Welcome to AOHC 2023, session number 209, Substance Abuse, Substance Use Disorders in Occupational Medicine. My name is Sajjad Sawal, everybody calls me Saj. I'm the moderator for this session. A little bit about me, my background is in family medicine, occupational medicine, and addiction medicine. I'm a fellow of the American College of Occupational and Environmental Medicine, and also of the American Society of Addiction Medicine. It's my pleasure to introduce our speakers, Dr. Ann Lee. As she says, she had a circuitous career in medicine. After an internal medicine internship at UCSF, she worked in medical legal consulting for about eight years in the San Francisco Bay Area. She says she was doing quite well, but then she had a, and she actually didn't even think of going back into medicine, but then she had a personal experience with a debilitating work injury, and ended up having like severe pain, nerve pain. Fortunately, she recovered completely, but not without discovering a renewed passion for clinical medicine. She had been on the other side of the table as a patient for that period of time, and then she wanted to come back and be that physician helping patients. She then began working as a clinician for a primary care and addiction medicine clinic, completed a preventive medicine residency up at the University of Michigan, and is board certified in preventive medicine and public health. When she had residency training in occupational medicine at the University of Pennsylvania, she brings extensive and diverse breadth of experience to her clinical practice in occupational medicine, for which she's about to be board eligible, and currently working as a staff physician at Frederick Health Employer Solutions in Maryland. Our next speaker, actually, they'll be doing a team presentation, Dr. Justin Yang, is a Harvard-trained physician and triple board certified in internal medicine, occupational medicine, and addiction medicine, so you have come to the right talk. He is an, he is the assistant program director for the occupational and environmental medicine residency program at Harvard T.H. Chan School of Public Health, and an assistant professor of medicine at Boston University School of Medicine. He is also the medical director for Quit Genius, which he tells me is the world's first technology enabled joint commission accredited digital clinic for substance use disorder treatments. Earlier in Dr. Yang's career, he was the medical director of an award-winning medication-assisted treatment program at a health center in Boston, leading clinicians across, like, seven clinics in helping patients recover from their substance use disorder. So without further ado, I will request Dr. Han Lee and Dr. Yang to give us their wonderful presentation. Dr. Yang. Thank you. Good morning, everyone. So just a little bit of financial disclosures before we start. So I serve as the medical director of Quit Genius. It's the world's first technology enabled joint commission accredited digital clinic for substance use disorder treatments. We are not going to go into the details of the clinic and whatnot. I do not own the program. I wish I was that innovative, but I'm just an employee. And as you can see, our affiliation's here. And I'm going to go to the next slide. This is going to be a very interactive session, so it's going to be fun. We're not going to ask you to sit here and just daydream. And so please join us with the QR code, or you can go on to slido.com and type in the session. And there is a Q&A part that is an anonymous Q&A. You can type in your questions at any point throughout the session, and then we'll have a Q&A session at the end. And I'll let Anne talk about the objectives today. »» Good morning. So the objectives of this talk are to review the basics of substance use disorders, which is hopefully a review for most of us. We're going to go over the current definitions and discuss some updates, and go over the 11 criteria for diagnosis of a substance use disorder, and review some important terminology and try to use non-stigmatizing terminology. And we're just going to briefly touch on three of the substance use disorders, specifically opiate use disorder, alcohol use disorder, and cannabis use disorder. And hopefully this will help us to improve our skills in surveillance and occupational medicine, so that we can consider using and integrating SBIRT and harm reduction approaches to our daily practice. So the DSM-5 criteria for substance use disorder, there are 11. And you can think of them in four basic groupings. The first grouping is for impaired control, which is excessive use and successful attempts to cut down, excessive time spent obtaining, using, and recovering. They kind of plan their day and their life around using the substance, and craving. The second grouping would be social impairment, and that's when their use starts to interfere with their work or major obligations, and they use despite interpersonal trouble, and their use is interfering with their activities. The third grouping is risky use, characterized by hazardous use, like their drinking and driving, and their use is contributing to medical problems or medical diagnoses and psychological issues. And then the last grouping of the criteria would be the pharmacologic criteria, when they develop signs of tolerance and withdrawal. I briefly want to discuss some of the terminology that has changed since DSM-4 went to DSM-5, because we still hear some of the terminology left over from DSM-4. We may even have some of these terms in our current EHR. Abuse and dependence, we're kind of done away with. It's all substance use disorders. In DSM-4, we used to have polysubstance use disorder, and now it's all substance use disorder. And something that is quite harmful to