either side of the main foyer outside this ballroom. Please do not forget to silence your phone and other devices. And AECOM staff have red lanyards and buttons identifying them as such. Please let them know if you need any assistance. You can also go to the membership booth at the fifth floor for assistance. I'd like to go ahead and get the program started. The, before I get started, I'd like to credit or blame the Pennsylvania legislature for creating this program or else you'll be somewhere else. And I also would like to thank the Pennsylvania trial attorneys for a lot of the references used. They list them on their website. And they also not only list them, but they also were able to describe what the importance of the data are. The impetus came after the passage of the Pennsylvania Medical Marijuana Act 16 in 2016. It had a lot of impact on the employers in our area. A couple other things that are occurring at the same time. One, increasing acceptance by a number of the workers for recreational marijuana on weekends. They would use it, but then they would stop and they would come in Monday, fine, totally productive, but yet they would still have presence of marijuana in their urine. The third thing was a number of the individuals, you would see them smoking in the parking lot prior to coming into work. And they were sweet, but the performance was exemplary. And they would meet the criteria ISO 2000, 9001. I often see this in the weight room in the morning. These guys would be reeking of marijuana, but their workouts were really intense and they would be on schedule. They would keep it recorded and everything else. So these were able to highly function despite using marijuana acutely. The last thing is the employers were concerned about how to identify who's truly impaired, but then how to assess and manage those individuals. Because it's hard to turn, replace workers. And when I was stuck as a hospitalist and nocturnist, but what I consider like an ACLS, when you had someone had a cardiac arrest, how do you assess them? But then you have to manage them. Once you recovered them, you got to get them to the ICU, you got to chill them, you got to call the cardiologist, you got to order the various tests, the echo, CT, angiograms, and so on. So, and this is what the employers were concerned about. So the employers contacted the insurance brokers. I'm not sure if many of you are familiar with, but they're very powerful individuals. They serve as the intermediary between employers and health insurance and also workers called insurance carriers. And these are issues we want to address. So they contacted my employer, even I work for AHN, who happens to be Highmark Health, which is the largest in the sympathy with Blue Cross of Western Pennsylvania, but now insures most of Pennsylvania, West Virginia, Delaware, but they also, Western New York, Empire Blue up in Northern New York, they're Highmark Stadium. And this is an issue the employers have raised. So they asked me, you know, if look into it, help figure out a strategy to help the employers. So, this is the Medical Marijuana Act 16. There's some features on there that's very, I would say favorable for the legislators and the state administrators, not as problematic for the physicians in the commonwealth, but it also becomes a challenge for the employers. And a couple of the things in there, Lynn bring up is the 10 nanograms blood serum for certain occupations. That's what they listed as what is the cutoff. But they kept on using the thing about under the influence and all these under the influence, you know, you can do anything, but you had to be under the influence. And how do you assess for that? They left it kind of vague. And the performance of being tasked. Couple of the data, couple of the things that have come up from there. Right now, there's 423,000 Pennsylvanians are receiving medical marijuana. Okay, 423. Now, Pennsylvania is one of three states that only allows anxiety as a diagnosis. Now, Spotlight PA had to go to court to get the Department of Health to find out how much a diagnosis for each one. 58% for anxiety, 35% for diagnosis of pain. The other 9% is for the other 23 diagnosis. You have to go see a DOH certified physician annually. And then they go to a dispensary, which is managed by a, which is managed by the DOH, but they're managed or the pharmacist are ones who determine what dosage, what clinical preparation is received. The third thing is there's no consistency even within dispensaries of medication. You don't know what you're getting. There's no standardization of compound. This is where the problem is really coming in, where it came into Pennsylvania Medical Society. This came to the Board of House of Delegates is that the physicians, other PCP and specialists had no idea what the patients were receiving and they're popping into the emergency department. So they had no clue about the dosage, root administration, classic chemo bar, which is TH predominant, THC, CBD balance and CBD predominant. And that information was never relayed to the PCP or a specialist. And then if you go on the ones on Epic, if you go and check your Epic on the medical marijuana, they don't have anything, they just listed medical marijuana. They had nothing else about that. So you're in the dark if you're managing these patients. So when they have the adverse events, which is a common problem right now, this is why it was brought up, they basically go back to a PCP and then the PCP has to adjust, has to adjust to whatever medications are used for other conditions. And but this is the other thing is a significant course for revenue, the Department of Health website lists $6.3 billion that come in since the inception. And that includes money that they, taxes on stuff that the growers who are licensed by the state to the dispensaries and then the state, the dispensaries list to the patient. So this is a huge source of revenue and the state may not change anything just because they have to replace that money. So the question I always said, what is the influence under the influence means? You know, that's, they leave it vague on purpose, I think. But anything, this is what I saw for Cornell Law School. I was looking for some other definitions in Pennsylvania law schools but they didn't list it on their website. So I kind of said what other laws in Pennsylvania address impairment? This is the first one, this came in the 1800s, I don't know what year it is, but this is what boating under the influence is what the regulations state about this. And this is serious and I grew up in Western Pennsylvania because, you know, there's a lot of commercial traffic and these kids with their boats, fast boats, they try to, you know, play around with these things, they end up having accidents and they drownings. And the water conservation officer is a concern and even on Lake Erie where I live currently, that's another issue because they go out on their hot summer days and they're either out for drugs and problem. So this is what the boating, and then this is the one that we're all familiar with is driving under the influence of alcohol. This is, you know, Title 7538 and so on. And it's under the influence if there are any drug or combination of drugs