who do not already require drug testing of job applicants and current employees should consider the appropriateness of such a testing program. That's essentially all it said, not necessarily any evidence to say why we should do this, but as we'll kind of get into with the background and the history of the war on drugs, which is really the biggest takeaway that I would like everybody to consider in this presentation, let alone anything else that we discuss, is to really understand what the war on drugs meant for people when it was initiated, what it continues to mean for people now and the tremendous harms that it has caused to numerous communities. So the standard now is really about 55 to 75% of companies in the United States do at least pre-employment drug testing. And it's only about 10% in Canada, which I think is interesting because it really shows that this is not something that we have to do. It's just something that we do and now we think we have to because it's a norm. But if we actually think critically about it, you don't really see that Canada is having any more occupational health issues related to substance use being reported and, you know, burning down the country or anything. And so it's interesting to see that this might not be necessary and that there's not necessarily a link between the testing and creating safer spaces for workers and for companies. So a few ethical considerations. Where I really want to bring people to is this paper because I think it's really excellent. A Nation of Suspects, Drug Testing in the Fourth Amendment. So the question is, are we violating workers' Fourth Amendment right to privacy to prevent unreasonable search and seizure in the absence of probable cause that substance use led directly to a specific public harm episode? And there's two specific legal cases which are very dense to like actually read through. So I was appreciative that this paper was willing to digest that a little bit for us. But Skinner versus the Railway Labor Executive Association where they wanted to start testing all railway workers for substance use and the National Treasury Employees versus Avon Rab, which was testing in the federal context. And so what I will bring in that I think is the most important about these cases is that in each different case, a couple of the dissenters, because they did end up ruling in favor of the people who wanted to continue testing the employees. So that pre-employment precedent was set very much with these two cases. One of the bigger consequences of that was that when HIV and AIDS epidemic came around in the 1980s, we then started to use this legal precedent and to importantly just bring attention to the fact that law is different than morals, is different than ethics and all these different kinds of things. We often think that the law is what's moral, is what's ethical and that's not necessarily true. It's just about what's based on precedent by certain courts that have ruled it to be so. So during the HIV AIDS epidemic, this actually, the precedent of pre-employment testing actually made it so that we were now allowed to forcibly make healthcare workers who might have been exposed to HIV be mandatorily tested and report that to their employers because of what we said about drug testing. And that is obviously something that we are now coming to a different understanding of. So my question is, can we come to a different understanding with drug testing as well? Violations of rights in the public versus the private sector, does it really matter or does it just matter that it's a job? And conflict of interest, which is a big thing that we could go into for a long time, but there's a lot of profit that drug testing companies are getting from toxicology screenings and it's important that we factor that all into what toxicology screening companies tell us about why they're important. So there was bipartisan dissenting opinions in each of the two different cases, which I just thought was interesting. So Thurgood Marshall, who's liberal-leaning, was a dissenter in the Skinner case. He said that in upholding the FRA's plan for blood and urine testing, the majority bends time honored in textually-based principles of the Fourth Amendment principles, the framers of the Bill of Rights designed to ensure that the government has a strong and individualized justification when it seeks to invade an individual's privacy. I believe the framers would be appalled by the vision of mass governmental intrusions upon the integrity of the human body that the majority allows to become reality. The immediate victims of the majority's constitutional timorousness will be those railroad workers whose bodily fluids the government may now forcibly collect and analyze, but ultimately, today's decision will reduce the privacy all citizens may enjoy, for as Justice Holmes understood, principles of law once bent do not snap back easily, which is why I really want to bring up that consideration of why dangerous precedent is dangerous. Then Antonin Scalia in the National Treasury Employees Union case said, so there was a concluding sentence within that case why they were saying that they were supporting the people who still wanted to drug test. So implementation of the drug screening program would set an important example in our country's struggle with this most serious threat to our national's health and security. And what Scalia said, who was obviously a very conservative justice, he said, I think that this justification is unacceptable, that the impairment of individual liberties cannot be the means of making a point, that symbolism, even symbolism for so worthy a cause as the abolition of unlawful drugs, which we could talk about also, cannot invalidate an otherwise unreasonable search. Those who lose because of the lack of understanding that begot the present exercise in symbolism are not just the Customs Service employees whose dignity is thus offended, but all of us who suffer a coarsening of our national manners that ultimately give the Fourth Amendment its content and who become subject to the administration and federal officials whose respect for our privacy can hardly be greater than the small respect they have been taught to have for their own. So I know that that's a lot of words, but essentially at the end of the day, this kind of precedent doesn't just affect people who could be potential substance users, it really affects all of us because it continues