Good morning, everyone. My name is Dr. Yang, and I'll introduce myself. I am the Associate Program Director for the Occupational and Environmental Medicine Residency Program at Harvard, and also Assistant Professor of Medicine at Boston University. I am board certified in three specialties, internal medicine, occupational medicine, and addiction medicine as well. And today, I am very excited to talk to you about this topic, substance use disorder in the workplace. This time, the discussion is going to focus on how to identify and provide recovery support as an occupational medicine clinician. Disclosures. I work with a few different companies, and none of the disclosed entities are ineligible company in the field of substance use disorder, and none have financially sponsored, guided, or reviewed the content of this session. All views expressed here are my own. They're not directly from my institution, including Harvard, Harvard University, and Boston University. Okay. That was a lot. So this is going to be an interactive session, so if you can take your phone out and scan the QR code. If you're on your laptop, feel free to go to slido.com website and enter the event code. Well, let's take a practice run on Slido. Did you attend the substance use disorder session at last year's AOHC when I presented in Philadelphia? Okay, so most of them know. That's good news. Good news is you're gonna learn a lot today. It's gonna be, you know, drinking down the fire hose kind of substance use disorder session. The bad news is I probably didn't have to make new slides. And also there's no loyalty program or punch cards for attending my session again. So case study. Let's start looking at a case. This is a 55-year-old male trained operator presents to the clinic. Showed up at work intoxicated and the MTA has a peer support group that they referred this trained operator to the EAP once they spotted him that he was intoxicated when he showed up at work. He got pulled away from work right away. When you see him, he reports that he was drinking one six pack per day. The last drink was before work that morning. And now when you talk to him, he said that he feels a little bit anxious. He has left hand tremor that he says gets better with drinking. He also told you that he had one failed rehab attempts in the past. He got kicked out of his house last night. His wife told him, don't come home until you get your life together. And that subsequently led to him intoxicated showing up at work. He has no history of DUI. He has no history of DT or ICU stay previously. And he doesn't really feel that he has a problem with alcohol. So the question, what do you think is the diagnosis for this trained operator? And again, the pertinent information is on top. It's a 55-year-old trained operator showed up at work intoxicated, drinks one six pack per day, feels anxious, left hand tremor, got kicked out by his wife, no history of DUI. Is that normal alcohol use? Is that at risk? Is that hazardous? Is that binge drinking? Is that mild alcohol use disorder? Would you say that he has moderate alcohol use disorder? Would you say that he has severe alcohol use disorder? What would your diagnosis be? I'll give you another 10 seconds before I move on. And on the Slido page, you can also ask any questions in the Q&A section throughout, and at the end, it's gonna show up on the screen. All right, so most of you guys answered moderate alcohol use disorder. Some of you answered severe. I am glad that nobody said normal alcohol use. All right, so the answer to this diagnosis by the definition of DSM-5 is actually severe alcohol use disorder. And you might ask why, or how do we diagnose somebody with a substance use disorder? So let's get the diagnosis right first. So how do you actually diagnose someone and with what severity, and why do we do that? The reason why we do that is depending on your diagnosis, you're able to say, hey, do you need a rehab or do you need to go to an outpatient clinic? And that's important because you don't wanna just send that patient to the emergency room right away. So the DSM-5 criteria for a substance use disorder, and this applies to any substance use disorder, including cigarette smoking, opiates, stimulants, anything you can think of. First, excessive use. Second is unsuccessful attempt to cut down. Tried to quit in the past, but couldn't. The third is excessive time spent on obtaining, using, or recovering from the substance. Fourth, craving. Fifth one is use interfering with occupation or major job obligations, such as showing up intoxicated. Sixth is use despite interpersonal trouble. So getting kicked out by his wife, that's interpersonal trouble. Use interfering with activities. Hazardous use. Hazardous use would be drunk while you're DUI or operating a crane while somebody's using fentanyl. Use is contributing to medical or psychological issues. So hand tremor would be one of them. Tolerance, building up a tolerance to the substance. Withdrawal symptoms as well. So if you have two or more of a criteria present over a period of 12 months, then that's by definition substance use disorder diagnosis. And also we have to look at that alcohol use disorder. It's actually more of a spectrum. You start with what we call, because it is a legal substance. So you start with the low risk category where it is what we call a healthy drinking or staying under the limit drinking. Based on the number of drinks, male on average of 14 or less drinks a week and female, it's average of seven drinks per week. And it goes to the severity of, and then it goes on to progressing to hazardous drinking. That means that the value is greater than the safe limit. And then it goes to harmful drinking. That's the introduction of alcohol related consequences, such as DUI or showing up at work intoxicated. Then you really get into the part where somebody can actually be diagnosed