that impairs in building. There are other two other impairment laws in Pennsylvania. The first one is boating, the second one is hunting and fur trapping, Title 34. That's kind of mirrors the boating and the other one's crane operation, but that's vague. So initially the Pennsylvania Bulletin, they initially did a threshold level THC at five nanograms. They amended it to 2011 and so on. And this is, I think, consistent with most states in the country right now. They use the cutoff at one nanogram for any type of impairment. If you show physical evidence of impairment, this is what they use to charge you for driving. So this is a report Compton did to the Congress on marijuana and driving. So basically he says, you have to have often, besides having the blood level, you have to show some type of objective information that this person's impaired. This is a really important article or report if anyone have a chance to read it. So one of the issues came up with the Pennsylvania Medical Society, which had CME programs on it, is what are the complications of medical marijuana? And this is a huge one right now. And this, I've seen articles in both Pennsylvania, saw some in California, the drug-drug interaction. THC has interaction, 392, CBD was 540. These are some of the common problems they're recognizing. And when they said, you're seeing with the anti-anxiety, the Xanax and so on like this Ativan, these people that have already been diagnosed with anxiety already on this medication, they're using this, and it becomes a problem also with the pain medication, some of the antidepressants. So these are common that they recognize to be drug-drug interactions. So this is Wang, this is, Canada has a lot more experience, the United States, and most of the literature on medical cannabinoids and drug problems and impairment has come out of Canada. This is Wang. So she, or they've identified the two issues with nervous system disorders and psychiatric disorders for impairment, but they didn't classify, the article did not classify what was a neurological disorder and what was a psychiatric disorder. This is what they classified. Now, non-adverse, serious adverse events is that they weren't hospitalized. So it could be anything under the gamut after that. From Edy in 2021, this is some of the medical impairment. These are some of the neurocognitive issues that they find that causes problems with medical marijuana. The various, and this relates to the testing that we're gonna show with some of the things that are affected. Individual characteristics affecting impairment. These are common ones. Comorbidity, genetics, endocannabinoid system, toner, the present use and so on. Metabolism and also chronic pre-existing conditions. Now, this is from Compton's article too. These are high-risk populations. These are people that already have a higher rate of car accidents compared to the general population. So if you have anxiety, insomnia, which a number of them have been diagnosed with for medical marijuana, this baseline, they already have an increased risk of accidents. You put this on front and they're a much higher risk. And also chronic pain patients, slower reaction time and so on. So one of the, I was asked several times, what do you define as impairment? These are various definitions. I've included, I generally use a National Safety Council one. But any ones of these, this is ones if you get asked, this is one of the various definitions of impairment. So this is where the bulk of the program really is heading toward, is what do you do, how do you assess someone? And this is the first one. These are the marine boat officers. It's kind of watching them on Lake Erie because we're about, when we go fishing, you know, we, Lampy, we're probably about 20 miles north, we can go 20 miles north and a couple miles inland. And it takes about an hour, an hour and a half to get to the logging dock. So they're gonna test you, the water conservation officer's gonna test you on a boat. They're gonna come in, they're gonna board you and they're gonna assess you. If you get too far out, the Coast Guard does that, or sometimes the border patrol, I haven't seen them yet. But these are the two ones. So the field assessments are done in a seated position. You cannot do what they do on land base, which we're gonna discuss further on. And the various impairment testing and scoring that they use are these four tests, the horizontal gaze nystagmus, finger to nose, palm pad, hand coordination. Now, the horizontal gaze nystagmus is present on both the land base and the water base, very important test. Now, if you take, bring them to land like we did in western Pennsylvania with the rivers, they have to leave them and stand for 15 minutes before they test them. And then they can go ahead and do a field sobriety test using themselves or if they use a DRE. Now, there's no government, the federal government has not standardized these, but each state has their own testing system. And I use this because for people that have physical disabilities, difficult to do impairment, you can utilize these tests as a form of testing for impairment. You don't need it, they don't have to have trouble walking, they have a pre-existing condition, this may be a valuable alternative. These are, this is where the bulk, this is where the program we're gonna be talking about later. These are the field assessment for impaired driving, land-based, standardized, and non-standardized. These have been determined by the government and they're used across every state in the country. And we'll be talking about them a little later. A couple of things is, if you look at the literature, this is used across all countries around the, I've seen in Europe, Australia, New Zealand, Hong Kong is using them, Japan, Korea, South America, these tests are used worldwide. And I've actually seen a couple of places across the country where they're incorporating to the examinations or training curriculum for medical students. So these are classified, I'm not an expert, as psychophysical divided attention testing. So this is a definition, but what my understanding is, you have to get mental instructions and then you have to incorporate the mental instruction to do a physical task and then you grade them on a scale. They say it's relatively easy for non-impaired people to complete. If you ask an older person, they may have difficulty. There is literature to show that people with traumatic brain injuries and so on, and some physiological factors, fatigue, tiredness and so on, have difficulty performing these tasks. So if you have somebody that's already pre-existing, having problems and trying to get them, they're gonna have a problem, but then again, why would they be using something that's potentially impairing them, such as marijuana, you know, we recommend that you use alcohol and so on. So these are the references that utilize to develop the testing if you wanna go on. These are published by the federal government and are available on the website. Last one we talked about, what we're gonna talk about later is the training program. Okay. David, you're the next one. I'd like to speak to Dr. David Andrujek from padui.org. He's in training program, in charge of training