to limit our rights in a way that is not necessarily founded. So the limitations of urine drug screens, just to go over this quickly, because I'm sure that you guys are all pretty well aware. It's the most common and practical form of screening urine drug screens. Obviously we can do blood and breath and saliva, but this is mostly what is happening. There's high false positive, high false negative rates. There's limited detection windows. So honestly, if you were a person who uses some of these substances that we are quote unquote more concerned about, things like heroin, things like cocaine, you can just plan that if I'm planning to get a new job, I'm just not gonna use that substance for a week before. And then because this is only pre-employment drug testing, I can use it afterwards. So my question is really, what is this single time point testing doing for us? And the few things that really do end up in the urine for a longer period of time, benzodiazepines and cannabis. Again, we're starting to just shift our understanding of these things. A lot of times patients, whether or not they should be, I have a lot of concerns about benzodiazepine use actually as an addiction medicine physician. One of the things I think we need to be so much more concerned about than we currently are, but we're shifting the landscape with how we are viewing some of these tests and these drugs that are actually in the urine for a longer period of time. So there's a lot of limitation to this. And my question is really, what is this single time point testing doing for us? What is it really predicting and what could it possibly predict? And is there any evidence that it does? So these are two studies that were actually done on urine drug screening and toxicology testing. The one on the left just kind of says, it doesn't really make sense for us to be urine drug screening. If you really wanna know if somebody is acutely intoxicated by cannabis in a post-accident evaluation, something like that, you can always do a blood test which will give you quantitative levels. But this urine drug screening for cannabis isn't necessarily doing anything beneficial for us. And then what I thought on, sorry, it's kind of hard to look sideways. So on this one on the right, I thought that this was really the most important because a lot of the things that we're testing for the urine drug screening are illicit substances. Alcohol, I could argue for days, is really the substance that is causing the most detrimental impact to society of the legal and illegal substances. Of course, tobacco also, but when we're thinking about the public health risk in the more acute setting. Certainly the thing that I am most concerned about with the patients who I treat in addiction medicine, it is far more alcohol and it is opioids than it is cocaine. And so in the employment context, alcohol use is much more common than other drug use or in industrialized countries. Suggesting that alcohol may be more related to industrial accidents than other drugs. As well, epidemiological studies suggest that alcohol is a major factor for traffic collisions, but research is inconclusive for other drugs. Finally, alcohol testing is, sorry, more justifiable than drug testing because the results of alcohol tests closely correlate with psychomotor performance while drug tests do not. And so we're not testing employees for alcohol use. Most people use alcohol to a varying spectrum of use. I'm not necessarily saying that we should be drug testing employees when they come in every day, but it just goes to show why are we looking at these illegal and illicit substances and barring employment based on them when the thing that is actually causing our society the most harm is not being tested for. And again, I would not say we shouldn't be employing people with alcohol use disorder or use alcohol to a healthy spectrum of use, but more questions and more questions. So this is essentially most of what I've been saying already but I'd really like to get onto the videos about the war on drugs because I do think that is important to hear from voices that are not mine who have been actually affected by these issues. But to, I guess, summarize this quickly, what is the purpose and the goal of pre-employment drug testing to detect which employees use illegal substances? And the question I have is why does it matter if the substance is legal? What is the value of knowing whether an employee is using illegal substances because it is assumed to reflect their general fitness or duty and my question is, does it? Does single time point testing accurately predict frequency or occupational impact of use in the long term? No evidence that it does from the research that I've been doing. Does abstinence from certain illicit substance use either guarantee or preclude loss of productivity or occupational stability that impacts beyond the individual? No evidence that it does. And why is this not also asked of legal substance use that can cause harm for and beyond the individual, alcohol, tobacco, sugar, caffeine, alcohol again. Why do we assume that testing negative for substance use at a single time point prior to employment start impairs fitness for duty, rather propagated by the war on drugs than just say no. And then this is the statistic that I saw coming up most frequently when I was looking at why are we so concerned about substance use in the workplace. 35 to 50% of workers' compensation cases are related to substance use in the workplace. This is the statistic I kept seeing propagated by the National Safety Council. And I was really looking to see where this information came from, like where is the primary literature to support this. I still haven't been able to find it. But my question is, more questions, does pre-employment and random drug screening specifically reduce this? There's use versus substance use disorder that we call addiction causing harm in a person's life and beyond the individual. Are these legal or illegal substances and which ones? Because I would not be surprised if a lot of this was actually related to alcohol use that we don't test for at all. And who are our regulatory agencies representing? And so this one I want to kind of breeze through quickly. But I went to the National Safety Council website and I took a screenshot of their main page. And you see young white men predominantly. And I think that it's really interesting. Obviously, there's gonna be a