Now, let's turn from substances of abuse to a quick look at treatment and rehabilitation. Remember, as MROs, we're only going to scratch the surface of this very complex area. And that's where substance abuse professionals and addiction medicine specialists will be great resources for us. It is vitally important that we understand drug rehabilitation from an employer's perspective. And this is so important that I'm actually going to read this to you. So for the employer, the goal is to permit an employee who has either violated drug and alcohol rules or an employee who has been identified as having a substance abuse problem to reenter the workforce. Some employers may have a philosophy of drug testing as a way to find them and fire them. Obviously, from a medical point of view, we want people to return to work and function at their highest capability. But in doing so, the employer and the public must both be protected by securing documentation that the employee is rehabilitated and no longer is using or abusing prohibited substances. The process of treatment and rehabilitation often does begin with our MRO interviews. Because in talking with somebody with a positive drug test, exploring the implications of that, letting them know that you'll be telling the employer and that the employer will be giving them a list of names of substance abuse professionals, we can encourage the donor to take this seriously, to see an SAP, and to follow through on whatever recommendations are made. So our first step is often the beginning link in a longer treatment and rehabilitation program. Remember that DOT does not require employers to either provide treatment for an employee or even to pay for an SAP evaluation. But some state laws have a higher standard, and they may require employers to offer treatment in lieu of termination. Treatment and rehabilitation are often highly individualized. Obviously, if somebody has been consuming large amounts of drugs and they're stoned, they may need to start with a detoxification program, which is often done as an inpatient. Once they're able to have outpatient evaluation and treatment, it could be medical treatment, but SAPs may also recommend what is called psychoeducation, where someone is taught to recognize the dangers of consuming recreational drugs, particularly in safety-sensitive situations. Once a person has been treated or educated, the key term in addiction medicine is relapse prevention, that is, preventing people from having recidivism. There are, of course, many inpatient treatment programs, although these have become less popular as cost constraints have come into treatment. There are many very effective family therapy systems and, of course, a lot of self-help programs, including Alcoholics Anonymous, Narcotics Anonymous, and others, and we'll go into those a little later. One of the vital components, though, of rehab and treatment is to have ongoing toxicology screens to ensure that the person has not relapsed and that there is continuing workplace safety. It is important for MROs to know about therapeutic medications. The classic drug used to treat alcoholics after World War II was disulfiram, or Antabuse. Alcoholics who had dried out would consume daily a liquid, and if they did take a drink, it would make them nauseous, they would vomit, and have systemic symptoms, and that's why it is called an aversive. In the 1960s, gentler and more effective drugs, such as naltrexone, were developed, and they also are an anti-craving agent for alcoholics. Naltrexone can also be used for opioids as an opioid blocker. And then you see methadone, buprenorphine, and suboxone, which is a combination of two drugs, can be used for opioid maintenance for those who are not able voluntarily to be opioid-free. This chart summarizes the major drugs that are effective in treating alcohol dependence. So in addition to the two we've discussed, you see that in 2004, acamprosate was also introduced and also that naltrexone can be injected in a long-acting form in depots. A burning question that you'll often be asked by employers is, how effective is treatment? Is it really worth the company paying for treatment, and can we really ensure that it's worth the investment? So I want to present to you the results of two classic studies. And although this is older data, it makes very key points. So the first is what was called treatment as equal opportunity. And what that means is that if you look at the percent of months that a main drug was used after treatment, you'll see that each of these paired columns shows a dramatic reduction after treatment. And that's true among men and women. It's true at all ages. And it's true with all different ethnicities. Here we see that effective treatment effectively reduces criminal behavior and healthcare utilization. So you see an 80 plus percent of reduction in the months of crime, 60 percent reduction in arrests, a 45 percent reduction in mental health and hospital episodes, 35 percent reduction in emergency room visits, and a 12 percent reduction in physician office visits, even though you would think that somebody being treated would have a higher utilization rate. The bottom line of treatment, of course, is economic impact. And here you see a cost-benefit analysis from this large major study, which compared the cost-effectiveness of residential inpatient treatment, social model treatments such as family therapy, outpatient care, methadone discharge, and then ongoing methadone maintenance programs. And the bottom line was that all of these methods were cost-effective, and the average benefit was $7 returned for every dollar that was spent. The other major study that we'll look at was the National Treatment Improvement Evaluation Study that was sponsored by SAMHSA. We'll present a number of key findings. The first is changes in the use of drugs and alcohol, comparing the 12 months before and the 12 months after treatment. And