program for the DREs for the state police in Pennsylvania. Okay. Place or whether it's for an assessment or an evaluation, they look the same. Some of the things we'll talk about, and again, this is gonna be pretty quick, but I do wanna cover some of the things that we train police officers. And this is kind of coming back around. You know, in the 70s, police officers reached out to the medical community and said, how does someone look when they're under the influence of PCP or how does someone look when they're under the influence of LSD? And these are the things that were discussed and put into the training program for police officers to determine when someone's under the influence or impaired or more importantly, incapable of safe driving. And we're coming back in circle to, you know, being able to train, now we're training school nurses in a school setting to do assessments on students that are in school, that are under the influence of different substances. And now we're working with doing other things with human resources and the medical community as far as what we've been doing for 40 or 50 years now with drug impairment, trying to get on the same page. And that's the hardest part is, you know, determining whether someone is under the influence or impaired, because all of the, everything is written to the impairment standard, but there's no like, this is impaired. There's nothing out there, you know, and they talk about, Dr. McVeigh talked about the medical marijuana act and the 10 nanograms, you know, we are used to, with alcohol, we're used to a number, right? And we know that the driving under the influence of alcohol, if your blood alcohol concentration is 0.08 or above, you're incapable of safe driving, we know that. There's a lot of studies, there's a lot of information on alcohol, we got this. But all of the other drugs, all of the other substances that are impairing, we don't have that education. We don't have that ability to say at this number or this level, someone's incapable of safely operating a vehicle or that they're impaired. There's no number, there's no magic eight ball. When you get a prescription and it says, use caution when taking this medication, how do you know what happens? You know, if you're driving, you know, you hit a tree, oh, I guess I shouldn't have been driving. There's no eight ball, there's no button to press. You know, there's, I feel a little bit different, but I think I'm okay. If you think about it, the first thing that happens is your judgment is affected from those medications that cause impairment, right? So your judgment is affected and you're, the first thing you say is, I'll be fine, right? And sometimes it just ends up tragically. So we're gonna talk a little bit about the definition of the drug and Dr. McVeigh had talked a little bit about how that's defined in certain statutes. We'll talk about how the standardized field sobriety test enable us or enable police officers to assess impaired drivers. We'll talk about the list of standardized field sobriety tests. Dr. McVeigh touched on, you know, the ability to divide our attention and that's how we show impairment. You know when you drive a vehicle it causes you to do multiple things at once. We talk about field sobriety tests. We want to see if a person can listen to instructions and be able to hold a position or follow those instructions. So we'll talk about those. We'll talk about some of the studies that were used that validated the standardized field sobriety test. We'll talk about the battery and we'll talk about most importantly the drug evaluation and classification program. Police officers that are trained to assess subjects under the influence of drugs and determine if that person is impaired or incapable of safe driving or more importantly that impairment standard. Whether that's in the workplace in the health place or anything similar. We'll talk a little bit about the seven drug categories and again this is going to be pretty quick but a drug is going to fall into one of the DREs drug categories based on how it affects a person. So it's not maybe not the same as some of the medical literature medical definitions of a drug but we'll talk about seven different categories. We're going to talk a little bit about what the police officers DRE role is when they evaluate subjects that are believed to be under the influence of a drug and the different tools that a DRE uses that you can apply to occupational health care to help determine impairment. Again that's the definition is incapable of safe driving or impaired and it's really difficult. There's a real fine line we talk about whether a subject is impaired and you know probably the even the part that's even more difficult is it doesn't last very long depending on the substance. You know within an hour the signs and symptoms of that impairment could be gone and that person could be back to a normal baseline where they're not impaired anymore. So you know that's it's constantly changing as well. So the definition of a drug is you know really the any substance or food that changes the structure functions of the bind or the body. As far as our our definition for police officers is it's any substance that when taken in the human body can impair a person's ability to operate a vehicle safely and you know that's the the main part is if someone's under the influence of that substance. We actually have case law court the courts have found that bug and tar remover is a drug. You know if you drink bug and tar remover it can impair your ability to operate a vehicle safely. So you know it's not just a traditional drug we have people that use or get high from inhalants. Sniffing glue you know paint you know those are still considered a drug when we we think about law enforcement we think about driving. You know it's kind of easy when someone's nose is glued shut that you know we know what they've been doing or there's a big you know gold circle around the around their nose and mouth and in police work we call that a clue. So but that's the definition of a drug and we're talking about those different substances that are going to impair somebody. A combined workplace definition so we take those definitions of the medical community in the law enforcement community and we come up with a definition of a substance that when taken in the human body can impair the person or the ability of that person to function their job function safely and effectively. And that's probably you know we use it for the nurses in the schools as far as being a disruption in the class or to be a disruption in school. In the workplace again it's it's someone that's able to perform their their job function safely. And again there are there are substances out there that people use every day whether those are recreational drugs whether those are controlled substances prescription drugs over-the-counter medications to get through the day whether that's for them to sleep whether that's for them to stay awake whether that's for them to come to work or to to deal with the problems at work. There are so many different substances out there that people are using every day in the workplace and again it's how to determine if that person's under the influence or more importantly