broad array of opinions on this. I've done social justice, racial justice advocacy work in the past. And this is a very contentious topic, more contentious than it should be. But just based on something like this, I do think that it matters. That obviously, we kind of have a narrow view about who it is that we are protecting and who our workers are and what safety means for who across what contexts. And so what about safety sensitive positions? So many legally prescribed medications can also impair cognitive functioning compared to baseline. Safety sensitive positions can drink alcohol and use tobacco on their time off, which have the potential to impair cognitive functioning during and between acute use. Ethical concerns with disallowing safety sensitive positions to utilize buprenorphine and methadone treatment, which has happened for some of my patients who are nurses and not allowed to continue buprenorphine even though it has saved their lives. And so again, more questions and nuance and context is really important when we're considering these things that limit people's rights. But this requires a much more involved conversation and so I think that it's important that we keep this connected to non-safety sensitive positions especially. And questions, is this different for cannabis, a schedule one controlled substance, but that we are increasingly developing a new relationship with on a national level. More questions. So learning objective two. So upon completion, participant will be able to explain the role of the history of human substance use and the war on drugs on the moral, ethical and legal implications of pre-employment and random toxicology testing. Few considerations, autonomy and justice. Low risk use versus addictive use. Medical versus free, euphoric, entheogenic or spiritual use. On duty versus off duty. Substance users rights versus employers rights versus public health rights. Law versus ethics and morals. The precautionary principle for both employee and employer. Proof versus propaganda. Pre-employment and random versus non-harm reduction focused monitoring program testing. And so this is a, I would honestly say is the most important point of my whole talk. So we're just gonna watch these videos quick which is why I'm trying to kind of rush through the rest of this. So let's see. Let's see if we can get the audio. Take a minute. Okay. Is there anything you guys can do or should I just expect it won't work? Okay, bummer. So I think that at least you guys would be able to know how to find this on YouTube based on what I have here. This one on the left was created and produced by Jay Z or Sean Carter. It's a really beautiful, very quick synopsis on the war on drugs and how it has so significantly impacted particular communities, especially communities of color, those in lower socioeconomic statuses, immigrants and refugees, people who don't speak English and why the war on drugs was created. To discuss that would take me at least 15 minutes to actually do it justice which is why I wanted to make sure that other voices who are better at explaining this and already have done it in a really beautiful way would have the opportunity to do that for you guys. And the one on the right is from the Drug Policy Alliance which is an organization that I've worked with in the past doing legislative advocacy work. I think it was a really wonderful video that they were also able to put together explaining their argumentation for why we should be decriminalizing substances and there was a lot of other good info in here too. But if not, then I will give a, I'm gonna try one more time and we'll see. Please try that. Yeah, I know, right. In 1986, when I was coming of age, Ronald Reagan doubled down on the war on drugs that had been started by Richard Nixon in 1971. Drugs were bad, fried your brain. And drug dealers were monsters. The sole reason neighborhoods and major cities were failing. No one wanted to talk about Reaganomics and the ending of social safety nets. The defunding of schools and the loss of jobs in cities across America. Young men like me who hustled became a sole villain and drug addicts lacked moral fortitude. And in 1990s, incarceration rates in the US blew up. Today we imprison more people than any other country in the world. China, Russia, Iran, Cuba. All countries we consider autocratic and repressive. Yeah, more than them. Judges' hands were tied by tough on crime laws and they were forced to hand out mandatory life sentences for simple possession and low-level drug sales. My home state of New York started this with Rockefeller laws. Then the feds made distinctions between people who sold powder cocaine and crack cocaine even though they were the same drug. Only difference is how you take it. And even though white people used and sold crack more than black people, somehow it was black people who went to prison. The media ignored actual data to this day. Crack is still talked about as a black problem. The NYPD raided our Brooklyn neighborhoods while Manhattan bankers openly used coke with impunity. The war on drugs exploded the US prison population disproportionately, locking away black and Latinos. Our prison population grew more than 900%. When the war on drugs began in 1971, our prison population was 200,000. Today it is over 2 million. Long after the crack era ended, we continued our war on drugs. There were more than 1.5 million drug arrests in 2014. More than 80% were for possession only. Almost half were for marijuana. People are finally talking about treating addiction to harder drugs as a health crisis. But there's no compassionate language about drug dealers. Unless of course we're talking about places like Colorado whose state economy got a huge boost by the above ground marijuana industry. A few states south in Louisiana they're still handing out mandatory sentences for people who sell weed. Despite a booming and celebrated 50 billion legal marijuana industry, most states still disproportionately hand out mandatory sentences to black and Latinos with drug cases. If you're entrepreneurial and live in one of the many states that are passing legalized laws, you may still face barriers participating in an above ground economy. Venture capitalists migrate to these states to open multi-billion dollar operations, but former felons can't open a dispensary. Lots of times those felonies were drug charges caught by poor people who sold drugs for a living, but are now prohibited from participating in one of the fastest growing economies. Got it? In states like New York where holding marijuana is no longer grounds for arrest, police issue possession citations in black and Latino neighborhoods at a far higher rate than other neighborhoods. Kids in Crown Heights are constantly stopped and ticketed for trees. Kids at dorms in Columbia where rates of marijuana use are equal to or worse than those in the hood are never targeted or ticketed. Rates of drug use are as high as they were when Nixon declared this so-called war in 1971. 