with an alcohol use disorder. And as I mentioned, this 11 criteria, two plus that would be a diagnosis. And based on the number of symptoms, then you can say two to three would be mild, moderate would be four to five, and then severe will be six plus. So let's go back to this case again. So 55 year old train operator show up at work intoxicated, drinks one six pack per day, six times seven, that's 42 drinks a week. That is a lot. So you get the first one, excessive use. Feels anxious since last drinks. So this person is withdrawing. So that's second criteria. Feels left-hand tremor improves with drinking that you can say that it's used contributing to medical or psychological issues, or you can also say that that's tolerance. So that's at least three. And then one failed rehab attempt. So that meets criteria number two. So that's four. Got kicked out by his wife. So that's used despite interpersonal trouble. So that's the fifth one. No history of DUI, no history of DTI to use stay. It doesn't feel like he has a problem. And then he showed up at work intoxicated. So that meets criteria number five. Use interfering with occupational or major obligations. So this person has at least six of them. So that's why we would diagnose that as a severe alcohol use disorder. So some need-to-know basics for substance use disorder. Everyone heard of the three waves of opiates in the past? Yes, raise your hand. No, yeah, okay. So that's why we say a lot like the three waves of opiates starts from the rise of prescription opiates used in the early 2000s. Pain clinics were setting up everywhere, Florida, if you watch Netflix documentaries. And then you get into the second wave because we start cracking down on prescription opiates. Those pain clinics started getting rated by the DEA. So then by that point, people resorts to heroin because it's easier to get, you don't need a prescription. And then the third wave started with fentanyl, which is the majority of what you see right now out on the street is fentanyl use. And then the fourth wave is what we're currently are in right now. It's fentanyl mixed with stimulants. So it's what we call a downer with an upper. So it's creating a lot of overdose and a lot of serious issues. 10 classes of substance use disorder, alcohol, caffeine is one of them, cannabis, hallucinogens, and inhalants, opiates, sedatives, stimulants, tobacco, and we group together everything else to other well-known. And so before I go on, I want to ask you guys this question, more than half of an adult's risk factors for substance use disorder can be attributed to, is it environmental factors, such as peer use, siblings, friends using it, so they started using substances. Is it prenatal exposure? Is it genetics? Is it family dynamics? Is it from their past trauma, domestic abuse, sexual assaults? Is it because of life stress that contributes mostly to their use of substances? All right, I am gonna reveal the answer in three, two, one. Genetics, life stress, past trauma are the top three. This is really great. The answer to this question is genetics, and I'll show you why. This is a famous study, it's called the Harbert-Twin Study, and there's multiple studies afterwards that also use similar model to sort of further proven this in other substances as well. This was done on cigarettes. And that, you see, the blue one, the blue part, the light blue is environmental factors, the dark blue is individual-specific environment, and then the red part is the genetic effects. Early on in their life, in someone's life, it starts out to be more environmental factors, such as, as you can probably think, peer use, we see that a lot, e-vaping in kids. But as you get older, the risk of, or what is contributing to substance use actually becomes more genetics. If somebody is still struggling in their 30s and 40s with substances, more than half of that is contributing to the genetic effects of it and not the environment. And why is that important? The importance of that is to understand that substance use disorder is not a moral failing. It is not because somebody just can't get themselves together. It is not because that they are in a family environment where it promotes substance use. It is actually, you have to understand and think about that genetic plays a lot in this factor. So when they come to seek help from you, or when they're disclosing that they have a substance use issue, because it is such a stigmatized topic in our society, it is important for us not to use words that will further stigmatize the situation and that will make them afraid of talking to you or revealing more of the situations so that you can get them to support. So words that we should not be using, and this is also in the DSM-5 criteria, when they revised it back in 2013. In the past, we used to use a lot of words like addicts, user, junkie, alcoholic, former addict, and anything that has the word addict in it. We don't use that anymore, or we try not to use that as much as we can. Instead, saying something like person with substance use, person with opiate use, or person in recovery. And abuse is also a word that we want to try to avoid. And we don't wanna say substance abuse, instead we wanna say substance use disorder. I know it's a little bit more words to use, but not using the words abuse or addict is moving one step further from stigmatizing the situation. Also, we hear this in clinic a lot, using the words like the urine is clean, or the drug screen is dirty. And I hear that all the time of the MA talking to a provider using the word dirty, the drug screen is dirty. We wanna stay away from that, and instead try to use the words of positive test, negative test, instead of clean and dirty. It's important for us because words matter, and the way that you word, and the way that you talk to the patient would make them run away from you, or open up more to you, and promote recovery