if they're impaired or are able to perform their job functions. As far as law enforcement goes you know we noticed there was a problem with people crashing and dying on our highways. You know in the in the 1970s driving under the influence wasn't a crime. You know you had some beers if you were too drunk the police officer would stop you throw your keys if you were find them you weren't you weren't that drunk and you can drive home. There was really no people nobody was arrested for driving under the influence there was no outcry and you think about cars were made a little bit different too in the 1970s they they withstood a little bit more than they do today so the lives that the people that were crashing may not have been injured as much but we started to see all of these deaths that were preventable on our highways. Victims you know in the late 1970s early 1980s Mothers Against Drunk Driving started and you know there was this this outcry of people are dying for no you know because someone's driving under the influence of an alcohol or a drug so you know that was a problem then and there was really no test that police officers had. Some officers would throw change or coins on the ground some would you know you know hold up fingers or do different tests but there was really no no test and you know in the 1970s the National Highway Traffic Safety Administration got involved and they wanted to evaluate the test that police officers were using on the street to determine if someone was impaired and then they had to standardize those tests and they developed a standardized field sobriety test battery and you know the Southern California Research Institute was really involved with the National Highway Traffic Safety Administration to come up with these reliable tests and they looked at you know the the six most commonly used tests among police officers and those were the HGN or horizontal gaze nystagmus or tracing a paper finger to nose test a walk and turn test one leg stand and a finger count and those tests were evaluated at what were the most effective and then they found that the the three tests that are still being used today almost 50 years later is a the HGN horizontal gaze nystagmus to walk and turn and the one leg stand these are the three tests that police officers use on the side of the road to determine if someone's impaired or not and they'll go from there so original study results you know there are six clues in horizontal gaze nystagmus there's three in each eye and if a subject exhibits four of those clues there was a 77% chance that they had a BAC of a point 0.10 or greater so when this was done the first BAC laws across the country were 0.10 walk and turn there's a actually eight different clues that show if someone's impaired and if they exhibit exhibit two or more there was a 68% chance a one leg stand where there's four clues if they exhibit two or more there was a 65% chance and a lot of defense attorneys they they hung their hat on this number like well if you got a 65% on an exam in school would you be happy with that you know it really wasn't really great numbers but it was the best we had it was the best that we had to determine impairment and it was you know if all three tests were used it was the best way that we had to assess that impairment 1981 they did a lab and field study and then they actually did a Maryland shock trauma study then after that and they've realized that standardization if it's done the same way each and every time that was the key to to it being as accurate as it could be standardized elements the procedures what what the officer tells the subject has to be the same the clues again there were six clues for the HGN and eight clues for the walk and turn and four clues for the one leg stand the criteria so if someone raises their arms what's the criteria is it four inches six inches eight inches so the criteria had to be defined as far as that particular clue the HGN horizontal gaze nystagmus is probably the the most effective test that all enforcement or police officers have for determining impairment and it is looking for an involuntary jerking of the eye and it's really caused by the effect of the central nervous system there's about 40 different types of nystagmus but we're looking for a specific neural nystagmus that's caused by the central nervous system being slowed or affected the lack of smooth pursuit is you know when the eyes go to the side if they if they go nice and smooth that's good if they exhibit the clue it's a lack of smooth pursuit so they're they're kind of jerking as they move to the side a distinct and sustained nystagmus at maximum deviation so the eyes go whoops the eyes go all the way out as far as it'll go we look for that distinct and sustained nystagmus at maximum deviation and the last clue there is an onset of nystagmus prior to 45 degrees so if it if the nystagmus starts prior to 45 degrees so for 15 inches from the face before 15 inches to the side that's a clue as well and and these clues are they're progressive in nature depending on the level of impairment so if you think about it if you're thinking about beers if you have like two beers you may show that first clue of a lack of smooth pursuit when you have you have about six or eight beers you then progress and you show the lack of smooth pursuit and the distinct sustained nystagmus of maximum deviation and you have a BAC at that point about about a 0.08 and then when you get to about a 0.10 0.12 you actually then exhibit the onset in nystagmus prior to 45 degrees and the higher the the concentration the earlier that angle of onset starts so it's kind of interesting is that it's progressive and and it's not just alcohol that causes it so all of our depressant drugs are inhaling drugs and our dissociative anesthetic drugs cause horizontal gaze astagmus and we'll get to that in a little bit the walk and turn is a divided attention test where the it requires a person to perform both a mental and a physical task there's two stages the instructional stage in the walking stage and this is the one you see on like cops or whatever TV show you know they had they're they're told to walk nine steps heel to toe down the line they turn in a specific manner and they turn nine steps right back and there's eight clues to that test the eight clues for the walk and turn are they can't keep balance during the instruction stage and they take they start too soon and again they're put in that heel-to-toe position to divide their attention so they have to hold the heel-to-toe position and listen to the instructions without starting once they start if they take an incorrect number of steps less or more than nine or they missed their heel-to-toe by more than an inch if they turn improperly not as instructed that's a clue if they stop walking at any time it's a clue they step off the line or they uses their arm for balance and those are the eight clues and again member two is our decision point for the walk and turn and again this is just showing impairment like I said there's some other factors dr. McVeigh talked about age weight you know physical abilities so there are some other issues when we we think about these physical tests the one leg stand is another divided