patients is when they think that when they're using an opiate for chronic pain, because they have to continue taking it to avoid withdrawal symptoms, that they're addicted to the opiate, when they could be using the opiate under medical supervision, and that particular specific was excluded from DSM-5. And as far as the duration of substance use criteria, it's quite broad. If they meet any of the two criteria within a 12-month period, you can diagnose them with a substance use disorder. And if there are two to three criteria, it's categorized as mild, four to five criteria as moderate, and six and over, it would be characterized as severe. When we're trying to determine if a worker is eligible to go back to work, we may want to know how long they've been in remission. And early remission is when they have no longer meet all of the criteria, and they've been in remission for three months, but less than 12 months. And sustained is when they've been in remission for 12 months or longer, hopefully validated with random UDS screens. So the first quiz question is, how many people in the U.S. have a substance use disorder? So on your phones, if you could make a selection, that would be great. I think we should be to, like, 36 people, if we're going to. Okay, so I think that's good. More and more people keep answering, so. So I'm going to reveal the answer now, or these are the responses, and I think it's 46. The correct answer is 46 million people. So according to the latest survey on drug use and health, there are 46.3 million people who currently have a substance use disorder, and that is 16.5% of the U.S. population. However, in the age group of 18 to 25, the prevalence is 25.6% of the population, which is incredible. And as you can see on the right, the vast majority of the substance use disorders is alcohol use disorder, followed by drug use disorder, and then they break it down from there. And as we know, the majority of people with substance use disorders are employed. In the 18 to 25 group category, over half of those are employed, 54.4% of those are employed. And in the age 18 and up, 38.1% are employed, which is the largest group, and 27.3% are unemployed, and 14% are other types of employment, including going to school and keeping house and taking care of your retired or elderly people. So I mean, that number can seem to be quite a bit, and I think there are actually reports that says 70% of people that are suffering from a substance use disorder are currently employed in one way or another. And I think when we think about substance use, we tend to think about opiates, and we are not thinking about all the other substances that are equally important and that are equally causing a lot of issue and heartache to our employees. And especially when you think about alcohol, just because it's legal does not mean that it's not an issue and it's not a substance that can be harmful and hazardous. And I think because of the fact that there are so many employees that are actually suffering and recovering from the substance, that it is very important for us to destigmatize substance use disorder and also be a culturally competent clinician and use terms that are non-stigmatizing. First, it's very important for us to know and understand that substance use is a chronic medical condition. People don't choose to be recovering from a substance. A lot of this is genetics. 40% to 70% of one substance use disorder condition is genetics. It's not entirely environmental. So you are, say, a health physician, in particular, as you said, between employee and employer. You may be interacting with the patients, in this case, the employees, at their lowest point in their lives. They are scared that they're going to be out of a job. They're scared that they're not going to be able to bring home income. So words that you use can actually save a life. And so that is important that we actually use the right words. How many of you think addict is an okay word to use? Yes? No? Okay. So what do you think, instead of saying addict or user, what would be a more appropriate term for you to use when you talk about someone who is suffering? Any thoughts? You can just shout. Yeah. Patient. Patient? Okay. Diagnosed with substance use disorder. Yes. Patient diagnosed with substance use disorder. Okay. That's a good one. Patient suffering from substance use disorder, recovering from substance use disorder. It is a mouthful, but it doesn't mean that we can skip it and just say addict or user. Or abuser. This is a term that we use so much in occupational health. Every time I hear that word, I cringe a little bit, especially when it comes to DOT, drug testing, and all that. We use the word abuser so much. It's on so many of our PowerPoint slides. It is not right. The other thing that we use a lot, the urine is cling, the urine is dirty. What would be the right word to use it when we're talking about urine drug screens? Positive. What's that? Positive. Positive. Yes. Inconsistent is another word that you can use, but we should never be using the word cling or dirty, even talking to your colleagues, your MAs, because you never know. The patient in the next room might be able to hear you, and when using that word cling or using the word dirty, that word amplifies, and it's so much that you're essentially stigmatizing and being part of that force of stigmatizing substance use within our society. These are sort of a list of words that instead of using addicts, user, junkie, alcoholic, we hear this so much in our society, that doesn't mean that we should be using it. Heavy alcohol use, alcohol use disorder, those are kind of the terms that we should be using. Even if the employee or the patient says, I'm a former addict, that doesn't give us the right to call them an addict. Cling