you'll see that whatever the primary drug was after treatment, the use was reduced by almost half. That was true for cocaine. That was true for heroin. That was true for crack cocaine. Financial activity was also significantly reduced, and that included beating somebody up, being arrested for any charge, and getting most of one's financial support from illegal activities, such as theft. The benefits to society were significant. Notice that a larger percentage of people received income from actually having a job. There was decreased number of people on welfare, and a significant decrease in homelessness. Lastly, SAMHSA found significant reduction in sexual behavior that put people at risk, and that included HIV risk among heterosexuals and homosexuals, and also a significant reduction in having sex for money or for drugs. Because physicians and other health care professionals have much more ready access to drugs, drug abuse is a significant problem among our peers. It's estimated that 10% to 12% of physicians in this country become addicted to alcohol or drugs. As a result, most state medical licensing boards, state medical societies, have supported the development of physician diagnosis, physician treatment, and physician monitoring programs, and licensing laws require a physician to report a colleague whom they feel is either addicted or providing poor quality medical care. These programs have become very popular. They've been well-evaluated, and here I show you the results of a study published in the British Medical Journal following 904 physicians in 16 states over five years. Almost 80% had favorable outcomes. 19% failed the program, that is, they dropped out of treatment or monitoring, usually early in the treatment process, but 81% completed the program, they resumed medical practice, and they continued to have substance abuse monitoring. Over the later five years, 19% of them did come back with positive urine tests, and that underscored the value of continuing monitoring. But after five years, 79% were still licensed and working. It's important for us to know something about MAT, that is, medication-assisted treatment, and I want to give thanks to my colleague, Jim Ferguson, who's an MRO. He teaches MRO courses, and he's also an experienced addiction medicine specialist. So usually when MAT is talked about, we're talking about these three commonly prescribed medications, methadone, which is a full agonist, naltrexone, which is an antagonist for opioids, and buprenorphine, which is a mixture of an agonist and an antagonist. They're used for treatment, and they have saved a lot of lives, but because they're all addictive, they also have had downsides. This recent data shows a progressive increase in the use of MAT, and that's true for methadone, that's true for buprenorphine, and also for naltrexone. The use of drugs containing a combination of buprenorphine and naloxone has become increasingly popular, and you see that they can be taken as tablets, they can be taken sublingually, and also a film that dissolves in the mouth. The use of MAT has been evolving, and as a result, the goals have changed and are sometimes unclear. Initially, MAT drugs were used as a short-term treatment method, a detoxifying agent, and they would help a person to get physiologically free from opiate dependence, and then they would be encouraged to go into an abstinence-based program. However, because of relapses and the experimentation with these drugs, a new philosophy has evolved that is called harms reduction, in which people are allowed to take the drugs for a longer time, not just a week or two, but for one to two years. And there's even a question about whether these people would be better off if they maintained it on a long-term basis. So as an MRO, we're going to be encountering people who are taking these MAT drugs, and we need to be familiar about them and whether they could influence drug test results. Now let's turn to alcohol, the most commonly abused and used substance in this country. As you know, there's been a kind of a raging debate in our society going all the way back to the revolutionary period. I live near Williamsburg, Virginia, and there was, during the revolutionary time, a great debate about whether the use of alcohol should be banned, and there was even a moral thermometer that talked about the benefits of abstinence and the hazards of drinking. Of course, this debate continued until 1919, when there was a constitutional amendment to prohibit alcohol. That experiment was not long-lasting, but it certainly activated a lot of people, including abused women, who had the statement, lips that touch liquor shall not touch ours. Despite alcoholism and heavy drinking being such a problem in society, it may seem surprising that it was not until 1956 that the American Medical Association declared alcoholism to be an illness and not a moral weakness. However, in the 30s, voluntary programs were started within the community, and two men, Mr. Bill and Dr. Bob in New York City, formed an organization that became known as Alcoholics Anonymous, or AA. They started out identifying six basic steps to recovery, and as they refined their approach, the steps grew to a 12-step method, and the book in which they were written became shorter and shorter. Other programs like Narcotics Anonymous or even Gamblers Anonymous have been built on the model of the self-help group, AA. And because of its historic and current significance, in this tab, you'll see some more general information about Alcoholics Anonymous, a identification of the 12 steps, and also what are called the 12 traditions. So that ends our run through substances of misuse and the treatment and rehabilitation. We're now going to turn much more directly toward urine testing, urine collection, and the MRO review of the results.

treatment and rehabilitation

substance abuse

employer's perspective

documentation

Alcoholics Anonymous