45 years later, it's time to rethink our policies and laws. The war on drugs is an epic fail. In 1971, Richard Nixon declared a war on drugs. America's public enemy number one in the United States is drug abuse. He lied. In order to fight and defeat this enemy, it is necessary to wage a new all-out offensive. 50 years later, the real public enemy number one is clear. It's not the drugs or the people who use them. The real enemy is the drug war itself and the policies and systems that feed it. Nixon's own aide admitted the drug war was never really about drugs. The war on drugs is a tool for racial and social control and criminalization, surveillance, and punishment. Black and white people use and sell drugs at a similar rate. Yet Black communities have been targeted and vilified, making up 26% of drug arrests, but just 13% of the U.S. population. The war on drugs is a tool for racial and social control and criminalization, surveillance, and punishment. but just 13% of the U.S. population. The drug war affects us all. The U.S. has the highest incarceration rate in the world, in large part because of the drug war. Of the over 2 million people currently incarcerated, one in five are locked up for a drug offense. Because of the drug war, our drug supply is unknown and risky, with overdose rates at an all-time high. Because of the drug war, we are not safe. Not in our cars, not in our offices, not even in our beds. It is time to end the drug war. The step we must take right now is to decriminalize all drugs, no longer arresting people for what they put in their bodies or carry with them, no longer choosing punishment over support. Decriminalization means a person struggling with their use is given access to treatment, not years behind bars. Decriminalization means a parent can focus on their child's wellness without the criminal justice system getting in the way. Decriminalization means a city can finally invest in health services and support instead of police and jails. We know a different reality is possible. We envision a world after the drug war, a world where someone's relationship to drugs isn't an excuse to take away the autonomy, justice, and safety every person deserves. After the drug war, stigma and fear will no longer rule our communities. Compassion and collective care will take their place. We deserve the world after the drug war, and we need to build that vision together. Join us in the fight for decriminalization and beyond. And so the biggest takeaway that I hope you guys might be able to take from that, other than just the education on the drug war itself, is that urine drug screening unequivocally is part of this history of the war on drugs. It is not necessarily something that has been evidence-based proven to actually improve the safety of our workspaces. So that's the really main takeaway point from all of this. So substance use and human history. I just thought that this was a really nice synopsis of things. There's a couple little editing problems with it, but humans have been using substances for a variety of purposes for 60,000 years. That's never something that's going to stop. It's never something that we should expect is going to stop, and what is most important is that we are keeping people who use substances, including the majority of people in this room who I'm sure use alcohol every once in a while, safe, and protecting their civil liberties and ensuring that we keep a harm reduction and stigma reduction-focused approach in the work that we do, because it's not only best for those people, but it's best for the public health. And as an addiction medicine physician, I can really testify to that from a personal perspective. So there's a spectrum of substance use, beneficial use to casual non-problematic use, to problematic use to chronic dependence that we would call addiction, which is really when substance use becomes harm to the individual or outside the individual based on the individual's own assessment. And so this is a spectrum, as is everything in life. There are no black and white answers or considerations. And this is just a nice graph about what we're looking for when it comes to questions of decriminalization, more controversially, legalization, and trying to just regulate the market, like we regulate the market when it comes to tobacco use and alcohol use. So just to touch on that. How many people who use substances develop addiction? This is a really excellent book by Dr. Carl Hart, who's a neuroscientist who works at Columbia. He very generously said that 10 to 30% of people who use substances will eventually develop dependence or an addiction. I personally have not seen rates up to 30% on a population health level. Tends to rest more on the high end from 10 to 15%, which means that the majority of people who are using all of these different kinds of substances do not develop an addiction that impairs their social and occupational functioning. And most importantly, what he says is that it's not necessarily the drugs, it's the context of the drugs, which is not having work and it's not having housing. It's social determinants of health, which are really causing problems that then get intertwined with the drug use. And at the end of the day, it's most important that we get people towards treatment, treatment which also includes occupation. Learning objective number three. So upon completion, participant will be able to explain the role of bodily integrity, autonomy, and the right to reasonable occupational access in considerations on the moral, ethical, and legal implications of pre-employment and random toxicology testing. Trying to finish so we can get questions in. So occupation is a social determinant of health. This is probably the most important thing that I learned in my preventive medicine residency training is the incredible importance of ensuring that we have strongly