dirty, testing negative, positive, currently using or not currently using drugs, and inconsistent is my preferred choice of words to use. So I'm going to go into a little bit about alcohol use disorder, because it is a really big topic, as you can see that most people that are using substances, the majority of them are suffering from alcohol use disorder. So to begin with, let's talk about a standard drink definition, which is sort of the base of everything. You can actually find a, there's a really cool sort of simulator or calculator online if you're typing alcohol use, or standard drink calculator, and you can actually toggle in between the different drink choices and see the amount, and see what, you know, how many drinks there are. You'd be surprised at, you know, what, how small of an amount a standard drink is. You know, it's five ounces of table wine, equals to 12 ounces of regular beer, and just 1.5 ounces of a shot of spirit. And you know, we also have to understand that alcohol use disorder, it's actually a spectrum. It isn't something that, you know, you just say you have or you don't. It's sort of like a progression, a continuum. You start with what we call a low-risk use, and that's based on the number of drinks. There's a, by definition, a male, a maximum of four days, four drinks a day, an average of 14 drinks per week, female, an average of seven per week, and a maximum of three per day. And once you get, you know, out of this range, you go into sort of a hazardous drinking limit. And then that, in addition to, you know, introducing sort of alcohol-related harmful consequences, and then you get into that alcohol use disorder part where, based on the number of symptoms, you categorize them as mild, moderate, or severe alcohol use disorder. There's also something called binge drinking. It is, it can be something that somebody doesn't have a defined alcohol use disorder, but their drinking habit, it's, you know, four or more drinks consumed for a female in a session, or five or more for a male on an occasion. You see binge drinking a lot in college. I'm pretty sure everybody has been there, done that during college, so it's not a, it's a culture norm for us. Heavy drinking is another, you know, eight or more drinks per week, 15 or more drinks per week for men. And so, there should be, okay, so the case actually, there should have been a Slido case. But let's take a look at this case. 40-year-old male reports drinking three to four times a week, five beers a time at a bar near his work. He craves alcohol and has to leave early from work. Arrives home after drinking, fights with his wife on drinking, feels anxious when he's not drinking. He tried to stop in the past, but couldn't. So this patient has, the choices would have been hazardous drinking, binge drinking, mild alcohol use disorder, severe, moderate use, alcohol use disorder, severe alcohol use disorder. Since the Slido isn't working for this particular question, I'm just going to ask you to raise your hand. How many of you think that this person has a binge drinking disorder? What about hazardous drinking disorder or hazardous drinking? Okay, okay. What about mild alcohol use disorder? Okay. What about moderate alcohol use disorder? Okay, getting more. What about severe alcohol use disorder? Okay, good. So if you go back to the definition here, when we get to the diagnosis of substance use disorder, it is based on DSM-5, as Anne mentioned, and it's based on the amount of symptoms that you have on DSM-5. And if you look at this person, three to four times a week, five beers at a time, that is about 15 to 20 drinks a week. So that's definitely exceeding the safety limit for drinking, so that's excessive use. And then craves alcohol and has to leave early. So that would satisfy the use interfering with occupation or major obligation. So since he's not able to continue to work, he has to leave early in order to drink. He drives home after drinking, so that is hazardous use, because it's threatening public safety. And then he fights with his wife on drinking, so that is use despite interpersonal trouble. Feels anxious when not drinking. So this could be withdrawal, this could be tolerance. So 10, 11 would both satisfy. And tried to stop drinking but couldn't, so that's unsuccessful attempts to cut down. So I've underlined every sort of criteria that this person has satisfied, and if you count all of them, it's about eight. So anything more than six is severe alcohol use disorder. So this person has severe alcohol use disorder. Does that mean that this person needs to go to rehab, needs to go to a detox, needs to be hospitalized? It actually doesn't correlate like that right away. It really is a case-by-case situation to see what kind of treatment that this person has had in the past. And sometimes a lot of the management can be done as an outpatient. About 70 to 80% of substance use disorder can be managed safely at an outpatient clinic instead of going to rehab. We're not going to get into that level of care discussion, because that's going to probably take up a whole hour. So a little bit on FDA-approved medications for alcohol use disorder. So there's actually only three that is FDA-approved, with the oldest one that everybody knows is end-abuse, disulfiram. It's the oldest medication out there. It essentially makes you hate drinking by blocking the metabolism of acetaldehyde. So it creates that disulfiram reaction. It is a daily dose. The thing about disulfiram is that adherence is such a big issue, because if one wants to not get the effect of severe discomfort from drinking, they would just not take the medication. So it is only suitable for somebody who's really highly motivated to quit drinking. And also, we say that somebody with strong family support. So