attention test where the person stands on one foot for 30 seconds and again you may have seen this on on TV there's two stages an instructional stage where the person stands there with their arms together and listens to the instructions and then they have the balance and counting stage where they stand with their foot six inches off the ground they look at their tail and they count and it's prescribed fashion 1001 1002 1003 and so forth then there's four clues for that test whether they put their foot down they use their arms for balance they sway or they hop those are the four clues for the one leg stand and again if they exhibit two of those clues that's an indication that the person may be impaired again it's not a perfect score sheet and when we think about it's not a pass or fail test you know if someone exhibits clues of impairment they exhibited clues of impairment that doesn't mean they're they're drunk or under the influence it just means that they exhibited it and and it's really a totality of everything that the officer sees not just those tests you know people get nervous right in the 1990s the federal government looked to change the federal threshold for the blood alcohol concentration from 0.10 to 0.08 and police officers have been using this three test battery for 20 years at that point but again they had testified and and had for years said that a person is impaired at a 0.10 so they went back and did additional studies to make sure that these physical agility tests identified impairment at a 0.08 blood alcohol concentration I'm just as well as they did at a 0.10 so then 1995 in Colorado and 97 in Florida 98 in California again looked at the sensitivity of the three tests the field sobriety battery and did did result in the fact that yes they still work at a 0.08 someone is impaired at a 0.08 that was why the the federal threshold for the BAC level was reduced from 0.10 to 0.08 okay so we're good at alcohol and and I'm sure all of you are pretty good at alcohol you you have an uncle Bob or an uncle Tom that you know came to parties family parties and had too many frosty adult beverages and exhibited clues of impairment you know the voice goes up the the word or language has changed we're pretty good with with alcohol we know when someone is impaired by alcohol we've seen it we've experienced it probably ourself at one time where we had too many frosty adult beverages so we're pretty pretty well versed with alcohol drugs drugs a little bit different so at the same time that the SFS teaser that battery was being developed in California we noticed that people were driving under the influence of PCP and LSD at that time in the 70s were very popular drugs marijuana obviously has always been popular and the initial response back then was you know there's nothing we could do we let the person go and you'd see there on that slide there there were dick started was a road of motors motorcycle police officer with LAPD I mean he'd gone to a crash in in Los Angeles and here it was his best friend and his best friend was killed in this crash and he had had dinner with him and his wife the night before and he responded this crash and his friends dead and the driver of the other vehicle he knows is under the influence he looks acts walks talk like a drunk but no alcohol no alcohol whatsoever and it was that point where where dick stuttered he he made it a you know a job of his to go and get the research to get the medical community on board to find out how we can look for impairment when it's not alcohol but we know it's impairment and it was it was a benzodiazepine at the time and again it's just a rough story but kind of where the program the the drug evaluation and classification program started in the mid-1970s so the SFS T's were originally developed for alcohol but we did do another study to make sure that yes someone that's under the influence of heroin or or methamphetamine or cocaine still exhibit those signs of impairment that we can identify impairment with those specific tests that we used the drug evaluation classification program again started in the in the mid-1970s and LA LA may have had a little bit of a drug problem but again this was new to the law enforcement community so you know whether it was toxicologist whether it was ER doctors whether it was PCP primary care physicians they were all asked what do you see when someone's under the influence and all of the different drugs and when they first started this training it was extremely long it took like six months for police officers to be trained or certified as drug recognition experts this really started you know back in the 70s and it's been changed and and overhauled and right now our training is is about a month it takes about a month for us to train a police officer to determine if someone's under the influence of drugs we'll talk about that in a little bit the DCP or the drug evaluation classification program created seven different drug categories they created the DREs or the drug recognition experts they created a 12-step process to go through each and every time as standardized and systematic checklist of things to check when looking for someone under the influence they use it yet they you utilize it through throughout the world and again there's a big DRE program in Canada big program here in in the country Pennsylvania we were the 39th state in the country to have a program we came aboard of the DRE program in 2004 so this is a copy of the drug matrix that that all DREs look for it's kind of like the Bible for the DREs so looking at the different seven different drug categories and different things that the DRE looks for in an evaluation whether that's the nystagmus whether that's a lack of convergence of the eyes are able to converge whether it's pupil sizes whether they're dilated or constricted reaction to light you know our pupils normally react to light in about a second and some of those drugs are going to slow down the reaction to light you look pulse and blood pressure every single drug that causes impairment affects a person's pulse and blood pressure so vital signs are very important when it comes to evaluating a subject that that's believed to be under the influence or impaired and again this is active impairment so you know if it's someone that smoked a you know a marijuana cigarette or joint three hours ago or their pulse going to be up as a body pressure or blood pressure going to be up probably not so those those vital signs body temperatures affected by some drugs and muscle tones affected by some drugs some drugs are going to you know most of the drugs that cause impairment affect the central nervous system and in certain ways you know obviously some drugs are going to mimic the sympathetic nerves they're going to be sympathomimetic and some drugs are going to mimic the the parasympathetic nerves are going to slow things down they're going to be parasympathomimetic but we use that matrix quite often when determining impairment and figuring out what particular drug category a person's under the influence of so the seven categories I'll be pretty quick the central nervous system depressants drugs that slow down the responses of the central nervous system probably our biggest drug category