And thank you for coming to this session. I know it's the end of the conference, so kudos to everybody for making it today. And so this is an, I think it's a very important topic in occupational health that we don't talk a lot about, and when we talk about it, we talk about enforcement, compliance. So today we're going to be looking at it from a little bit of a different angle, from the barriers for the employees and the impact to the employers, and how you as an occupational health physician and clinician could facilitate in that discussion as well. So my name is Dr. Justin Yang. The introduction on the Swapcard app is actually a little bit outdated. I don't know why they pulled my information from two years ago. So it's pretty outdated. I'm currently a medical director at Quick Genius. I'm also an assistant program director for the occupational environmental residency program at Harvard School of Public Health, and assistant professor of medicine at Boston University. And I am triple board certified in internal medicine, occupational medicine, and addiction medicine as well. So this is going to be a very interactive one hour presentation. It's going to be engaging. So we're going to use a system called Slido. So if you can take a QR, take a picture of the QR code on your phone, and it's going to bring you to the browser page where you can ask any questions that you have for later. You can ask them anonymously. And also, there are going to be questions throughout that you'll be interacting and putting your answers anonymously as well. The disclosures. I am the medical director of Quick Genius. It is the world's first technology-enabled joint commission accredited digital clinic for substance use disorder treatment. So I think, first of all, let's get the definitions right. What exactly is substance use disorder? And some of you that have made the Monday session that myself and Ann has together, we talked a lot about the definition of substance use disorder and the treatment and the diagnosis of it. But today, we're not going to focus on that too much. I'm just going to briefly go through the DSM-5 criteria that we use for substance use disorder. Excessive use, unsuccessful attempts to cut down, excessive time spent on obtaining, using, or recovering, craving is a big part of it. And then, obviously, the use interferes, the occupation, or major obligations. And that typically comes with interpersonal trouble and interfering with their daily activities. And usually, we see a lot of hazardous use, such as DUIs. And then, use is contributing to medical or psychological issues. A lot of substance use disorder patients have concurrent depression and anxiety, so most of them check this box. Tolerance and withdrawal as well. And there's a big change between DSM-4 and DSM-5, where they did away with a lot of the, what we call stigmatizing word usage, such as abuse. It's all just called SUD, substance use disorders now. It is a little bit lengthy, but that's a better way of using the terminology and as we try to de-stigmatize substance use. And there's 10 classes of substances. There's DSM-5 added severity criteria, mild, moderate, to severe. And these are the 10 classes of substance use disorder. Alcohol, caffeine, cannabis, hallucinogens, sorry, it's a little bit early in the morning. Inhalants, opiates, sedatives, stimulants, tobacco, and other more unknown. Those are what we categorize as things that are not bucketed in those nine categories. When I was giving similar lecture to residents at the program, they were saying pretty much all of the physicians have caffeine disorders, which we have to go back to the diagnostic criteria and I would probably agree that most of us has mild caffeine use disorder, but I digress. So the first question here, and feel free to answer this question on your phone, and that's the QR code right there, 40 to 70% of individuals' lifetime risk for substance use disorder can be attributed to prenatal exposure, environment, either that being, you know, peer use, et cetera, family use, genetics, family dynamics, life stress, or just boredom. Give another five seconds to put your answer in. Okay, genetics has the most answer, and yes, that is correct. Genetics plays a huge role. Environment is second. Obviously, a lot of people answer boredom. Yes, for some people that is correct. But the 40, you know, from statistical studies, 40 to 70% of a lifetime risk for substance use can be attributed to genetics, and it's important to know, before we talk about anything, that substance use, it is a chronic disease. It is not a choice, and that sometimes, you know, people blur out, oh, like it's a life choice that you make, and, you know, we've had multiple studies over the past decades that shows that there's what we call addiction genes, so it is highly heritable. Obviously, environmental plays a huge part to it, violence, trauma, and this is why in military we see a lot of veterans with substance use disorder because of all the violence and trauma that they've endured in their career, stress, peer who use drugs, and it just fundamentally changes the chemistry in your brain. I put here heart disease just for, as a comparison for you to sort of understand that it is no different when you look at the different factors that influence a chronic disease in what we, what the society thinks it's okay or it's a norm to have heart disease, to have diabetes, but you know, at the same time, just as, you know, just as like heart disease or other chronic disease, substance use has exactly the same risk factors to it. And this is the study, it's actually multiple studies. It started with, if you Google Harvard Twin Study, and there's multiple twin studies afterwards across different universities and different registries that look at how genetic factors and environmental factors sort of interact with each other. And what you see on the x-axis is a person's age, and a person's age as in defined of, this is, this study in particular is on tobacco smoking, of the amount of tobacco they smoke on a daily basis. And the red part is the genetic effects, and the light blue is familial, environmental factors. So, typically, you know, if you see a family member smoke, or if