somebody who has a really strong family, you know, wife is there all the time and supportive and being a cheerleader, that person might be suitable for disulfiram. Naltrexone is what we use the most. It is a mu-receptor antagonist. It's originally approved for opiate use disorder. It is now also approved for alcohol use disorder. It comes in two forms. A lot of you probably have heard Vivitrol is a form, which is a monthly injection. They come into a clinic once a month, they get injected, they're all set for the rest of the month. And then you can also do a PO form, which is 50 milligrams per day. It works by decreasing the pleasurable effects of alcohol. It is actually very effective. A number you need to treat to prevent return to heavy drinking is only 12. And then if you are using the Vivitrol, the IM form, it's also associated with very significant reduction in heavy drinking days per month. Side effects is quite mild, nausea, headache, depression. And then there's a third medication called Kempersate, which acts by restoring the balance between GABA and glutamate. And the number you need to treat is also just 12. The issue with Kempersate is that some patients of mine that has complained about this before, it's what they call the horse pill. It is extremely big. And in addition to that, you have to take two tablets three times a day in order for it to work. So think about it, it's six a day. It's like taking vitamins every meal. So that's a little bit too much. But if one is able to be on it consistently, I've seen success in using Kempersate as a treatment as well. It is safe in people with liver disease. So people with cirrhosis, we typically put them on Kempersate. It is contraindicated for chronic clearance less than 30. So in this talk, we're going to talk more about treatment and just like really basic substance use disorder topics. I have another session on Wednesday morning, it's sort of a self-promotion right now, that talks about the impacts of substance use on organizations and their employees. And we'll also go into ADA as well in that session. And there are also discussions on new trends in substance use disorder care. So feel free to join me on Wednesday morning, the same time, 9.45 for that session. So treatment for alcohol use disorder, detox, withdrawal, residential or outpatient. Some patient can be managed safely as an outpatient. So we have this concept that everybody needs to go to rehab. Drop everything, go to your rehab for 30 days, 60 days, and sort of, quote, get yourself together. That's what we hear a lot from what people say on TV. That's actually not really, that's not a one size fits all kind of way of treating alcohol use disorder. A lot of people can actually be treated outpatient and can be managed, can be detoxed as an outpatient. In addition to medication, there's the primary method is also with counseling CBT. CBT and motivational interviewing is very important when it comes to goal setting and understanding craving and all those very important CBD topics to talk about. 12 steps, AA, smart recovering, and all these different support groups is really important. AA tends to be, some people say that it's a little bit too religious. So they don't like it. But when you look at the foundation of AA, it's actually not about religion. But, you know, that sometimes it gets a little bit too skewed on the higher power part. But there's not just AA. There's a lot of other recovery support groups out there that's not faith based. So there is one chapter that the patient can join if one is interested in and motivated in being in a peer support group. Other treatments, medications, off-label use for alcohol use disorder, Topamax is one of them. Gabapentin. I have to be very careful with gabapentin these days because we're seeing a lot of gabapentin use, recreational use. A lot of times, especially up in the New England area, it's sort of mixed together with fentanyl and other opiates to prolong the effects of opiates. So gabapentin has been sort of a medication that has been misused quite a lot recently. And harm reduction. Harm reduction is something that is very important when you think about alcohol use disorder. And not every employee needs to be abstinent from alcohol. When we think about alcohol use disorder and treatment for alcohol use disorder, it doesn't necessarily equal to abstinence. And yes, there are positions, safety sensitive positions, where abstinence is the only way to go. But the majority of positions out there are not safety sensitive. So it's about meeting them where they are. And that's the goal for harm reduction. And harm reduction is actually evidence-based. That there is this combined study that shows you that by just reducing one to two level of reductions in WHO drinking risk level during the treatment, there are significant reductions in systolic blood pressure and improvements in liver enzyme levels, significant better quality of life. And there are subsequent studies that have shown significant reduction in anxiety, depression, and psychiatric disorders, and insomnia, and other things. So harm reduction in alcohol should be embraced. That we shouldn't be asking the patient to say, you have to be abstinent from alcohol. You have to stop drinking right away. Because what ends up happening is we typically lose that patient. Because they're just very scared of what's going to happen if they just stop drinking all of a sudden. And sometimes it's actually quite dangerous to do that. So instead of that, it's more of an approach that we embrace these days, is meeting them where they are. Just getting their drinking to a healthier level, to a level that doesn't cause harm to their body. So I'm going to let Anne talk about opiate use disorder. Okay. So another quiz. If you can get on