supported social determinants of health within our societies. We tend to really look at things downstream, drug use, substance testing, when really we should be thinking about housing and jobs and education and healthcare. And if we fixed those kinds of things from a top-down policy, we wouldn't have to be catching people down at the end of the river. So social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affects a wide range of health functioning and quality of life outcomes and risks. So of the social determinants of health, I don't think this thing works. I'm not gonna touch it. So education access and quality, healthcare access and quality, neighborhood and built environments, social and community context, and economic stability. And I just wanted to pull out, let me see if this works. So I just wanted to pull out a couple of studies, but really there is a tremendous amount of literature showing that housing first. People deserve housing before they need to prove housing so that they can get treatment for their substance use disorders. Work first. People need work even if they are active substance users with an addiction so that they can not only take care of themselves and take care of their family, but to also continue contributing to society. Work gives us a tremendous amount of things that are important, which is essentially money and work and purpose and a place to be and feeling like we are contributing back to the society. And so occupation is treatment. We shouldn't be trying to keep drug users out of the workforce. We should want them to be working so that we can benefit the public and we can benefit these individuals as well. Bodily integrity, autonomy as a negative right. So the principle of bodily integrity sums up the right of each human being, including children, to autonomy and self-determination over their own body. It considers an unconsented physical intrusion as a human rights violation. Negative rights are the duty not to interfere with an individual's action, in this case, upon their body. And this was a really excellent work that was put together, sort of like a dialectical ethical analysis on what does our bodily right mean to us? Because I think we have a very basic understanding of what it means to have a right and the importance of being able to determine what we put into our body, what we don't put into our body. And this is, again, I'm gonna give a caveat here because I'm an incredibly strong supporter of the public health, not to, I guess, be a hipster about it, but I was like one of the first people who I knew to be supporting masking when it came to the COVID-19 pandemic. So I don't wanna at all say here that bodily integrity supersedes all of our other rights, but we'll explain why this is different from the context of COVID-19 in just a second. So this was just a really beautiful article. Bodily self-determination is our right to determine what we do and do not do with our body. Respect for bodily unavailability of the other is not necessarily our right to infringe on another person's body without clear and convincing evidence that that is absolutely necessary. Care for bodily individuality, so everybody has a different relationship to their body and what bodily autonomy and integrity means to them. And recognition of bodily cooperation, which is that we are these individual bodies, but we are also working within a community of other bodies, and that's when we have to consider public health considerations as well. So does drug testing surpass the employer's legitimate sphere of control by dictating the behavior of employers on their own time and in the privacy of their own homes, which is a question that was raised by this paper. I would consider possibly not. And by another paper that was written by the National Research Council and Institute of Medicine, despite beliefs to the contrary, the preventive effects of drug testing programs have never been adequately demonstrated. We do not have proof that this is necessary, and if anything, it can be causing a tremendous amount of harm, which means that the burden of proof needs to be on the people who are violating the right, not the people whose right is being violated. Limitations to upholding right to bodily integrity. So the COVID-19 pandemic and masking. If strong evidence for direct link of use to public harm can be made, i.e. a high communicability of disease, then bodily integrity can be overruled by distributive justice, civil liberties versus the public health. So this was obviously a very controversial and difficult weighing during the COVID-19 pandemic, which is still continuing now. But this is essentially why there was a much stronger argumentation for saying that people in public spaces needed to wear masks. When it comes to the vaccine argument, while I'm an incredibly strong supporter of vaccination, I do think we tread into difficult territory there with some of the mandatory vaccination requirements. But when it came to masking, I was always fully a supporter of public masking, and that was a limitation of civil liberties so that we could protect the public health. That link is much stronger than it is for the use of drug testing in order to keep occupational spaces safe. So it's a different consideration, but an important question. And if we had longer to discuss it, we could really go into the detail about that for a whole hour. So can we prove that ensuring abstinence from only certain illicit substances with single time point toxicology testing for pre-employment and random purposes improves the occupational public health space? The burden of proof lies on the potential violator of the civil liberty when that civil liberty is violated without clear convincing evidence that the public health may be deleteriously affected without doing so. And so the wrap up here is a lot of words, but essentially just to summarize everything I've been talking about. The war on drugs has led to an excessive vilification of normal levels of substance use that have been prevalent since we evolved to our current genus species of Homo sapiens. This has increased stigma, reduced access to treatment, and led to the over incarceration of people, especially communities of color, immigrants, refugees, those who don't speak English, and people living in poverty. Occupation is a social determinant of health and bodily integrity are rights that ethically must only be infringed in the case that harm from