as well. All right, so prevalence of substance use in the general population. It is a lot more than you might think. This is from data from 2021 from SAMHSA. Past year substance use disorder in America, that's about 17% of the adult population. Of that, alcohol use disorder is about 30 million people. Then you get the drug use disorder, marijuana use disorder, and all the rest. And not to forget that there's a lot of overlap as well. For somebody who has an opioid use disorder, 99% of the times that they do smoke cigarettes as well, and we forget that cigarettes is also a substance. And for people, alcohol, about one third of them would also be smoking as well. So the other part is that most of these people that use these substances are actually very active in the workforce. They're not the typical picture of what you see on the news of somebody walking on the street intoxicated, or injecting substances out in the open. They are actually the secretary that has a morning cup of joe, but instead it's Bailey inside, or the train operator that shows up to work drunk. That's about 70%. Of all the workforce, when you think about it, most of the people that have a substance use disorder, 70% of them are actually active. They're what we call functional, and you just don't know that. They just don't talk to you about it. So this is also a reason why it's important for us as AHRQ health providers to actually screen them, and to make sure that we ask the questions that we should be asking. And this is not in your handout. I added this last night. If you work with different industries, and if you consult with a lot of different occupations and industries, this is actually a really good report to use to take a look at the prevalence of substance use disorder in that specific industry. The QR code on the slide gets you to that report. Unfortunately, this report was published in 2012, and it showed the prevalence, past year substance use prevalence, between 2008 to 2012. We unfortunately don't have any report that is newer than that, but the thing that we know is that substance use is only getting worse in our society, so these numbers are probably an underestimation of what the current situation is. This chart shows you that in the category of past year substance use disorder among adults, we see the industry that's impacted the most is hospitality, accommodations and food services. That's about 17%, and construction, 14%. I had a lot of patients, most of my patients in the past are construction workers that's using opiates. It all started with them getting injured at work, they got that first prescription, and then they started just snowballing after that. You got a lot of arts, entertainment, and recreation industry as well, about 13%. We know that alcohol use is very prevalent, so are stimulant use as well. For the hospitality industry, the most commonly used substance in that industry is actually cocaine. And I've heard stories of chefs that said that they would need to go to the back alley during their breaks to do a little bit of cocaine in order for them to continue to work because of just the stress and that they have to stay very mentally alert when they're on shifts. Even in healthcare, that's about 6%, so it is a very prevalent problem in all kinds of industries. And the next question is, why should employers, and why should us as health clinicians care about supporting employees' recovery? Any one-word thoughts, we can shout that out? Anyone? Why do we even care? Safety, yes, I was gonna say that. That is definitely gonna be the first answer that I hear. Any other answers? Yes, yes, yeah. And I actually have data to show you that. Any other shout-outs to this question? Retention, I heard that, yeah, okay. So absentees and retention and all that. Those are really great questions and answers. And one of them, if you're a corporate medical director, that you have to think about is cost, cost to care. So the first one is safety impact, right? So this is all in your handout. Different studies showed different impacts of what substance does to the workplace. Up to 40% of all industrial workplace fatalities are caused by individuals with a substance use disorder, 40%. Almost 20% of people that are injured at work showed up to the emergency room testing positive for alcohol. So all of this are important safety factors that we have to think about. Why do we want to support people to recover? It is not an individual issue. It actually is a safety issue. It actually impacts others as well. It impacts the bottom line for the employer as well. This study came out last year by the CDC. They analyzed and they looked at 162 million employees and they highlight that substance misuse or substance use is a top five cost driver for employers. And it would contribute the annual attributable mean cost of any kind of substance use disorder, including multiple substance use disorder was $15,000 per employee. So that's a lot. It's a lot of money that the employer is throwing into this issue. And if you can get people to recovery, the cost of care for, especially for self-insured employers, it goes down dramatically. And then the third part, workers in recovery, and as someone said, they actually make really good employees. This study looked at a model that look at missed workdays. And the red circle box there, it showed the total missed workdays for the general workforce in this study was about 67,000 respondents every single year. In that survey, the total missed workdays was about 11 days for the general workforce. As you can see that people with substance use, it goes up. But if you go to the very right hand side, the employees in recovery, their total missed workdays are actually less than the general workforce. So to someone's point, they do make better employees once you promote them and support them to recovery. And that also, there's another study that