your phones, the majority of opioid overdose deaths in recent years are from prescription opioids, recreational use of prescribed opioids, heroin, synthetic opioids, codeine. So hopefully you can participate and answer and pick one of those. Oops. Okay. So I'm really glad to see that most everyone picked synthetic opioids. Because the large spikes in overdose deaths in this country are largely attributable to synthetic opioids. And as we have probably seen in the news, there is a large increase in drug-involved overdose deaths. And this pink line shows that the majority of the deaths are due to a very large increase in synthetic opioids, other than methadone. And in 2020, the numbers of overdose deaths were 93,655, and of those, 70,000 were due to opiates or synthetic opiates. And in 2021, the number of drug-involved deaths were over 100,000, and 80,000 of those were due to synthetic opiates. And synthetic opiates, you hear a lot about fentanyl, fentanyl, fentanyl. They're talking about fentanyl analogs, because fentanyl is actually a class of medications. Fentanyl proper is used in anesthesia every single day, and there are probably a thousand or so fentanyl analogs. Some of them don't even have names. And there are probably about 200 that have been pretty well characterized. And a more proper term would be fentanyl analog, or fentalog. And carfentanil, which is actually a pharmaceutical form of a fentanyl, or elephant tranquilizer, is 10,000 times as potent as morphine. And when you think about the morphine mill equivalents, heroin, fentanyl, and carfentanil are just so much more potent, and that's why they are very, very effective at causing overdose. Because in the dose-response curve in toxicology, we all remember, these have a very straight line. It just goes up and up and up. Because the more medication you take, or the more opiate you take, you'll have greater and greater levels of respiratory depression, and sedation, and so forth. Overdose deaths due to drugs are largely occurring in our working population, and that's why we should be much more cognizant of screening for the use of recreational drugs. This is an age-categorized overdose death graph, and it shows that in 2019, the age group of 35 to 44, which is that blue line, they had the most deaths per 100,000 population, followed by the age group 45 to 54, and then the age group of 25 to 34, that pink line, was next. And that green line is the age group of 55 to 64. And farther down is the age group 15 to 24 and 65 and over. So what does that mean? That's actually just showing us that it's the working-age people that are dying from overdoses. And as we all know, in popular press and media, there are reports of fentanyl analogs found in a lot of different recreational drugs, street drugs, and even some retail forms of drugs. In my county, which is Montgomery County, Pennsylvania, this was a news article that appeared in February this year, and they said, fentanyl is found in THC gummies that were sold in a smoke shop. And then just recently, March 24, at the Hackensack Mall, there were five women who died after what they thought was cocaine, and it was laced with a fentanyl analog. So because of all of these opioid overdose deaths, it's easy to think that the actual incidence of opioid use disorder is greater than it really is, but it's actually quite small. In 2020, they reported that, well, the report from the National Substance Use Disorder and Drug Survey showed that the prevalence of opioid use disorder was only 1.1 percent. And then in 2021, we have better data that shows that the prevalence of opioid use disorder is around 2 percent. And in the age group of 18 to 25, it's actually lower than older age groups. So there are three FDA-approved medications to treat opioid use disorder. The oldest one is methadone, and it is scheduled to full mu-receptor agonist. And for substance use disorders, it must be issued by an OTP, which is a daily attendance type of clinic. It's highly abusable. It's a full agonist, and it's very frequently found in overdose deaths, and it can still be abused. And substance use disorders can develop around methadone. And then there is buprenorphine and naltrexone. Buprenorphine is often compared to methadone because they were both classified as MAT, but it's very different from methadone, and it's classified as a Schedule III drug. It's very different because buprenorphine does not have a linear dose-response reaction. It actually plateaus. So with higher and higher doses, you're not going to get increasing levels of respiratory depression. And so that's why it makes it safer, because it's much harder, so to speak, to overdose on it. Now there are many accepted ways of initiating getting on buprenorphine with microdosing protocols, and these have all been proven to be fairly safe. And I have seen so many patients who are on buprenorphine who have gotten their lives back and get their lives together. They reestablish their relationships with their family, and they're able to get their life back so that their disorder is much more in the background of their lives. And the third type of medication is naltrexone. And when I was working in an FQHC, I never saw very good compliance with this because people would get their Vivitrol shot one month, and then they wouldn't show up the next month for another shot. And there is a PO form of naltrexone. It's taken every day, 50 milligrams. And they can just stop taking that because it's a short-acting type of use. So the actual utility of naltrexone is a little bit limited for opioid use disorder. Okay. I don't know what happened. Okay. Okay. So this is a quiz question. Which of these is the first-line treatment for opioid use disorder? Intensive psychosocial treatment, medical detoxification followed by