when it comes to what we see on the streets as far as impairment alcohol is a central nervous system depressant and there's probably about 600 different prescription central nervous system depressants so whether those are anti-anxiety or antidepressant tranquilizers whether sleeping pills or or benzodiazepines barbiturates all of those drugs fall into that same category and they affect the person just like alcohol so again that's probably a big drug category for us as police officers on the road and look dealing with impairment central nervous system stimulants as far as recreational drugs cocaine is probably still one of the most common or most popular drug that's used on the streets so we see crack cocaine or cocaine methamphetamine quite often in subjects that are that are using to recreationally get high so those drugs that are going to speed up the central nervous system I'll fall into that category drugs that cause hallucinations we don't see this too much with driving you know if you if you're driving down the road and you look at a stop sign do you see a dragon it's not good not good at all right you know we we we tend to see people that are under the influence of LSD and pretty much any other drug that has like three or four letters because they're chemical designations we find them like in in in the woods and tents and in their basements but usually not driving for the most part they know not to drive using those substances dissociative anesthetics drugs that dissociate the mind from the body on drugs like PCP most common dissociative anesthetics but those drugs again very popular with the drug culture the narcotic analgesics the opiates the opioids probably our second or third most common we see with driving whether it's heroin and we're not even seeing much heroin anymore, more the fentanyl now and then obviously other drugs that are that are laced into the fentanyl. But narcotic analgesics is our fifth category. On the inhalants, so our paint, you know, our paint thinner, our model airplane glue, you know, the dust off cans. You know, we stop cars and their whole back seat is filled with dust off cans that they take and they inhale it, they pitch the can in the back seat and the back seat gets full of cans of dust off. Crazy stuff. But the inhalants, you know, do cause impairment. You think about gasoline. Gasoline, for the most part, as far as an impairing substance, it's cheap, right? For three hundred or three dollars and seventy cents you get a gallon. You have that gallon of gas, you put it in a rag and you sniff that rag all day and you can maintain a drunk high pretty much all day from that gasoline that costs you three dollars and seventy cents for that gallon. So interesting stuff on the inhalants. And then the cannabis or cannabinoids. You know, Dr. McVeigh had talked about the medical marijuana. I don't know, as police officers, we're used to people that smoke a lot of weed. They're easy to pick out. If you look at anybody's car that's smacked up on all four sides, they get high a lot. And you know what? They don't care, right? They just keep driving it. You know, they got their bumpers are all smashed in. They just keep driving it. But yeah, I mean, if you talk to, you know, I've been talking to a lot of medical marijuana patients trying to get a little bit in into their head to find it. You know, they're using medical marijuana for the most part to help. So there's, you have the people that have a medical marijuana that use the medical marijuana to sleep or to help with anxiety or to help with pain. You know, you have that group and then you have another group that has a medical marijuana ticket card to get high, right? And even the people that use it for the medical purposes, you can ask them and they'll say it's still a fine line before they start feeling high, right? If whether it's a tincture, whether it's something they're putting under their tongue, whether it's, you know, something they're vaping, it's a fine line before they feel like they're high, right? And many of them that use it for the medical benefits, they don't want to get high, right? They want to take care of the medical issue. So, but the cannabis is definitely a problem when it comes to impairment. And again, the general acceptance as far as recreational, medical, people get high, we're used to it, people drink, right? You know, you can die. If I drink a bottle of Jack Daniels, it can kill me, right? The alcohol concentration in my body can get to a level where I stop breathing and I die. I can go out and smoke a field of weed and I'm not gonna die, right? And that's, I mean, that's the defense, right? Why is this legal and this one isn't? And I can understand that, but it does cause impairment. So, whether or not we, you know, admit to the fact that there are some uses for cannabis, the big news is it does impair somebody. And again, if you think about even some of our movies where, you know, we joke about, dude, where's my car, right? But it's true, it does cause impairment. So, you know, it's out there and we need to determine when someone is, they use Saturday or Sunday and right now they're not impaired, they're not affected by that drug and we need to figure out when they smoke the joint on the way in and they're high. And they're a problem or a disruption to the workplace or the environment. So, and again, that is such a, that's our issue. That's our issue on the highway as well. You know, we have very limited amount of officers or troopers that are trained as DREs. Very, you know, we only have 400 and, you know, or actually 250 right now trained in Pennsylvania. That's nothing compared to how many police officers are out there. But the Drug Recognition Expert Program is a three-step process where we make sure it's not alcohol. So, we have to verify that they don't have a blood alcohol concentration and their level of impairment is not equal to that BAC. We need to make sure it's not a medical condition. You know, we actually deal with people that have, you know, whether it's a specific medical condition that can mimic signs of impairment. Whether that's pink eye. You know, if you have pink eye or an infection in both eyes, it looks like you smoked a big fatty, right? It really does. So, you know, that can be confused or mistaken. You know, there are other medical conditions that, you know, diabetics, if someone's having a diabetic episode, they can look, act, walk, talk like someone already influenced alcohol, right? It can even have that, that odor, that sweet odor on their breath. So, you know, we need to make sure it's not a medical condition that a person is experiencing that it is actually a drug or an impairment from a drug. And then we need to use those diagnostic procedures, that 12-step process, determine what one of those seven categories or more that that's likely causing the impairment. So, you know, that's what the job of the trained officer is, a 12-step systematic process. They're able to make a conclusion based on all of the information they develop in those 12 steps. And it's really based on not just impairment tests like the field sobriety test, but their overall appearance, their behavior, how they do on those tests, their eyes, their pupil sizes. We