you see your brother smoke, since it's a twin study. And as you can see, over time, as one gets older, that environmental factor starts reducing, and by the time that they're in their adulthood, you know, in their 30s, essentially all of that, the majority of all of that is genetic effects. That is, keeping somebody from continuous use of substance throughout their lifetime. And pretty much all of the studies showed the same results in cannabis, in alcohol, in smoking, so this is widely known as the genetic factor for substance use. Another question, number one source of pain reliever medication misuse is from prescription from a provider, or friends and family, or drug dealer, or other stranger. Okay, interesting. Okay. Okay, so, the actual answer is that most of them are actually from friends and family. And this is why public health education is so important about not putting your opiate on the counter where your kids could reach. And so, as you can see here, this is a study from 2021 that showed that almost 45% is given or bought from or took from a friend or a relative. And then, about 43% is through an actual prescription from a healthcare provider. The proportion of this is getting smaller and smaller as we continue to limit and restrict opiate prescription. And so, the majority of it is actually from friends and relatives. All right, next question. Which of the following is the number one preventable cause of U.S. mortality? Cardiovascular disease, cancer, alcohol use disorder, tobacco use, opiate use disorder, and because we're at AOHC, so I threw in work-related injuries. All right, we have 46 responses, 51, okay, perfect. Yes, the answer is tobacco use. And the reason why I put this question here is we need to not forget that tobacco use disorder is the number one preventable cause of U.S. mortality with almost about half a million deaths a year. It's something that we easily forget, and I think this is an important thing to remember as a occupational health specialist that tobacco use disorder and tobacco cessation education is important for us to talk about with our employees. The current U.S. prevalence is actually, you know, at all-time low, at about almost 14%, 34 million people. And here are just a list of the benefits for smoking cessation. Increased life expectancy of up to 10 years, reduced risk of cancer, and not just lung disease, just lung cancer, GI, urologic, GYN, all sorts of cancer. Reduced risk of cardiovascular disease, MI, CVA, PVD, and reduced risk of lung disease, COPD, and asthma. I typically tell my patients, when you stop smoking by the time that you get to about 10 to 12 years of smoking cessation, your risk for getting lung cancer, having lung cancer is the same as the general population. And that, a lot of times, is very strong incentive for people to quit smoking. And smoking of quitting, about 60% of them actually can quit successfully if they have determined that they want to quit. And 67% of current smokers at the report, they have an interest in quitting. And so this is a very important statistic when you think about it, because if your employee comes into the clinic and, you know, you notice that they're a smoker, you know, about 70% of them actually want to quit. So it's important for us to do a brief intervention to actually get them to continue to think about quitting. And when they're at the stage of they're ready to quit, they're going to make that action. Next question. Which of the following medication can be used to resuscitate a patient experiencing opiate overdose? Naltrexone, naloxone, buprenorphine, suboxone, and supplicate. And I mistakenly didn't make the slide right. So now you're going to be able to see the answer right away. So yes, the answer is naloxone. And I kid you not, out of the three boards that I've taken, this question actually appeared on two of them. And so it's an important topic, and it's important for us to know what can reverse opiate overdose. It is commonly known as Narcan as a commercial name. And if you're watching, following the news that it has recently been approved as an over-the-counter medication, does not require prescription anymore, which is great. Because in the past, there has been a lot of issues with people wanting to get naloxone to try to save their friends, family, relatives, or even their colleagues. But it requires a prescription, and it shows up on your prescription list. And so that was a huge issue for insurance and even for life insurance. But not anymore, so that's a good progress. And as I mentioned, back on Monday, there were a company that came to me and asked if we can do a Narcan vending machine at their construction site, with now that it being an over-the-counter medication, they can put in all the vending machines that they want. And it is not an opiate. It is not a treatment for opiate use disorder. The onset is very rapid, half-life is about two hours. You don't just, you can use, you know, you use it as nasal spray, IM, it's most commonly seen. You can actually be using, you know, various different routes, sub-Q, IV. You see some of that when they're, you know, severe OD cases in the emergency room setting where they just have to continue to push IV naloxone. It has no effect when there's no opiate present, and it definitely can precipitate withdrawal. So, you know, patients can wake up, you know, violently, and they're, you know, disgruntled that you took away what's in their system. So that was just a little bit of a preview. Now let's get into the actual part of the epidemiology of substance use in the US workforce. So you just learned that an employee at your organization is in the hospital due to an opiate overdose, unfortunately. And according to the CDC data on opiate overdose trends, the most likely type of opiate the employee overdosed on is prescription opiates, recreational use of prescribed opiates, synthetic opiates, heroin, suboxone, or codeine. All right. A lot of people got this one right. So the answer, yes, is synthetic opiates. And this is a slide that you see over and over when you go to any substance use talks. As we, you know, in our society, we've had three waves of the rising opiate overdose deaths within, you know, started