psychosocial therapy, opioid agonist medication or MAT in psychosocial therapy, and the last one is opioid agonist medication or MAT. So please make your selection. Okay. So I'm going to go on and reveal the responses. So the majority of you believe that opioid agonist medication and psychosocial therapy is the first-line treatment for opioid use disorder. And the correct answer is actually the last one. Opioid agonist medication is the first-line treatment for opioid use disorder. And that's because a lot of times you can't get them to psychosocial therapy right away. You need to stabilize their pharmacologic issues with MAT first. So whoever CLG is, you got the right answer. Who's CLG? You don't want to identify yourself. That's okay. So I wanted to explain this a little bit more because this was explained at an ASAM conference. The first-line treatment for opioid use disorder is only the medication. And that's because it's first-line. That's what's going to save their lives. And you can think of it as it's an opportunity to put them on a medication that will prevent an overdose. And the data shows that there is no improvement or return to use in patients who only receive medication without psychosocial treatment. And the medication by itself for a long period of time is extremely effective at stopping the behaviors characterizing addiction. And so as clinicians, we shouldn't feel that we cannot provide adequate treatment if you are unable to refer them for psychosocial treatment. And this is also borne by a Cochrane review, which showed that there is no additional benefit in receiving psychosocial treatment in addition to opioid agonist therapy. In fact, when psychosocial treatment alone was used, 80% of those returned to use within two years, even in inpatient intensive environments, like in rehab. And so that's the opioid agonist medication is the most important part of opioid use disorder treatment. Okay. So this is another question that kind of leads into the next part. Which of these substances would be considered disqualifying for a DOT driver who is in remission from a substance use disorder? Okay. So I'm going to reveal your responses. And the majority of you correctly stated that it's methadone. I'm going to quickly go over cannabis use disorder. And these are some quick facts about marijuana and cannabis use disorder. We all know that serum levels are not very useful in measuring impairment. And that's because of the pharmacological properties. It's very lipophilic. And so serum is not lipophilic. And so this dose response, this concentration curve with the time shows that it peaks and then it declines exponentially. And the performance, the impaired performance occurs much later than the peak serum level. And cannabis use disorder is becoming much more common. And the age where it's the highest prevalence is age 18 to 25. And the treatment is, unfortunately, we don't have FDA-approved medications for treating this. It's mostly a combination of CBT, MAT, and contingency management, and off-label use of medications, particularly antidepressants. Contingency management is external, and it's rewards for maintaining abstinence. And the way that I saw it in practice was frequently, like in custody battles, a man would be trying to gain custody in a divorce proceeding. And in order to, he was court ordered, like if he had a substance use disorder with cannabis, he would have to get hair tests to show that he had been abstinent for months. And then he was rewarded by time with his children. And that was court ordered in California. And so I want to get into SBIRT. SBIRT stands for Screening, Brief Intervention, and Referral to Treatment. And in our practice, we can actually do a lot of pre-screening by just two questions. And then if there are risks for a substance use disorder from those pre-screened questions, we can further validate their use with either an audit or a DAS-10. And a brief intervention can be simply one sentence. And same with the referral to treatment. You can give them a handout or have an MA give them a list of places where they can find help either online or in person. And so these really quick pre-screening questions that you can memorize is for men, how many times in the past year have you had five or more drinks in a day? And for women, it's how many times in the past year did you have four or more drinks in a day? And if they have any response other than zero, you can further screen them. And then for drugs, you can ask them how many times in the past year have you used a recreational drug or used a prescription medication for non-medical reasons? And if there's any time that they answer other than zero, you can further screen them. And this is basically the one-question screening test, which is used by a facility in Oregon. And it's just really easy to answer, but they spell it all out there. I know that we don't have a lot of time left, so this is the last section, and I'm just going to go quickly a little bit on harm reduction. And harm reduction, by definition, is meeting the person where they are and helping them. So it's part of de-stigmatizing substance use disorder and also making sure that we are saving lives. And this is something that it's important for us to think about. The first framework is a public health strategy. What we know the most is syringe service programs that have shown dramatically decreasing the amount of HIV and hepatitis C in new cases. There's also supervised consumption space. There are a few states that are testing this. It's very prevalent in Canada and the EU. They have seen dramatic decrease in overdose and safer injection. And the most simple one is just overdosing education and naloxone distribution. And this is the part where I think we as occupational health