actually check their pupil sizes in three different lighting conditions, room light, near total darkness, and direct light. We look for the reaction to light, right? The vital signs. Remember, the vital signs are affected in all seven of those impairing drug categories. So, pulse and blood pressure and any other evidence that we have as far as the evaluation. So, the 12 steps to limit them or list them are, you know, we start with that breath alcohol test to make sure, again, it's not alcohol causing it. We talk to the people or the arresting officer or those that dealt with the individual to find out what they observed, you know, how the person spoke, how they talked, how they walked, how they acted. Those kind of things is what the DRE looks for. A preliminary exam, again, to make sure it's not a medical issue. So, you're looking at that first pulse, I'm looking at their pupils, looking at their eyes, you know, make sure it's not a head injury, make sure it's not some type of stroke. So, you know, those are issues that the DRE goes through in a preliminary exam. Then we look at the examination of the eyes. So, horizontal gaze nystagmus, we talked about that, vertical gaze nystagmus, and lack of convergence. So, looking at those eyes and how they look during that evaluation. Now, the divided attention test then come next. Again, looking for impairment, not just the test that the officer does on the street, but adding a modified Romberg balance where they, you know, see how they can estimate time and how their ability to close their eyes with their head back. So, that's looking again for euphoria or impairments or those kind of things. So, they do those divided attention tests. Then they look at the pulse blood pressure and body temperature through the vital signs. Then they look at the dark rooms. They look at pupil size and room light. Then they evaluate the pupil size and near total darkness, as dark as we can, that we can see the pupil. And then that direct light and the reaction to light at that point. And then we also look down, you know, when the room is dark, we can take that flashlight and kind of look around on their person themselves. We can look in their mouth and their nose for signs of ingestion, whether they had, you know, smoked something or snorted something or spilled something. You know, usually when someone's getting high there, they're not real neat about it. So, a lot of times there's still some things on them. Again, I talked about the clue before. You know, if someone snorts cocaine and we look in their nose and the cocaine is still in there, call that a clue again. It's pretty easy. So, that dark room examination and the ingestion sites, we look for the muscle tone and drugs are going to cause the muscles to be either real rigid or flaccid. So, we'll look for the muscle tone. Look for injection sites. And then we take the pulse again. So, we actually take the pulse three times during that 12-step process. Then we talk to them about what we observe. Usually, you know, when you have a discussion with somebody and you ask them if they're using a substance or an impairing substance, they're like, nope, nope, nope. Or they'll tell you, yes, I smoke weed, but it was three days ago. That way that covers if it comes back in urine or whatever. But when you have that discussion and it's pretty obvious because your pupils are this and your pulse is this and your blood pressure is that and, you know, it's still in your mouth and you've got seeds in your mouth or whatever. You have that discussion. Most of the time, you're like, wow, that really works. Yeah. And they'll tell you. Most of the time, especially with the opioids, the opiates, those, when they know that you know, they'll tell you everything. Like how they got hooked, how much they use a day, how much they spend, what they stole to get what they needed to get, you know, their whole life story. They'll tell you it all once they know you know. So, it's kind of interesting to get to that step. And then after all of that, I'll come into the opinion and not just have the opinion, but then have that confirmed by toxicology. So, that's the 12 steps that a DRE does. And again, that's something we're working with to try to share because, again, we got this from the medical community as far as a partnership almost 50 years ago. And now, you know, when we're seeing so much of it in our workplace and issues there, there are things now that we can share that we've seen just with evaluating subjects that we're driving all the time. We talked about those one, the divided attention tests, the validation. So, we had studies and field studies, again, to determine whether this works or not. So, you know, 1984, 1986 were those last couple studies and that's in your records if you'd want to refer to any of those. You know, the results really said this works. The New Jersey Supreme Court is really dealing with a case now where the judge had weighed all of the evidence of the DREs in the case and it really said this, you know, this is really close to a medical procedure or medical evaluation. And the officers that are trained for a month of just drug impairment have enough experience, knowledge, and expertise to determine if someone's under the influence of a drug. So, you know, in the studies, you know, the numbers were much better. When we spend 40, 45 minutes with a subject, it's much better than those initial studies on the side of the road, you know, with wind and rain and, you know, uneven subsurfaces. You know, when we spend 30 to 45 minutes in a controlled environment with a subject and going through a, you know, a standardized and systematic process, it's a little bit easier to determine when someone's under the influence or impaired or not. So, the studies had shown that we're about 91%. We do our tests here, our certification part of our training in Philadelphia, and we use subjects that we believe are under the influence of a drug. We ask them to help us with our training off the street, and we gather oral fluid samples, and right now we're at about 95% confirmation with our students. So, our students had just learned that 12-step process, and they're able to use that process and come to an opinion, and it's confirmed by toxicology just about every time. So, interesting stuff as far as the drug recognition expert program, the information, the 12-step process, and now we're moving again to share back. So, you know, trying to give those certain skills to the medical community, to the school nurses, to the HR departments of companies that need to determine what is impairment. You know, what does this employee, you know, what do they have to exhibit to show impairment? And again, it's so difficult. You think about it, you know, sometimes marijuana, you figure marijuana, for the most part, the impairment, although it can last up to 24 hours, is usually within about three hours. So, you know, as you determine or you think someone or suspect someone is under the influence, by the time you get that person assessed and decide, you know, if they are or not, the time's ticking, right? So, if it's an hour later, a half hour, 45 minutes, an hour and a half, they may be sober by that point, right? And again, and now, you know, it's