lack of infringement is directly causally related to occupational public harm. Due to occupation as a right and social determinant of health, barriers to employment should be minimized as far as possible and especially when balancing civil liberties versus public health. Limiting access, increasing barriers to employment requires meeting a high threshold of proof for clear and convincing evidence of necessity which does not currently exist. Employees have the ethical right to uphold their bodily integrity except when the public may be clearly, directly, and significantly affected. This proof does not exist in supporting necessity pre-employment and random toxicology testing. When we perform pre-employment and random drug screening on potential employees and current employees, we make the assumption that single time point testing, sorry, I lost it, that single time point knowledge of substance use is a direct indicator of employee occupational safety risks. However, there's a healthy spectrum of substance use and the legal precedent is not inherently equivalent to moral or ethical action. Duality is false or at least incomplete when little is all or nothing and most is spectrum. So infringement of the negative right to maintain one's bodily integrity in the absence of proof of direct causality for substance use to occupational or public harm is a violation of autonomy that is also not proven to benefit the public health. In absence of this proof, there is no strong argument for the ethical viability of pre-employment or random toxicology screening, especially for cannabis as the landscape begins to shift, but also for other substances currently disqualifying for employment in many and varied fields in the majority of scenarios. New laws increasingly support the elimination of toxicology screening for cannabis use as it becomes increasingly accepted. This contributes to the belief that there is a morality, sorry for the typo, contributes to the belief that there is a morality or its lack depending on the substance of use, which there is not. Abstinence from illicit substance use does not ensure or preclude healthy occupational functioning. A single time point test tells us little about a person's history of substance use or the chronicity of their use or the use in the future and whether it's impacting occupational public health and safety and therefore does not stand as reasonable evidence that their civil liberties to reasonable occupational access and bodily integrity have the right to be violated in order to protect the public or occupational health. So in conclusion, elimination of pre-employment and random toxicology screening is a social justice and health equity and population level preventive intervention supporting occupational health through top-down policy change that ensures universal standardized implementation, elimination of the right for the employer to utilize pre-employment and random toxicology testing to screen or discharge potential and current employees from employment in the public and private sectors in most fields is recommended. So the new recommendation is to get rid of pre-employment testing, to get rid of random testing, and again that's not going to get rid of toxicology testing across the board. And is there ever a time for its use? And so certainly post-accident with reasonable suspicion, but what does reasonable suspicion really mean? So at the end of the day it's still important that we think critically about the use of toxicology testing even in these situations, which I'm not necessarily advocating for it to be removed from. And this is important. These are three videos that I just think are great about how other countries are handling issues with drug use. One of the reasons why the United States is having such a horrifying epidemic of substance use, not just when it comes to opioids, but alcohol, tobacco, is because of the way that we view and treat substance users. So a lot of these points I already discussed previously, but there's an importance to decriminalization, but also a limitation, which is why consideration of legalization is still incredibly important, but certainly not the hardest push that a lot of harm reduction agencies can make at this time because it's far too controversial. But really this would change everything so that we are thinking about substance use from a rehabilitative rather than penalizing approach, and it's important. If substances are decriminalized and legalized, is it reasonable, ethical, or necessary to test for them in the pre-employment and random settings? Because if people are allowed to use alcohol and we're not testing for that, people are allowed to use other substances, why would we start to test for that either? And really is this more about policing what people are doing rather than safety, even though that's the norm that we expect with the work that we're doing with the drug testing. So Drug Policy Alliance, National Harm Reduction Coalition, these are organizations that I really respect and are so important in the work that I do. If you guys are interested in looking more into them, you'll see more of the work that they're doing to help people who are using substances and to help the public health as well because the way that we spend money on trying to penalize substance use actually takes money away from things that are very important for all of us. And so thank you for your attention, and are there any questions? That's what I'm hoping, that's why I put some of those extra videos in there. I'd be very happy to send them to anybody individually. I should have probably put my email here, but if you can find me on like the the swap, I'm happy to send them out. But yes, these particular, a few of these papers and some of the videos I wasn't able to show, you obviously can't get access to that through the handout. So if you can find me on the swap, please connect and I'll be happy to send them out. So is there a role for possibly doing behavioral screening with like surveys to examine whether or not people might be using substances that may include, you know, urine drug screening? Certainly I always think that screening for illicit substance use can be very beneficial for certain populations. I gotta be honest, I don't remember the most recent USPSTF recommendation. I believe that it's still inconclusive for screening the general population for substance use disorders. They're finding that it's not