from in the 90s. The first wave is prescription opiate overdose, you know, the famous Purdue Pharma. And if you have Hulu, there's a show that I, you know, I definitely recommend you to watch. It's called Dope Sick, and it is sort of a documentary-ish, but it's kind of like a captivating movie of how a small town doctor was fighting Purdue and just, you know, when everybody was dropping like flies because of opiate overdose and how, you know, they're raising awareness and whatnot. It's only eight hours of your life. It is a really great eight hours, I promise. So it's called Dope Sick. So if you want to watch that on Hulu. And then the second wave is, you know, the rise in heroin overdose in the 2010s because now we've started cracking down on opiates and then people resorts to street heroin. And then the third wave started, you know, in recent years where there's a dramatic increasing synthetic opiate overdose. And these days it's fentanyl is what we see the most. Fentanyl is, as you know, extremely potent. And now we're seeing, you know, all sorts of garden variety of opiates, including carfentanil, which is used on, you know, horses and animals and mixed together with fentanyl. So this is the number in the early 2010s of substance use in the general American adult population. Back then it was about 8%, 20 million of American adults answered that they have had used substances in the past year without being the most alcohol. Just because it's legal doesn't mean it's right. So alcohol use disorder was 16 million percent, 16 million, and marijuana was 3.5 million. This has dramatically changed in the 2021 data. The past year substance use disorder percentage has gone up to about 16% of the general population. That equals to around 46 million. Alcohol use disorder, as you can see, back then was 16 million 10 years ago. It is now about almost 30 million. And marijuana use disorder back then, 3.5. And with a lot of state legalization of recreational use, it's about 16 million right now. And I think this number might be slightly less or miscounted with just the prevalence of legalization these days. And so, yeah, as you can see that there's still a significant increase in the different types of substances that people use. And what is also important to know is that there is a lot of concurrent use. So this chart shows you that, you know, somebody, an individual that has an alcohol use disorder, 9%, almost 10% of them also have a marijuana use disorder. 4% of them has a cocaine or opiate use disorder and very little heroin. These days we don't really see that as much as back in the 2010s. And what's interesting, as you can see, you know, for the cocaine use disorder part, 60% of them also have an alcohol use disorder and 20% of them also misuses marijuana as well. So this chart sort of tells you just the amount of concurrent substance use. So it's important when we look and we think, and if somebody or an employee comes with a marijuana use disorder, that we ask the other questions, that we do the screening for other substances, because a lot of times they have a concurrent alcohol use disorder or other use disorder as well. And this is actually from a study published in JOEM in 2017 that looked at the amount of substance use disorder, people with substance use disorder that are actively in the workforce. So they actually, you know, between the different studies that you see, we generally say 70%, but with this study, you know, they calculated it, it's anywhere between 70 to 80% of people that are having one form of substance use disorder and they are active in the workforce. So there is a very skewed or a misunderstanding of that people that are using substances, they're homeless, they're financially not stable, they're unemployed. And the fact is that almost between 70 to 80% of them actually do have a functionable life. They actually work, they are employed. They are employees that you see in your clinic. They're there and they're just not actively seeking help or being screened or being asked about substance use. So it's important for us to know this and being able to offer help when they're in the clinic. So this question, you're a consultant for a construction company and being asked on what your industry prevalence in the construction industry of substance use in the past 12 months might be. You're being put on the spot by the HR director. So your answer to that is one to 2%, five to 10%, 15 to 20%, greater than 25%. All right. It's interesting. So we have, oh, it's a tie right now. Okay. Oh, it's great. Okay. So it's a segwatching election. So the answer is actually 15 to 20%. Yes. And this is where we're getting our statistics from. So if you're ever a consultant for any company, I always, right when I get this question, you know, on Zoom, I just, you know, on my phone, Google substance use disorder report, substance use disorder by industry report. And then you'll be able to pull up this one that was published by SAMHSA in 2015 that gives you a breakdown of everything that you need to know in order to sound professional and an expert in substance use. So on your left, you see past month, heavy alcohol use amount adults by industry. And then on your right, you see past month substance use disorder. And there's actually a lot more graphs if you Google and search and find this report that you can actually use. But one thing that you'll notice, regardless of, you know, which substance you look at or alcohol, construction, arts, entertainment, recreation, and hospitality, you know, accommodations and food services. And all this really, all these industries and mining as well, all these industries have extremely high prevalence of substance use. And then if you go down and you look at, you know, sort of the traditional so-called white collar industries, they're actually more than what you would think they would be. You know, healthcare and social assistance is anywhere about, you know, 5% to 6%, which is quite a bit. So this is a great way to know, and also a great way to raise awareness within the industry that you serve on why this is an important matter. Just because HR decides not to talk about it doesn't mean that they don't exist. And a lot of times HR don't