physicians need to think about, you know, yes, obviously, drug use is not something that we want to promote at workplace. And at the same time, we sort of have to acknowledge in certain industries, such as manufacturing, mining, construction, the prevalence of substance use can be as high as 20% among the workers. So how to keep them safe and how to make sure that they do not overdose and, you know, die on site, it's something important to think about as occupational health physicians. I have once had a construction company that came up to me and said, you know, I want to install Narcan vending machines at my construction sites, which I said, it's a really great idea. I'm actually all for that. But back at that point, Narcan was not over the counter. It is over the counter now, FDA recently approved it, so they could actually do vending machines now. But back then, it was more of a legal thing that they require a prescription. So just things like that, you know, thinking about how we can help and making sure that our employees don't die, that is the most important thing. And that is the core concept of harm reduction. Another framework, movement for justice, equity, decriminalization as part of it, clinical approach on human rights, incrementalism, pragmatism, and just making sure that you're meeting the person where they are. Obviously, safety-related duties, there's certain things that we have to meet. But if they're not in those positions, think about how you can help them in a way that you can actually help them. This is something that is very interesting, I think, as the last note I want to make. Portugal decriminalized drug in 2001, and this is the drastic difference that they're seeing in terms of overdose deaths between 1999 to 2016, newly diagnosed HIV, number of people incarcerated for drug offenses. As you can see, the dramatic decrease because of decriminalization. It is a very hotly debated topic, and it's something to think about as we move forward as a society. And again, Wednesday morning, I know it's 9.45, it's a little bit early, and it's the last day. If you would like, please join me for my session on Wednesday. Q&A, so we do have a few questions. Are you seeing any PCP use? Me, personally, I have not, and I've heard this a lot. There's not a lot of PCP-positive urine drug screens that we're seeing. And do you have stats on how many people are using cannabis? So no, not, hold on, I think I saw that, yes, do you have any stats on how many people are using cannabis for recreational use among working population? We don't really have a really great number, at least I'm not, I don't know if you guys know, but one of them I've seen is, you know, Quest has come out with their drug testing index in 2021, and they did see a 50% increase in positive marijuana screen, and at the same time, that's only like 4% of all of their drug screens. But when you think about it, people tend to behave differently when they know that there's a drug screen coming up. There's another survey that actually was to workers, white-collar workers, and I think it was like a 2,000 respondents on whether or not they have used marijuana recreationally at home or when they're working from home in the past three months. And the answer to that, I think, was around 23%. I might be wrong on that exact number. So it is there, but we don't really have a good national number yet. I'm not sure if you know of any. The latest survey did report a very high incidence of use, but I'll come back to that. If someone contacts me, I can provide you with the graph. Any other questions? Yeah. Yeah, so that's a really great question. And DOT never, or FMCSA, never really said that it is disqualifying. Part of it is when they first came with the first guideline, buprenorphine was not approved, and methadone was a disqualifying medication. In the 2022 guideline or the handbook that they published as a draft, they did say that suboxone or buprenorphine is allowed, or you can pass somebody on buprenorphine as long as you know the history and you know that the person is stable on his or her recovery. So I would say, me personally, as a DOT examiner, if I know that that person is stable and that person has been on recovery, and we've seen that a lot. People on suboxone, they can be stable on just one film a day for 10, 20 years, and they're not impaired. So a lot of people would just, you know, fail them, but that's their livelihood. So I think there's a balance that we have to think about. Any other questions? Please use the microphone because it's being recorded. Great presentation, thank you. This came up recently, a woman applying for a job at a paper mill, relates to a long history of heavy drinking, recently came off of alcohol independently, no treatment of any kind, and you know, professes a commitment to remaining abstinent, has no plan, no program, no treatment, no treater. She's been sober for six months, and I have no way to verify that. A, what do you do with that person? Do you hire them for a safety-sensitive job where they'll be operating heavy equipment? Or do you, and would it make a difference to you if the number was not a year, not six months, but a year or two years? Yeah, that's a tough one. I would say it doesn't really, I can, the second question is easier. It doesn't matter if it's six months or a year or two years. Recovery is a lifetime process. Any point of time in their lives, it could be an obstacle. They could revert back to substance use. So it doesn't matter if they're in recovery for six months, a year, or two years. Timeline in this case doesn't really matter. You know, I think there is a lot of statistics showing that if somebody is not on a medication-assisted treatment, including naltrexone or campersate, any of the FDA-approved medication, if