also showed that retention is a big key as well. If you support them to recover, they're two times more than the general employees in retention rate in not switching to a different employer. So the next topic I wanna talk about is sort of the meat of today's talk, is substance use disorder diagnosis and treatment 101 for all health clinicians. So what can we do as all health clinicians when it comes to this topic? I think there are three clinical techniques that's very useful for automatic clinicians to support substance use disorder employees. The first one is SBIRT. The second one is understanding readiness for change. And then the third one is motivational interviewing. Does anyone know what SBIRT stands for? Anyone? Has anyone heard of SBIRT? Brief intervention. Yes, B-I stands for brief intervention. So SBIRT is an evidence-based and highly effective strategy and a way of using in the clinic. S stands for screening. So identify individual at risk. Brief intervention. Provide personalized feedback and some advice. It can be very brief, five minutes or less. Referral to treatment. Timely connect that individual to the appropriate care. And it is highly evidence-based and it is very cost-effective. A study showed that every dollar that you invest in SBIRT, whether getting software or just your time, it's a potential saving of $47 in healthcare costs. So how can you do SBIRT at your clinic? That's the next question. Audit C, alcohol use disorder identification test. This is one of the many screening questionnaires that you can use. It's a very easy three-question questionnaire and it can be self-administered. You don't need to ask your employees this question. You can just put them on a piece of paper and they can answer it while they're waiting for you. And positive screen for men is four or more and for woman is three or more. And there's a lot of other tests as well. And this is also on your handout that you can use. And I included a link to the website. These are all clinically validated ways of asking them. There's a difference between adults or adolescents, it's alcohol or drug use, and how it's administered. It could be administered by the patient themselves or by the provider. So these two slides are charts of everything that's clinically validated that you can actually use in your clinic. And they actually link to the survey as well. So the next one is behavioral change is definitely very hard. So it's important for us to also take time to measure and to assess the motivation for change and the readiness for change. As we know that change is five stages, pre-contemplation, contemplation, preparation, action and maintenance. If somebody is at that pre-stage, no matter what you say, they're not ready. So if they say that I'm not ready to quit smoking, if you give them a box of Chantix, that's not gonna work. But if they are at the stage of contemplation, they're thinking about making a change, they're getting to that preparation part, you are gonna be able to support them and empower them to get to the next stage. And there's also studies showing that for people who are in the pre-contemplation stage, the number of times that a clinician talks to them about it, it increases the chances of them getting ready and be ready to the next stage. So that's why we need to ask them every single time they come in, what do you think about your smoking? Are you, you know, what do you think about it? Are you ready to make a change? And the more that you ask them, the more that they will think about it and the more that they'll be ready to get into the next stage. The next part is motivational interviewing. So we don't really, at least during my training, talk a lot about motivational interviewing. And it is definitely something that is very important and not just in your substance use disorder field, it's for anything. It's for anything that is related to behavioral changes. If you tell somebody, you know, I think you should try to cut down on eating sweets or, you know, lose some weight, they're not gonna be ready or receptive to that. But if you use a motivational interviewing technique and you ask open-ended questions, you provide information and you listen to them and using all these techniques, you're able to enhance and empower their own motivation and commitment to make a change in their behavior. Studies have shown that they can increase 10 to 15% increase in the likelihood of reducing alcohol use. So it is just as effective as a CBT therapy. The key to this is ensuring that you're expressing empathy and avoid confrontation. And I'm sure that you've all had your own personal experience of going to that PCP and that PCP says, you need to do this, you need to do X, Y, Z, or you're gonna, I guess, die or something. That never works. People just, you know, the patients just run away from that person. So express empathy, avoid confrontation, and you explore that change behavior and you affirm that and you provide that positive feedback. So always make sure that you're, you keep an open mind on what they say to you. And in that, they're gonna be, in return that they're gonna open up to you as well. Next question, which of the following is the number one preventable cause of US mortality? Oh, this is actually a title question. So you can put your answer in the app or you can shout it out and influence other people's ideas as well. Okay, cardiovascular disease, yes. I trick my residents into answering cardiovascular disease all the time. The answer to this question is tobacco use. We tend to forget about tobacco these days, but the average, the national prevalence is still about 14%, so tobacco use is still the number one preventable cause of U.S. mortality, with about 480,000 deaths per year. Current U.S. prevalence, about 14%. I highlighted in yellow that I think there's, people are very jaded, especially clinicians, that, oh, people who