want to talk about this, it's a lot of stigma, and also they just don't want to touch it, which is unfortunate because these are people that actively really needs help, and you see a lot of issues. And impact to the workforce, which is something that we're going to talk about now with the impact of substance use disorder in the workforce and the workplace. And this is actually a free text type answer that you can type in. Anything that you think of, the impacts of substance use disorder for employers and the workplace. Doesn't have to be an essay, just a few words is fine. Okay, so I'm seeing safety, absenteeism, disability, absenteeism. Again, accidents, injuries, safety. Decreased morale, yes. We're seeing accidents and safety comes up quite a few times. Productivity theft, that's a great answer. Didn't think of that. Impairment, yes. Okay, more accidents. Medical cost, yes, yes, very good. Reputation, yes, okay. Decreased profits, that's an answer from a CMO, I think. Absenteeism, low productivity, perfect. Okay, so as a medical director consultant, how do you persuade the HR director or the chief people officer to focus on substance use disorder, such as adopting a smoking cessation program, campaign, anything that costs money to do and for your employees? And you can just shout out answers because I know typing might be a little bit difficult. ROH, ROI measures, yes. Returning investment, yes. Any other answers, ROI? Yep, okay. Anyone knows, just shout out that answer, that's also fine as well. The recent tragedy in your workplace is related to the issue. Recent tragedy, unfortunately, that's a really great answer. Unfortunately, that usually happens. We only fix issues when they actually cost us money. Yes, do the right thing, that's great. That's what we all came into medicine for. Value of investment, well-being program, it's the right thing to do, yes, perfect. All right, so I think, you know, at the end of the day, it's really for the employers, unfortunately. It's really about how much money can I save? We, as medical directors and CMOs, we tend to say this is the right thing to do, but if you work at one of the Fortune 500, they'll say that's not good enough. You gotta show me the real numbers. So here are the numbers. And thanks to the CDC, they actually published this in January, 2023. That actually, their research on 162 million employees, that really highlights that substance misuse is a top five cost driver for employers. And that the annual, and this is a direct quote from the study, the annual attributable mean cost for any substance use disorder diagnosis, including multiple substance use, was 15,640 per affected enrollee. And this is not, this cost is directly related to their healthcare costs, and not counting the absenteeism, presenteeism, retention, mortality, and all that. Those are not addressed. And a lot of times when you talk to HR, they really don't think those soft, indirect costs with just absenteeism, presenteeism is something that they look at as hard numbers. So, you know, just, you know, the number of 15,640 is what they really look at of what is really costing the company. And this is sort of, this is from statistics from other studies. As you can see, average general population, the medical spend per year is about $8,000, $8,276 to be exact. If somebody were to have just tobacco as a disorder, just the medical cost alone, that adds up another 3,600 to their medical cost. If somebody has alcohol, this is from a study that showed alcohol use disorder employees, their medical costs cost twice as much as the general population. So that, you know, you add on another 8,000. And then another study to show that opiate, somebody has an opioid use disorder, you're going to add up, you're going to add 20,000, about $20,000 more to their annual medical spend. So the hard dollars is there, that, you know, you can see the amount of money that people are spending and employers are spending on their employees because of substance use disorder. And just taking a closer look at tobacco, as this is something that has been studied over and over, we have the most data on. This is from a study back in 2014 that also breaks down the excess absenteeism, presenteeism costs, even the smoking breaks. And in addition to the healthcare costs, and they're also adding pension as well. And the high range of this annually for an employee is more than $10,000. And the low range, you know, the bare minimum that they're going to increase is almost $3,000 in healthcare, in all costs included for the employer. So these are pretty compelling number, in my opinion, to go to the HR folks and say, we really need to implement an effective tobacco cessation program. This is going to save you a lot of money, especially in industries like construction, mining, hospitality, where the smoking prevalence is a lot higher than the general population. So the absenteeism impact, as I mentioned, smoking costs, you know, $517 in lost productivity due to absenteeism. And then there's another number for alcohol use disorder as well. A study showed that those who has an alcohol use disorder diagnosis, they're accounted for about 14% of all missed work days in America. And those with severe alcohol use disorder, they miss 32 days of work annually. And that is 2.5 times more than those without an alcohol use disorder. And the table that you see down here is a direct screenshot from the study where you'll see the bottom with, you know, mild to moderate to severe. The alcohol use disorder, the higher the severity, the more missed days that they have from just 17 days a year to almost 24, to almost 32 when they have severe alcohol use disorder diagnosis. And then this chart shows you that that's, you know, let's say, what if we say just substance use in general, not talk about alcohol, smoking, you know, any substance use disorder of any kind, total missed days is about 15, 14.8. And in this study, the general workforce is at 10.5 days a year. And when you get to pain medication use disorder, that's 29 days. Even with marijuana use disorder, they're missing more days than the general workforce at 15 days. What is very important to see on this chart, and this is a lot of, this is a foundation