a very difficult time. So, it is, it's not easy. It's not easy for us as police officers to determine when someone's under the influence while they're driving, and it's definitely even more difficult to determine if someone's impaired in a workplace, mainly because of that time constraints and the particular individual themselves. Employers, so we do have that drug information training for DITEP, drug impairment for educational professionals, and again, well, that's something we've been presenting for about 10 years to school nurses. It's probably one of my favorite classes to teach. It's two days, but when you talk about all of the signs and symptoms that someone exhibits under certain drugs, especially some of the older nurses, you can just see them, they're just shaking their head. It's just, it's just really, really neat that they've seen it. They see it every day in the schools with students under the influence or using particular drugs, and again, it's a really simplified informational program for signs and symptoms of the seven drug categories and then how that equates to do an assessment in a school to determine if someone's under the influence. And again, this is something that we can adapt for employers, so we've been talking about the ability to share that information or put that together as far as whether that's going to be online training or a combination both of online training and in-person training. Be able to do that assessment and not only be able to talk about the information or the material, but see it. That's probably the most important thing for the police officers is to be able to see it, not just hear the information, not just hear, you know, the bruxism or the body tremors, but to see those body tremors, to see that person under the influence of crack cocaine or methamphetamine, the itchiness, the scratching, you know, all of those different indicators, so very important to see it. This is our building in Harrisburg, and again, we pretty much deal with anything impaired driving related. I was the first DRE in Pennsylvania in 2004. I was a trooper from 1992 to 2015. I've been retired eight years from the state police now, and I still do this. I still teach police officers to determine drug impairment. We have another class of DREs that start next week. I'm looking forward to getting 18 new police officers and grabbing them for a month and ending here in Philadelphia on Kensington Avenue with doing the assessments, doing the actual evaluations on subjects under the influence of alcohol. So that's our building. That's where we are. That's what we deal with. We talk about applying the techniques. Obviously, in an occupational or medicine area, you wouldn't be doing nine steps walk and turn, you know, wouldn't stand on one leg, right, but definitely the pupil sizes, definitely the modified Romberg balance, you know, that's done in the medical community now. You know, how the pupils react to light, all the general indicators of all of those seven different drug categories. When someone's under the influence or even when they exhibit signs of the downside, of the opposite effects of, you know, the drug wearing off or the body fighting against that drug to change the actual symptoms. So, you know, developing those, the needs for the medical community as well as the employers. Really important, again, that we talked about the definition, the validated clues, the terminology that the police officers use is mentioned in there. RSFSTs, we talk about the divided attention and, again, the latest studies showed HCN about 88% accurate, our most reliable test. You can't control it. It's not affected by tolerance in any way. You know, it is the fact that the central nervous system is slowed by the drug and it causes that delay. It just causes the delay of the eye movement or following equally. So, the walk and turn and one leg stand a little bit less and you can look at those on YouTube. You can find them and, again, pretty much any police show you can find them. We actually started training police officers in advanced roadside impaired driving and this is to try to train all police officers to look for those certain indicators. You know, whether it's the big pupils. You know, when you shine a light in someone's eyes, their pupils should get small, right? If the officer comes up to the car and they shine the light in, the pupils should constrict. If they stay really, really big, something's not right. And, really, that training is about teaching officers when something is not right. Whether that person is speaking really fast or sweating or their speech is slurred or their pupils are constricted or dilated. It really is to identify those signs of drug impairment and then take those signs and be able to call an officer, call a DRE to get more information on whether or not the person is under the influence. So, kind of interesting stuff. We talked about the matrix there and how it, how the drug categories fit into there and how the person exhibits certain clues. So, you know, those are things, again, that we can replicate for health care and in employment areas. So, and these were the general indicators. So, this is kind of on the on the other side of the card that we use, those general indicators. And there's actually 240 general indicators of the different seven categories. And some of them are similar, but some of them are definitely different among the different categories. So, being able to see it, usually when someone's under the influence of a drug, it's not just one thing. You know, we always say if a person has a high blood pressure, does that mean they use cocaine? No, that means they have high blood pressure, right? But if their pupils are really big and their internal clock is really sped up and they're excited, you know, people should not be excited to see the police. You know, hey trooper, nice to see you. Thanks, thanks for stopping me. It's a beautiful day today. Hmm, that's not right. Something's wrong, right? It's pretty easy, but, you know, that talkative, exaggerated reflexes, you know, it could go right down the column and all of a sudden there's six, seven, eight, nine different things on top of the pulse and the blood pressure that points that finger to that column. So, again, it's not just one thing. It's a totality of everything. So, that's kind of that matrix that the DREs and even the officers trained in A-Ride follow. That's kind of all I have. And, again, talking about the ability to combine these programs, what we look for for impairment on the street and what the employers and healthcare looks for as far as someone under the influence and bringing us together at some point to share our knowledge, to share our information, and then to be able to work together to determine if someone's under the influence or not. Dr. McVeigh? I'd like to thank everyone for staying put for this one. The last time we did this, everybody left halfway. It was at the end of two days. Do we have any time for questions? No questions? Okay. Make sure you do the evaluations and have a good day, everyone. Pardon?

drug impairment

workplace

Dr. David Andrujack

medical marijuana

12-step DRE process

law enforcement

vital signs

divided attention tests

SFSTs

training