they don't have therapy in place, they don't have a sponsor, they don't have any sort of peer support program, their chances of relapsing is really high. So whether or not, and I'm not sure exactly where that person is in terms of if it's pre-employment, or if it's some other for-cost situation that came up, as I said, you hear that part clearly. But it's, I think it's really individualized in terms of what is needed for that person. Yeah, so thank you. Great presentation, by the way. With more and more states legalizing marijuana, either medical and or recreational, one of my biggest concerns in the workplace is identify who might be impaired. So when we saw the low correlation between like blood tests and definition of impairment, any recommendation for how to identify what we can do to identify individuals impaired in the workplace? That's another tough one. There's a lot of tough questions in substance use disorder, because we just simply don't have enough answers, and especially when it comes to occupational health. I would say the short answer is there isn't a measurement that is good enough, and it's where we're at. Unfortunately, a lot of it has been because it is a scheduled substance. It's a scheduled substance according to our federal regulations, so not a lot of research can be done for the particular substance. And do you have any thoughts on this? Do you want to come up? That graph that I showed, that shows that the serum levels decline exponentially where the psychomotor signs of impairment are peak after, that was actually research that was done in Germany. And so when you look at data and research and reports about marijuana and cannabis, we might actually gain a lot by looking at other countries and how they have handled it and how they're addressing this issue, because it's everywhere. Yeah, Justin, great presentation. Good to see you here. Good to see you. And yeah, this ties in with the question over there. I think because of the ADA, you would have to hire them. You'd probably want to talk to HR and legal, because once the person is in remission, they're protected. But this ties into one of the recommendations of people who have alcohol use disorder, allowing them to continue to drink. With the ADA, how does that tie in where, OK, how do you define remission if the person is still drinking? Because I know a lot of policies or organizations, it's a no-use policy. So how do you manage that? If a doctor is saying that, OK, the current regimen includes alcohol and the person is in remission, how would you navigate that? Yeah, John, I think that's a really great question. I think if you see the evidence in clinical research that when somebody reduces their drinking, their days of abstinence also goes up. One of the research studies that I saw within 12 weeks, their days of abstinence could go up to as much as 70% when they start cutting down on their drinking. So it's not saying that they're going to continue to drink. There might be a chance where they would get to a point where they're abstinent from alcohol. I think this is the hard part about substance use. It's so individualized. Everybody's journey is a little bit different. So when it comes to workplace policies, I don't have the right answer for this. But there is much work that we need to do in terms of looking at our workplace drug policy when it comes to safety sensitive versus non-safety sensitive and whether or not abstinence is the only answer or can it be an approach or stepwise approach to abstinence at one point. So that's the answer I would give to that. So I just wanted to come back to your previous questions about assessing impairment. We had that same question discussed a lot at Temple University. And we decided that what we were going to do is use the totality of the circumstance, not a drug level, but what brought the person to our department? Why did they send them for a fitness for duty? Look at that issue. And then look at whether the person had a positive screen in terms of even cannabis. And then not take one thing but look at the whole issue, the totality of the circumstance to decide whether the individual was impaired or not. And I think we've had good results with that. I think it's a mistake to take one thing and try and say you are impaired or you're not impaired. Rather look at the whole picture. I think that's the safest way to do it. And it's not only true for marijuana, but I think it's true for other substances as well. Yes. I would say that's a great approach. And as I mentioned, I think that substance use, it's a really individualized approach. And a workplace drug policy tends to be very one size fits all. But it's not that. So I would say that is definitely a great approach to look at substance use in the workplace. Thank you. Before I thank our wonderful speakers and the audience, there was one comment here about like sort of like being controversial and not to be using a full agonist for opioid treatment. Like taking one away and the other. So the full agonist is the approved one is methadone. And the good thing about methadone is like it does not give you that euphoria or surge that you would get from like synthetic or natural occurring opioids used in substance use disorder. The other thing is once you're on a steady dose methadone, it's easier to taper one down and eventually take them off along with other psychosocial therapies. So methadone does not give that surge or euphoria. Thank you. Thank you again to our wonderful speakers. Justin and Anne. You've been a great audience. Thank you so much.

substance abuse

substance use disorders

occupational medicine

alcohol use disorder

opiate use disorder

cannabis use disorder

prevalence

harm reduction strategies

SBIRT techniques

medication-assisted treatment