of why we say it is important to talk about substance use and for employers to actually help their employees, is you look at people in recovery. If you look at people in recovery, their total missed days is actually lower than the general workforce. Just see how dramatic of a change is when someone is in recover, that they're able to get to the baseline of people who, of the general workforce that does not have a substance use condition, and sometimes even better when they're in recovery. So it's very important for us to know that this is why we advocate when we talk about we need to get people the help that they need, not just for their own personal life, but it really affects and impacts their colleagues and your workforce and productivity as well. And I think a lot of people answered the safety aspect of this, and these are just some data showing that breathalyzer tests detected alcohol in 16% of emergency room patients that came in because they were injured at work. And up to 40% of all workplace fatalities are caused by individuals with a substance use disorder. And the third one is actually internal data from Harvard Pilgrim, where they found through claims analysis that employees prescribed with just one opiate pill, they were found to cost four times more in their workers' comp claim than those who weren't prescribed with any. So I think that those are really compelling numbers to see. How do you show that to the emergency room physicians? That's a really great suggestion. I'll just send this site out to all the chiefs out there and ask them to distribute. But they're actually doing a better job these days, I would say, but I digress. Let's go on. So this part of the talk, I want to talk a little bit about COVID-19 and the impact of that and the substance use care that we're facing these days. So an employee in a non-safety sensitive position presented to your clinic seeking help on her alcohol use. What would your next step be as an occupational health clinician? And I think this is a free text answer. EAP, EAP, yes, refer to EAP. EAP, again, EAP, EAP. Thank you for sharing. Okay. Acknowledged, but nothing to do. Okay, so that's great. Give them a safety, okay. Refer to behavioral health after care EAP assess. Okay, so counseling, yes. Okay, so really great answers. And I see the majority of answers are from invited. Okay, SAP, these ones, yes, okay. Pray, thoughts and prayers, that always works. Okay, so I'm going to go on to the next slide because I'm going to start laughing. So EAP is mostly what people would say. And when I talk to HR directors and CPOs and that's like the 100%, that's like, oh, we have an EAP program. We'll just turf that employee to the EAP program. But a few things, first of all, EAP is, what is the utilization of EAP in the typical organization? I think studies shows that it's anywhere between one to 4%. I had consulted for a company that has 7%. I was like, oh, that's a really high number. It's usually extremely low. And in addition to that, what can EAP really do when you think about it? They essentially give a list of providers, local providers to the employee and say, hey, good luck, these are a list of substance use disorder clinics that I can go to. And on top of that, that may do three sessions of counseling for you because your benefits provides you for three sessions or six or nine, depending on how much your company wants to spend. And that's really not something that is a prolonged or an effective way of treating substance use disorders. We know that it is a chronic medical condition. It requires somebody to see someone on a weekly and monthly basis. It requires medication, a CC program. So that's why a better option is needed. And a lot of times it's the barrier to access. That is the problem that we're seeing. The acceleration of substance use through COVID is very apparent. This is actually from a report that actually more people died in San Francisco from overdose than from COVID in 2020. The number is 697 died from overdose versus 257 from COVID. And in 2020, there were 40 million people living with a substance use disorder. And as I mentioned, more than 70% of them are actually are active in the workforce. And at the same time, only about 10% of them are getting treatment. So there's a huge gap in access and barrier to care in today's world. And throughout COVID that we're actually seeing, those that are hit hardest by COVID, women, black people and people with children. This is a photo from Trader Joe's. It was funny at the time, but now we have a lot of alcohol use disorder issues among women. And so it's sort of not funny anymore. So black people and people with children are the subgroup that had increased alcohol use significantly during the pandemic. And women now comprise the fastest growing population of alcohol use. And heavy drinking increased by 41% in female during the pandemic. And in the 20, I think it's a 2021 data of the national survey, girls and young women now are drinking more than their male counterparts in terms of last 30 day drinking. And these are like really alarming numbers because if you look at numbers from 20 years ago, male comprises about two thirds of people experiencing substance use disorder, but now female gender is catching up. So telehealth, I'm going to spend just a little bit of time on telehealth changes during the public health emergency as everybody has sort of been there, done that. So before the pandemic, there's something called the Ryan Haight Act of 2008 that prohibits the online internet prescriptions of controlled substances. And that requires in-person evaluation before somebody can prescribe controlled substances. And we know buprenorphine is something that works. It's an evidence-based medication assisted treatment for people experiencing opioid use disorder. But buprenorphine is a class three controlled substance. And because of this, it was very limited. And there was a study by SAMHSA, I think 2015, that showed that more than 50% of counties in the US, 50%, they did not back then have a prescriber that is able to prescribe buprenorphine. So those people that live in those 50% of counties, they essentially have to travel hours in order to get a prescription. So