smoke, they're a chronic smoker, they're never gonna make a change, but 60% of them are actually able to successfully quit smoking, and almost 70% of the current smokers, they actually want to quit. They just, no clinicians talk to them about it. And we should not and cannot count on PCPs to talk to them about smoking, because PCPs are also burned out. But we're the happiest and least burned out specialty in the world, and we have a lot of time. Well, not a lot, but we have more time. So definitely make sure that you use that extra five minutes during the encounter to assess them and to provide support to them. Treatment, I personally think treating smoking cessation, or smoking cessation is something that we can do as an AHRQ Health clinician. It's very easy, there's not a lot of risk. It's nicotine replacement therapy, and you potentially will use bupropion or Chantix. Bupropion, another name for it is robutrin. The effects, Chantix is better than bupropion, and then better than a nicotine replacement. Studies have shown that combination therapy actually works a lot better. So think about, instead of just using a nicotine patch or ask them, you know, just put on a patch, think about that plus a Chantix, that plus robutrin. So you work from reducing Chantix, reduces the craving, and then the nicotine replacement, the patches, the gums, that actually help with the withdrawal from tobacco. So that's why it's more useful and more successful than just using a monotherapy. The next question, every patient diagnosed with alcohol use disorder starts their treatment journey with detox and rehab. We see this a lot in MTV, I guess. You know, celebrities going to Malibu rehab, and that sort of is ingrained in our society that, oh, you have an alcohol use disorder, let's send you to a rehab. Okay, false, very good. I got 3% that answer true. So substance use treatment care is a continuum. This is the chart that's made by the American Society of Addiction Medicine. So not everybody starts at detox and rehab. In fact, only about 20 to 25% needs to be managed in a rehab setting. 75 to 80% of them actually can be safely managed at an outpatient setting. And as you can see on the very left, prevention is key, that's level 0.5, is you don't want them to progress to the stage where they start needing real treatment for substance use disorder. Alcohol use disorder treatment, this is a very, very broad and general overview of what are some sort of the modalities that we use. I would say if you work in an industry that has a very strong union, or that has a strong EAP system, as occ health clinicians, my suggestion would be to make sure that you work with them and not just, you know, turf them to somebody else, but actually work with them. Do warm handoffs, referrals, talk to those people, talk to the support groups, talk to their EAP to ensure that the best treatment facility is identified and that they actually get treated. Most of the time, we just send a referral and just say, hey, like, you know, go see an outpatient clinic and that's it, and then they will come back to us. So it's important for us to actually, you know, have that closed loop communication with them. So detox, withdrawal, detox and rehab, that's a typo. Detox and rehab facilities, usually it's two to seven days of detox, and then three to four weeks of rehab. And then you have what we call the intensive outpatient treatment. Outpatient management typically consists of counseling and medication-assisted treatment. And medication-assisted treatment, we have, you know, the very, very old medication that pretty much nobody uses anymore is Entebuse, which is Staxofram. It makes you sick if you take it. The problem with that is if the patient does not take the medication and, you know, they won't feel sick when they drink alcohol, so the compliance rate is very poor. And then you have, you know, Traxone, IM injection or PO, and then you have Icamprosate. There are other medications that's currently being investigated or off-label use, so I'm not going to talk about them. Another part that I want to spend some time on talking about is harm reduction as well. Not everybody, absence is not everybody's goal. And harm reduction in substance use. So this is the part where, you know, we talk about harm reduction in a way that we're not talking about safety injection sites or clean needle program. Those are part of harm reduction as well. What the harm reduction part that I want to talk about is, for a lot of people, abstinence is not the only way. If you can get them to actually reduce the amount they drink, especially in alcohol, or reduce the amount of cigarettes that they smoke, they might not get to that point of abstinence on day one, but over a period of time, it has been shown in studies that they will get to that pathway of abstinence from the substance. And this is what's called a combined study, which shows you that, and this is the WHO alcohol risk drinking levels, categorizing people from low to very high risk. The combined study showed that if you move somebody from one category over to the left, whether that being very high to high or high to medium, just one category, it significantly reduces systolic blood pressure and improvement in liver enzyme, and just significantly better quality of life. So the goal here is, somebody comes in, abstinence is never the only answer, unless they're in a safety-sensitive position. And a lot of them, they can actually start by just reducing the amount they drink. And at one point, they are going to be completely free of substance, potentially. Naloxone is also important, Narcan. And when I talk to different industries, leaders and employers, some of them are thinking of putting Narcan or giving Narcan to shift managers and supervisors, which I think is a very good idea. Studies have shown that Narcan does not promote use. I think that is a misconception