necessarily helpful, but I will be embarrassed if I look into it later and it's actually a B recommendations because it's either one or the other. But with that question I guess what I would really be wondering more is are we trying to protect the employee or are we trying to protect the employer? And with the extra, you know, point at the end like which may include substance use testing, what I really find in my work as an addiction medicine physician is that if people are having an unhealthy relationship with their substance use that they are ready and willing and wanting to work on, they will report that substance use to me. I personally have a lot of feelings about the way that we do toxicology testing. Even in the medical setting we really just throw it on for certain populations of people and that gives me consults to our addiction medicine service for a lot of reasons that are not necessary and that person never really gave consent for their urine to be collected for a urine drug screening. Especially, I want to use the word horrifying, I know this is a big one, but especially horrifying when it comes to pregnant women who are screened without their consent because that can cause a lot of other problems as well. So I always think that, you know, checking in with people about substance use is something that could be beneficial for them, but my real question is are we doing that for them or are we doing it for the employer? And if, you know, and I don't necessarily know that it's necessary in the work I've done in employee health through my residency program, all the things we were doing really were to make sure that the employer was protected. And so it really wasn't about the health of the employee, like that was what we referred them out to their own doctor for. So I would really be wondering, even if we were using behavioral screening, is that really more, you know, to try to bring something that we feel more comfortable with to continue to police people? I think in general medical settings that's a great thing, but I think that it could get sticky, especially when you say, oh, this person screened positive, now we're going to urine drug screen them. That's an issue. Does that answer a little bit of, or at least my opinion about it? Okay, thanks. Yes. So, yeah, yeah. Yeah, so you're going into the question on absence of evidence doesn't imply evidence of absence. I think that's kind of the question that you're asking. And I'll be honest that I really pulled things through like, again, an advocacy journalistic perspective. This was not a systematic review. It was not a meta-analysis. If anybody finds a study that really clearly links toxicology testing to safety concerns that are large enough to limit the civil liberties of a giant population of potential employees, I'd like honestly really be happy to see that, because the work that I do is most important, that I am telling the honest truth from the most that I have personally been able to research myself. So when people bring in other concerns, I'm very happy to discuss that. I think that the most dangerous thing that we do when it comes to advocacy work is having obviously a very strong opinion about something, and then because we have that strong opinion, no longer allowing other ideas in. So I'll be honest that I don't, I just did not find any studies that did support it, and I found studies that showed that there is no link, and so these are the ones that I had that I had put here in the link. I can see that that this probably raises a lot of personal feelings for you. So I think that this is the best that I was able to come up with, just to like be honest. I'm not trying to hide anything. That showed that there's actually a link? No, I personally did not find any. Again, the couple that I showed here were honestly two of the ones I was working with another board member on the cannabis regulation company, or not company, the Doctors for Cannabis Regulation. I'm getting nervous because I can see that this caused some upset in this, but this is what this work is about. And so he was the one who actually found two of these, because he did a similar talk like this pretty recently, and there's just not a lot of evidence out there, and so I was just kind of showing you guys the best of what I was able to find, and I know that there's certain holes. If this had been a systematic review meta-analysis, this would be incredibly weak work, but because it's an advocacy journalistic approach, I did the best with finding what I could, and again, that could absolutely be a link that hasn't been tested yet, but my bigger question, again, given all the things, is probably that it is likely not going to be a link that we find, most likely. I would be very surprised. In any sort of way, that would actually mean that we should change the primary argumentation that I'm making in my talk. Please. Sure, so that is, yes, so I'm wondering if there are multiple people within an employment context who are concerned that somebody may be actively using substances on the job, or that that use is impairing their work, do I think that they should be able to be toxicology screened at that point? And yes, what I always say is I think we should be careful, careful, careful, because obviously not being careful has gotten us into a very dangerous position, but absolutely, if somebody thinks that someone is coming to work using opioids, someone is coming to work using alcohol, I absolutely believe that there needs to be a tremendous amount of accountability that needs to happen, especially in safety-sensitive positions, but really everywhere. You shouldn't be coming to work after you've used substances. I feel like that's something that should be pretty clear to people, and if toxicology screening is going to be able to tell us whether or not that's occurring, yes, and that's why random and pre-employment testing is specifically what I wanted to focus on here. That's a great question. That's why toxicology testing shouldn't be just done away with, it's just in these contexts I think we can reconsider. Yes, sir. So I think the best that I can come up with now for that question is, is it our job to be deterring people from substance use, or is it their right to determine whether or not they would like to engage in that themselves? I think that it sounds like you're coming from a place of like very positive intentions, which is maybe the ideology that substance