when you think about it, street dealer down the street versus a addiction medicine doctor an hour out, for people that are suffering, sometimes the choice was evident for them. So during the COVID pandemic, the secretary of HHS issued a telemedicine exemption that sort of applied to all schedule two to five controlled substances. And that has been why we're able to prescribe and through telehealth and telemedicine, suboxone and substance use disorder treatment to a lot of patients that did not have this service and weren't able to access this service in the past. And before I go on, I think this is a question that I want to see where everybody's at. The question is, I feel comfortable with virtual care in the management of substance use disorder, either receiving counseling or medication assisted treatment prescriptions, buprenorphine or suboxone through a telemedicine virtual care setting. Okay, I have about 43. Okay, got about 70% saying yes, very good. And so about 40% saying no and growing. And so, and I think, and the reason why I want to ask this question is, you know, I think there's, you know, even the DEA has a lot of doubts on, you know, is it safe to prescribe buprenorphine? Because after all, it is a partial mu agonist and it is an opiate at the base of it. And so there's a lot of doubts on or question about whether or not it's safe. And so some people are feeling very uncomfortable. And even, you know, when I go to American Society of Addiction Medicine ASAM meetings, you know, in the last year, you know, people, there were some addiction medicine physicians that were also like, kind of like, but what about drug screening? What about this and that? So, SAMHSA, you know, our great federal agency on substance use, they actually compiled all of the research in the past three years. And they have found that on the patient level, high satisfaction, people are accessing care that they weren't able to access in the past. They're able to go on recovery. In studies, there was no difference between in-person versus telehealth care, the rate of continued substance use, on retention of treatment, on engagement. There were no significant report of diversion, people still in suboxone, or overdose, or harm. And on the provider level, high satisfaction, because who wouldn't like working from home? And it allows better access to underserved areas, areas where, you know, that 50% of counties where they had no suboxone doctors in the past. And they provided better patient-centered care from the provider's perspective. On a systemic level, telehealth also gives you that rapid scalability of care, and that ability, as I mentioned, to effectively reach that vulnerable population, people who just couldn't access in the past. And also, now, instead of taking out three hours or a whole morning to go to a clinic, you can actually just hide in the water closet, janitor's closet at work, and then do a telehealth visit and get your prescription refilled while you're at work. So talk about increasing productivity there. And rapid evaluation has demonstrated that it is effective and it's also safe. And so SAMHSA's conclusion after, you know, now we're sort of at the tail end of the pandemic, is that, you know, previously held beliefs on telehealth and the concerns on telehealth have sort of all been dispelled by the studies that we're seeing coming out of COVID. So this is why they, you know, started doing some changes to substance use treatment post a public health emergency. So if you're following the news, in December, 2022, the president signed a bill that removed the data 2000 waiver, so-called the X waiver restriction to prescribing buprenorphine. So now anybody with an active medical license, you can actually prescribe buprenorphine if you want. But that comes with, there is a requirement for a one-time eight-hour training on substance use for practitioners renewing or applying for DEA registration. So everybody's going to get trained. Everybody's going to know about buprenorphine. And, you know, it's at your own comfort level. If you feel that you want to, you know, help out your patients, either to bridge them to a clinic or, you know, to provide a few days of prescription because their doctor is not available. In the past, you were not able to do that because you're not X waiver. But now with this elimination of X waiver, you are able to do so. And then the DEA, you know, because of there's just this significant amount of people that's utilizing telehealth right now to treat their substance use disorder. So, you know, public health emergency is coming to an end in May and the DEA has to propose something that's permanent. So they did propose that back in February. People were not happy about it. So they received 30,000 public comments. My friends at SAMHSA is laughing at them because now they have to answer 30,000 comments in less than a month, which good luck. And there's a reason why people are not happy about it because the proposed role that they have is that they're only allowing a 30 day supply of buprenorphine without an in-person evaluation. So now if you want to get a refill, you then require to actually have that in-person evaluation by that same prescriber, which at the end of the day, it's still setting up barriers. And we have to know that DEA, it's not, they're not run by MDs, they're run by people with the JD. So, you know, do no harm is not their first model. So, you know, they have until the end of PhD to come up with, you know, answer and revision of the proposal. So we'll see what happens. But right now there is, as it is, there is a kind of going to be a limitation or restriction on telemedicine practice in substance use disorder management. So drug testing in the workplace. This is the last section. We're just going to really briefly go through this. And this question, under the ADA, which of the following cannot be performed until a qualified candidate has been tendered a job offer? Select all that apply. Medical history questionnaire, health risk appraisal survey, physical exam focus specifically on essential job duties, alcohol breath testing, urine drug tests. And I messed up the slide again. So now you're going to see answers, but still