of, oh, like if I give the supervisor Narcan, am I trying to promote that this is a workspace that promotes drug use? Studies have not shown that. Studies have actually shown that it saves lives. So that's something that's very important to think about, and it doesn't increase liability. I would say that if you don't provide Narcan to them, that's probably more liability than not to. All right, next question, and this is, I think, the last question. You get a PCP that came in to consult you because they know that you're an ArkHealth physician and that you are also certified to do DOT exams. So a commercial vehicle driver came in with opioid use disorder. They're very stable in recovery on medication. Per the current FMCSA guidance, which FDA-approved medications below will automatically disqualify that patient? Is it naltrexone? Is it suboxone? Is it methadone? Is it suboxone and methadone? Is it all of the above? Is it none of the above? Key to this question is, will automatically disqualify? And I know that there's a DOT session just before this, and actually right now. So they talked about this probably like an hour ago. All right, methadone, none of the above, 40%. Methadone, 30%. All of the above, 20%, interesting. Okay, so the answer is actually none of the above. And this is because that the medical examiners handbook 2024 edition that just came out in January actually says that methadone and suboxone are no longer automatic disqualifying medications. In the past, methadone was an automatic disqualifier, but it's no longer the case, and suboxone as well. And naltrexone, it is not an opiate. So, and it only works to reduce the craving. So it has traditionally always been allowed by the FMCSA. And some people might have the question of, wait, am I out there on opiates? Like you think about safety, you're like, oh, they're driving with an opiate in their body. Is that even safe? Like, do you feel, am I, do I even feel comfortable as a narc health provider to let them drive? Who thinks that, you know, who has like concerns about that? Yes, no, ish, maybe? Okay, yeah. So I'll tell you, this is the way I think, and this has been shown in studies as well. People who use an opiate, they, you know, the level of opiates in their body with fentanyl, with all the other medications are so high that the, really the dangerous part about fentanyl is the fluctuation, you know, of going extremely high and then going down to baseline. You have to, you have to always recognize that these people are already, they already have built up a physical and mental tolerance to opiates. So they actually function on the baseline with opiates in their body. So this chart shows you that buprenorphine has what we call a ceiling effect. The good thing about methadone and buprenorphine is that the blood serum concentration of these medications are actually very stable, especially for buprenorphine, it actually has a ceiling effect, so you don't get the fluctuation. So you sort of provide them that baseline of that opiates that's already tolerated by their system, and you don't go up, you don't shoot up high and then come back down. That all the way up is where they, they're gonna be very unsafe, it is where they're gonna start having issues. But if you keep them at a certain level, that actually helps them to function and be a contributing member to the society, and that doesn't cause a significant safety concern. I can tell you that people that are stable on suboxone, they probably can catch a baseball more than you can, or at least I can. So that's what the ceiling effect is, so there really isn't a lot of concern in terms of that. But then, that's the one thing that, why the guideline says you have to talk to their treating provider, because you have to make sure that they're actually stable in recovery. And a lot of people on suboxone and methadone, they've been recovered for like five, 10, or I have patients 20 years or 30 years. So it is definitely something that is very, very effective. And once they recover, they're very successful in recovery as well. Some shows that I recommend, Dope Sick, great show, you're gonna get sucked into it right away. It is not a typical documentary, it focuses on people that's impacted, it's a story. It's a very captivating story about that Virginia town that started, people started dying, and how that's impacting their lives. And the center of the story is that doctor who also got addicted to opiates, Oxy back then, and how he's fighting back to Purdue. Painkiller focuses more on the Sackler family. They portray Richard Sackler as this weird, very odd guy, he kind of is. That's on Netflix. And also Pain Hustlers, that focuses more on the Purdue sales strategy, and that's like a movie by Chris Evans. So if you like Chris Evans, that would be a good two hours for you. So these are shows that I recommend. They're great shows for the topic of opioid use disorder, and just to understand what our society is going through. Oh, that's pretty much it. So there are no questions, but this test one that I entered last night. So any questions from the audience? And before I open up your questions, if you need any support on your organization's substance use disorder policy, if you want, if you're a medical director, if you're in charge of a health clinic, and you want me to provide some educational sessions for your providers, I'm happy to do that. Just send me an email and we can get in touch. Yeah. Yeah, that's a great question. There really isn't a number. I would say six months is actually already pretty good. It depends on, well, first of all, it depends on your population. If your population is the unhoused, it's, you know, it's, they, you know, the expectation of them in recovery and being stable is a lot less or shorter than people who are stable but who are active in the workforce. People who are active in the workforce, they're