use is bad, we shouldn't be using substances, and therefore we should be deterring people from use. But again, that raises kind of the question, are we trying to deter people from alcohol use with our tests? Because again, in the work I do as an addiction medicine doctor, alcohol is certainly the thing that I'm most acutely concerned about on a chronic basis. Yes, in the acute context of overdose, with especially these young kids, we're really thinking about the opioids, but most of my patients who have had a substance use disorder for a long time that has really negatively impacted their social occupational functioning, why are we not considering that in this drug screening? We don't care, even though that's really what's causing us societally the most problems, as well as tobacco use. So I guess my question with another, to answer your question with another question, is like, is that a responsibility, even though I really do believe that you're likely coming from a positive place with that, given your current perspectives on substance use, if that answers some of that. Yeah, okay, thanks. Any other questions? Okay, yes. So I did start looking into that, but I think one of the things that stopped me, given that this was already such a hefty lecture, is that my personal concern from my subjective experience of wanting to advocate for substance users to have the right to bodily integrity and to employment, is that the costs to a private employer aren't necessarily what I am centering as the most important thing here. So I started to kind of go in that direction a little bit, but really what I kept finding is this National Safety Council statistic about substance use is just related to lack of productivity and things like that, but it was really like too broad, too general. I wasn't able to find the primary sources for any of that, and as I hope kind of came across here, most people who are using substances do not have an addiction, which means that their social and occupational functioning is actually deterred by their substance use. It's only about 15 percent, 10 to 15 percent of people in most cases, up to 30, but I really haven't seen that. I think Dr. Hart was being very generous, to be very honest, that that can be the case, but most people who are using substances do not have an addiction issue, which would affect occupational space. And so when it came to productivity questions, again, that's just the same statistic without an ability to find primary literature that I found, and then I think that the other question is really about, you know, cost to the employer, and because again there is no direct link to substance use based on a single time point screening, which honestly doesn't even predict whether or not there are people with substance use disorders within your organization, seeing if that actually limits productivity to any level significant enough to violate the civil liberties of individuals, and I think that that's one of the most important pieces here, too. Are there possible linkages to, of course, someone with an active alcohol use disorder who has not been identified and they're not coming to work as much? Obviously those things are going to happen. In the work that I do with working with patients with substance use disorders, I don't expect that we're going to have no detrimental impact from substance use in the society, but we also have to accept that there's a certain level of detriment that's going to come from a variety of health issues, including people who have a sugar addiction and develop really severe diabetes and whose care is then chronically incredibly expensive. Like, I don't want to really go in that direction too much, but really when we're talking about costs and the public health and the public harm, why aren't we thinking about alcohol and tobacco and overweight obesity and things that are leading to diabetes with food addiction really very quickly coming up to be toe-and-toe with, you know, tobacco use with being the leading preventable cause of early injury and death in the country, but we're not telling people stop eating doughnuts and we shouldn't be telling people stop eating doughnuts. So I know that that's not like a directed question, but again, questions with more questions because that's what kind of advocacy work is about. Does that answer some of it? Okay, I appreciate that. Yes. Hi, thank you for your presentation. You mentioned that public safety might be a reason to consider the balance of benefits of harm in regards to far away and segregated communities. Can you share with us your thoughts on these two points? What can we consider a substantive addition and how people get served by that? And second, can you share your thoughts on the ability to enter into contracts as part of respecting autonomy? Okay. Can you repeat the question? Sure. So in general, so questions about piggybacking on the issue of balancing the ethical dilemma of individual integrity, bodily autonomy, and the public health. And first, having me explain what I would consider a safety-sensitive position, who decides what a safety-sensitive position is, and then is there an amount of entering into a contract that may possibly limit our ability to engage the maximum amount of our bodily integrity and autonomy? Because I'm not an occupational health doctor, I actually don't know who decides what a safety-sensitive position is. The biggest thing, again, because I really wanted to just hone on the part that I was presenting here, is that I think we have to be critical about our determination of what a safety-sensitive position is. It seems to be any job that is related to heavy machinery use, that is related to care of other people in a way that requires complex decision-making and a certain high level of attentional ability. So I'm thinking of transportation, I'm thinking of healthcare workers, I'm thinking of people who work in machine operator kind of plants. Again, I'm not an occupational medicine doctor, I mostly do addiction medicine. Did you want to contribute? Dr. Hartenbaum? Yes? Oh my gosh, guys, are you Dr. Hartenbaum? Hi, she's the one who let me come here. Thank you. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. 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drug testing

urine drug screens

Fourth Amendment rights

marginalized communities

harm reduction

decriminalization

policy reform

access to treatment

workplace safety

compassion