put them in because this is, everybody's going to answer this question a little bit differently. And remember it's, you cannot perform it until a qualified candidate has been tendered a job offer. Okay. Okay. So the correct answer is the only thing that you cannot do is the alcohol breath testing. And let's talk a little bit about ADA and substance use disorder. So this is something I would say at the end of the day, if you do encounter issues or questions from this, consult a JD or a legal counsel that's your employers, because it can sometimes be confusing. So alcoholism or alcohol use disorder, it can be a protected disability. History of drug addiction can be a protected disability. Being under treatment for substance use disorder of any kind can be a protected disability as well. However, if a donor test positive for any controlled substance that is not medically authorized, they cannot show that, you know, they have a medical use for their substance, they're automatically excluded from, sorry about that, that's my 50 minute warning. The donor is automatically excluded from protection under the ADA. And the ADA does not interfere with an employer taking appropriate action for alcohol or drug use or impairment on the job. So alcohol, it's tricky, I think because it is a legal substance, though that we have a lot of use disorder. It's, you know, it's, I say, you know, I say as a medical test, pre-employment alcohol testing is prohibited by ADA. And that can only be performed after a job has been made, a job offer has been made. And drug tests are not medical examinations under ADA, so they're not subject to the same restrictions as other employment physicals. ADA does not impact an employer's ability to perform drug testing for applicants or employees. So the key here is, you know, before any job offer, you should not test for alcohol, but you can definitely test for drugs. All right, so the last part of this presentation, I just want to spend a minute on language use. I think people that were in the session on Monday have heard about this as well. And as I mentioned, you know, at the beginning of this talk, substance use disorder really is a chronic medical condition. They don't choose to live this way. 40 to 70% of it is because of bad genes or genetic condition. So you're, you know, you're interacting with a patient, you know, at their lowest point in their lives, especially when you're at an occupational health clinic, they're here, they are concerned that they are going to lose their jobs, and, or, you know, they just don't want to talk to you because they think that you are going to talk to HR. So words that you use can really, you know, save a life of somebody who's suffering. So it is very important for us to use the right word. Obviously words like user, addict, junkie, alcoholic, you're drunk, and former addict, and all that. Those are words that are pretty stigmatizing and it reinforces the stigmatization that we have as a society. So instead of that, it sometimes can be a little bit lengthy, but use the word of, you know, suffering from substance use disorder, suffering from opiate use, people in, a patient in recovery, or just patients. Those are better word usage. And a lot of times we use the word clean or dirty and when we talk about a urine, I hear a lot about that. And it's definitely something that I cringe every single time I hear it and try to correct it. When you say somebody is clean or dirty, you are stigmatizing that person and their condition. So instead of that saying positive test, negative test, or consistent test, inconsistent test, those are better word usage. And, you know, patients can hear you. You might think that you're talking to a medical assistant down the hallway, but the walls are thin and, you know, if they hear that, they're, you know, it's just going to hurt them more. And the same thing with your medical assistant, because they don't have the same kind of clinical training as we do. So sometimes they use words that they see on TikTok, and then they say, oh, that patient has a dirty screen. Those are words that we should definitely correct whenever that we hear them. All right, so now we get to the Q&A session. We have about six minutes. Feel free to type in any questions that you have, and which will be anonymous, or you can just raise up your hand and ask questions. I'm going to start with, yes, well, I will share my slides after the meeting. I was making them until last night, so I wasn't able to share them. And how often is the Substance Use Across Industry report updated? This is a really great question. I have not found a report, an updated report, aside from that one. Maybe it's, I think it's time for them to update it. So that's definitely a good feedback. Safety, yeah, safety is important. Questions? Yep. What is your definition of this substance use disorder in marijuana, with marijuana being legal in so many states that are not supposed to be regulated? Yeah, that's a really good question. So the question is, what is the, I think it's the definition of marijuana and substance use disorder, and also like it's been legalized in so many states. It is a headache for, especially for occupational health. And let me put it this way. Legalization does not mean that it's not a medical condition, right? So it is still a medical condition when you're diagnosing somebody with marijuana use disorder, we're still following DSM-5 on those criteria of, the craving, withdrawal, dependency, and interfering with job duties and personal relationships and all that. So there is still a spectrum of marijuana use being really recreational use, somebody just having a brownie over the weekend because life is hard. And then somebody who is using it on a daily basis, then that's, you still go by the definition of DSM-5 to diagnose someone. As in terms of how to deal with this legalization in occupational health setting, I think that is, that itself can be a one-hour talk. Any relationship to, do you think impairment testing is better than drug testing for random testing? I think that's a great question. I just don't think that there is an impairment testing that is universal, in my opinion. And it definitely is something that we need