functional and they have, a huge part of this is the support surrounding them. So if they have enough support, they're usually pretty well on recovery. And it sounds like your client is in, probably in the safety sensitive industry. That's probably the concern there. And you know, there, I would say that there, you know, specific guidelines from, on this from the DOT if it's in the transportation industry. Other than that, it requires and it requires sort of a collaborative discussion with that treating provider. Because the treating provider of that employee actually has a lot more data than just that six months. They have their prior history. They have, you know, a lot more history on that patient. So I would say have a collaborative discussion with them, with that person, with that PCP. And assess whether or not six months is, that person is stable. And another part of it is also, when, I cringe every single time that people say that this is a legal issue, that's, you know, we always have to have clinicians on the table when making policies like this. So it's also a joint discussion to actually say, hey, let's sit down and set a policy on this and talk about whether or not this is the right thing to do. People, a patient as well. A patient on methadone therapy with 110 milligrams, phase 27, quite stable during the last six months. All the tests were integrity, so any tension or symptoms in the jawlines. Patients are actually quite stable without any craving. Patient's psychiatrist is clear for any comorbidities. Sleep study was good, and he wanted to come back to the job. What do you offer to the employee? Also to this patient, switching to Suboxone, switching to sleep study, switching to naltrexone, or send the patient with 110 milligrams to this sensitive job, working in a nuclear plant near the city that you and your family are also living in the same city? Switching from methadone to Suboxone takes a lot of time, and it's years before that person is stable enough to actually say, hey, let's consider Suboxone. We have a lot of fear when it comes to methadone. The thing is, methadone needs to be administered by a methadone clinic. That actually is the strictest compliance program in the world. So that person is stable on that dose and functioning, and if they pass all of the cognitive and physical tests that you give, you throw everything in the kitchen to that person, and that person is still able to do their job. From an addiction medicine point of view, I do not see why that we would say you cannot do your job and you need to do something else. We also have to think, I get that there is a balance between safety, and we also have to think that that's that person's life. If you restrict them, if you give them the no and they get terminated, you're upending their whole world, and that is actually one of the most common triggers that we see for people from stable to unstable. These people, once they have a financial catastrophic event, they end up on the street. So that's something to think about as well, just balancing that. Yeah, yeah. That's a really great question on healthcare. I will tell you that substance using the US healthcare system is significantly more of an issue than on the global level. We are in the crisis of substance, comparatively speaking, with other countries or other westernized countries. With a lot of historical issues with opiate misuse. The prevalence, there's a few things to think about when it comes to healthcare. Still, the number one prevalence is still alcohol and tobacco. They're sort of fighting for first place. You see a lot of nurses that they're still smokers. If you go to the outside of the hospital, you see them smoking all the time. And clinicians and healthcare professionals are typically the one that they think, that they know their body the best. And so it's hard to even open up and just that idea of quitting. But if you talk to them, they sometimes will actually tell you that, I just, I thought about it. I just never really got the chance to do so. So alcohol and smoking are the two things to think about. The prevalence of any kind of substances in the healthcare industry, we don't really, different studies that you look at has different numbers. I would say it ranges anywhere between five to 10%. So that's something of concern as well. We only, the cases that only gets to us are those that are stealing fentanyl. Those are the cases where, and that's already too late. But there are others that are sort of just under the surface, like the iceberg, under the surface that's about alcohol, that's about tobacco and all the other things. And a lot of, well, not a lot, but there's a lot of cases for, that goes to the physician health service that is because they use stimulants or they misuse stimulants. So those are things to think about as well. Yeah. Yeah, as you look at your crystal ball, what are your thoughts about THC and safety in the workforce? Ah, okay. I know that question was going to come up. I have a slide on marijuana use. I did not add that in because I thought I was going to run out of time, but the slide actually didn't take that much time. So we have time. Marijuana is really a topic right now that we talk about. It is the third most common used psychoactive substance worldwide after tobacco and alcohol. It is right now at schedule one, but as you have heard from the Biden administration that they're declassifying it in, not declassified, but they're reducing the schedule probably at the end of the year. What does that mean? It doesn't mean that we are promoting or advocating for marijuana use. It actually only means that people don't go to jail because they use marijuana. So that's the point. It's about the correctional system. It's about our legal system. And also that it opens up to, now we actually get a chance to actually do some research on impairment. I don't have an answer