more evidence and more research on. And it's easier to just use drug screen as positive or negative for compliance for a program. So I think that's a good question. And any other questions? Yep. Yeah, thank you. It was a great talk and slides that you're sharing. I was recently asked on behalf of an employer who does pre-placement cotenine testing for smokers. Pre-placement what? Pre-placement cotenine. They've seen your testing for new hires, but will conditionally hire them if their negative 10, 90 days is permanent. Not a bad idea. Do you know if there is a drug test that will differentiate the values from a pre-placement? If not, where might you apply the testing? That is a really great question. The short answer is I don't know, and I'll be candid on that. And I think, you know, when we do drug testing, we have to be careful because it's always very controversial and I get where the employer's coming from. But, you know, it's also important to know that there is that five stages of change. And when we think about CBT, when we think about motivation interviewing, which is something we talk about a lot in substance use disorder and mental health, if somebody is not at that stage, if they are made by the company to do something, the effect of that might not be lasting. So just something to think about when we talk about nicotine replacement and smoking cessation programs in the workplace. Yeah. Do you have recommendations or best practices for companies with substance use recovery programs or literature to support those programs? Yeah, yeah, I think that's a great question. There's a lot of literature showing the return of investment in companies that provide a more comprehensive approach to substance use recovery. That being, you know, having a center of excellence or working with a third-party vendor to provide substance use care management to their employees. And I can definitely share those literatures with you afterwards. Yep. So, as we know, THC is an issue for all of us, right? And have you heard of any advice or any research that's being done to be able to determine the level of THC like you do for alcohol, right? To determine if they're currently degraded. Right now, there's no way of knowing if they've smoked two minutes enough or if it's a positive from last week, right? Yeah, yeah. So, what's the stage of challenge and what's the advice for you when you get there? Yeah, that's a great question. To my understanding that there is, so here's the thing about marijuana or THC in general is that it is so complicated in terms of their mechanism and metabolism. And that, and also we don't really have a correlation between concentration and impairment. And everybody's tolerance, especially when it comes to marijuana is very different. So, even if there was, and also because it is illegal on the federal level. So, there is limited federal fundings and research into marijuana right now. So, we still don't know. There's a lot of things that we still don't know, but there's more research on impairment in Europe and in Canada, but not here in the States. The short answer is that there isn't a good way to correlate that right now. And also that I think there's a lot more that we need to do to get to that stage. Yep. I have looked for information, but have not found information on the specific impact of alcohol withdrawal syndrome on safety at work. And I wonder if you're aware of any literature that looks at that in particular, not the general issue of alcohol use disorder. Specifically on the period of withdrawal? Correct, because it creates a lot of issues for people in terms of performance. I'm just curious if you've looked at that. Yeah, that's a really great question. And top of mind, I don't really, I can't really think of a literature that specifically look at the impact of withdrawal, alcohol withdrawal to the workplace or workplace safety, but I can definitely get back to you on that. Great, and if I can offer a comment. First of all, I've attended both of your lectures. I think they're marvelous. Thank you. Great command of this and a gift for laying it out for us. I would love to see a talk in the future about the various roles that occupational physicians in different settings can have in dealing with this complex issue. One of the things I have in a clinic, in a mill somewhere, is the opportunity to sit down face to face with someone and talk frankly about what's going on, which is a wonderful opportunity. But there are lots of other practice settings and lots of other ways we can be helpful. So just a thought. Yeah, yeah, that's a really great comment. Thank you, and that's probably gonna be my presentation next year. I know we're over time. Thank you all for coming. Last question. George Borosdi, I'm president of Portuguese Society of Patient Medicine. Last year I made a presentation, a concurrent session about alcohol, tobacco, obesity, and sleep. And about the alcohol, what we know is the factor context around is very important. So our systems are very different from Europe, from the United States. And if we focus only individual, if we stay only in the clinic, if we don't do the program and don't do the prevention collectively in the field with the colleagues, with the peers, with intervention in the group, I think we will fail much more. Or otherwise, other way to say, and I ask your opinion. What about to think that always we need to act with the help that the surrounding could give us? What do you think? Yeah, yeah, that's a really good question. I think substance use treatment, a lot of it is peer support. And this is why AA, even though some people say it's too religious, actually has been demonstrated to be one of the most successful way of alcohol cessation. And there are a lot of recovery groups that provide similar sponsorship. And from what we're seeing from literature, counseling, and also peer support group are what maintains one's recovery and sobriety continuously. So thank you for that comment. Thank you all. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

substance use disorder

workforce

employers

employees

occupational health physicians

comprehensive approach

prevention

treatment

telehealth

marijuana legalization