for you. I, you know, for this, because we don't have any data and rescheduling it actually provides us the opportunity to actually start looking at impairment and for us to use grants and funding to do that. So my short answer for your magic able question is just similar to all the others. We have to think about tolerance, right? So a lot of people who are getting to the criteria of marijuana use disorder, they have a certain level of tolerance. So they're functioning in that level, but does tolerance mean impairment? It's not an equal equation there. So that's something to think about. And the first step to that answer is that we have to be able to study it. And we're probably gonna see a lot of study that's gonna tell us that in the next three to five years, and we're gonna be able to regulate it better. And, you know, putting it, rescheduling it does not mean that, you know, it's legal everywhere now for recreational use. It is still, you know, it depends on your state law. Rescheduling it, it's still controlled. So it's still only for medicinal use. For states that are not recreational, it doesn't give them the right to start using marijuana recreationally. Any other questions? Yeah. Do you have any comments on some state programs like AA in your field to be reviewed? Yes, great question. AA, I remember when I was still doing my internal medicine residency, that was, you know, there was a question on what is the best modality, the most effective modality for alcohol use disorder treatment. AA was the answer. AA has been most studied, and AA has shown to be, to have the highest success rate. I would say that treatment for alcohol use disorder, it is a combination of things. For a lot of patients, and AA, by the way, has a lot of like that, a lot of patients actually say they don't like AA because of that religious concept, and they have an issue with that. I also, I often tell them, hey, there are AAs that is not that religious. There are what we call them peer support groups that doesn't really just use that 12 steps. So there are different peer support groups that can join, but AA has been shown to be very successful. We have to combine AA with individual counseling and therapy, and also medication-assisted treatment such as naltrexone as well, because naltrexone is actually really, really effective. Number needed to treat for using naltrexone to reduce heavy alcohol drinking is only 12. So you can see that if somebody is on naltrexone, it's a very good medication to reduce the craving to, or the desire to drink, but we're not using it enough. About 1% of people that is suffering from alcohol use disorder are on naltrexone. The 99% of patients are not on, and that's, I think that's also, that's because we focus too much on AA and less on the medication support and the counseling support as well. Any other questions? Yeah. Yeah, curbside consults, that's a great question. Don't do them. That's my short answer. When it gets to substance use disorder, it becomes very tricky when it comes to legal HR implication of those. I would, my recommendation is have everything on paper. Ask them to send a formal evaluation. Don't give them advice or suggestions just based on them talking to you. Because you never know what's gonna come back and bite you. So that's my recommendation, and making sure that there is a paper trail. And because it gets into the space of ADA, and that's the part where you have to be very careful. And you also want to make sure that you are supporting that employee. And if they know, or when they talk to you and they feel like you've already talked to HR, you've already made up your mind, then they will just like, you know what, I'm gonna lose my job. I'm not gonna talk to you anymore. I'm not even gonna seek support. I'm just gonna go out and use my substance. So that's why I think everything should be in writing, and everything should be a formal documentation. Yep. Yep. Yes. In monitoring people with alcohol abuse, how quickly do you carry out the objective testing on the monitoring test? So your question is the frequency of testing for alcohol use disorder of people that is in the monitoring program. I am not a SAP, Substance Abuse Professional, so I would say I don't have the answer for that. And it really is individual-based, and it depends on what the SAP thinks of what is a typical schedule for that specific employee and whatnot, and how to do it. So, but you know, there really isn't a great answer on drug screening frequency, to be honest. Yeah. I think we have, well, just one last question, then. Yep. I'm from Illinois, and recently there was a news that like marijuana is not having changed for Schedule 3. So how, does it have an impact? Is it any related to how we are dealing with the substance abuse? Yeah, yeah, that's a great question. The question is more on gateway drugs. Is marijuana a gateway drug? There's not enough studies and evidence to show that. So does it lead to opiate use disorder? Does it lead to alcohol use disorder? There is not enough evidence to show that. Interestingly speaking, tobacco has actually been shown to be a gateway drug to alcohol and opiate use and other substance use. So when you say the impact of marijuana versus smoking, I would say that smoking is probably, that leads to, you know, that's a gateway to other substance use is more of what we know from the evidence. But I would also caution that we don't have enough evidence because marijuana has never been studied largely in a large setting in the past. If you have any other questions, I'm happy to answer that. And my email is here. Feel free to send me an email if you have any more questions. Thank you.

Dr. Yang

Associate Program Director

Occupational and Environmental Medicine Residency Program

Substance Use Disorder

DSM-5

Recovery Support

Stigmatization

SBIRT

Motivational Interviewing

Harm Reduction Strategies