Good afternoon, everyone. My name is Dr. Stephen Mandel, and I am clinical professor of neurology at Hofstra Northwell in New York, and I'm also a fellow of ACOM. Today, we'll be addressing addiction as the healthcare crisis. As a neurologist, I have seen the acute and chronic consequences to include stroke seizures and death. When I think of addiction, I think of it in four categories that we will discuss today. Number one being prescription drugs, not only opioids, but tranquilizers, Adderall, and many other medications. Number two, illegal drugs, predominantly opioids and amphetamines and methamphetamines. Number three, over-the-counter medicines, including cough medicines, cold medicines, antihistamines, and motion sickness, and then alcoholism. The American Medical Association reported in June 2022, 107,000 overdose deaths. They also reported 996,700 near-fatal overdoses. 70% of those suffering from addiction are employed, the third leading cause of health problems in the United States. 7 million people are either dependent or addicted to chemicals, and those who have an addiction problem are three and a half times or more, more likely to have a work accident. It costs the American business $81 million. So we are beyond the stigma of atmosphere of silence. I'll repeat that, atmosphere of silence. And now we must put words to action. Today will be one more step in the process to understand the scope of this addiction problem and suggest programs that may have uncertain futures. So can we have the next slide please. I will initially do my presentation, then I will turn it over to the panel members, following which time we will have a panel discussion. We would like you to put questions in the question and answer, rather than in the chat, and we'll get to as many as possible. Next please. So I'd like to introduce everyone very briefly. Each person, upon speaking, will do a further explanation on who they are and why they're here. We have Doug Martin, Kurt Hageman, Fabrice Czarnecki, Alexander Streitner, and Les Kerté. Next. As you can see, these are our disclosures, and essentially no one has any relevant financial disclosure. Next. The objective today is we will look at the benefits of starting a discussion about addiction with fellow clinicians and care providers and the advantages to the patient. Next, we will describe several critical questions to ask of patients or other care providers, and how to start the conversation related to addiction. And finally, we will contrast the different specialties needed for addiction care and the unique location occupational health plays in orchestrating a return to work efforts. Next. So next slide. So you know who I am, occupational medicine. So I indicated that substance use disorder and alcoholism is prevalent and is a major health crisis. We will address fitness for duty and safety. What is or is not the individual capable of doing? What are the safety risks to that individual, his coworker, and to the public? We will look at various evaluations, including testing, random testing, etc., look at the liability for the physician, and look at impairment, and the question as to whether addiction is a disability. Next. When we talk about compassion management of pain, Doug will give us a case report of someone who has suffered from an injury, and we will go over the appropriate use of narcotic and other medications. Kurt will go over a tier that the American College of Occupational Environmental Medicine is currently updating. We will also address an issue that I believe is not well studied, although in the past, the term pseudo addiction was used to where patients perceived that their treatment was under prescribed and therefore seeking further drugs by illegal means. We will talk about evaluation and treatment approaches. We will also discuss healthcare disparity for those populations who are considered to be marginalized or underserved in our community. We will talk about the impairment programs, not only for the acute treatment, but employee assistance programs, and those that could be initiated to prevent relapses. Next. Next, please. When we talk about human resources, we want to know what human resources are available. Is the person trained as a physiatrist, pain medicine person, addiction person? Do they know the difference between a psychiatric treatment and an addiction treatment? What is early intervention? How do we recognize early intervention? What is the access to services? Will the insurance pay for it? Will there appropriate personnel be available? We will go over opioid assessment tools. Which tools can be used and which ones are reliable? Again, employee assistance services, many large companies, those with 5,000 employees, 80% have employee assistance services, but those who are smaller may not. Finally, we will go over recovery. What is a recovery? What is remission and what is relapses? Next. Finally, SAMHSA has indicated what is a brief referral for treatment and recommendations. This reduces the prevalence of adverse consequences of substance abuse. It's basically motivational interviewing, identifying individuals where drugs and alcohol can be harmful to your health. My last request is that when we continue with our panel, I'd like you to think of a word. I'd like to think of a word that brings emotion to you for the addicted person and how you feel you could be empowered, committed to save a life for someone who is suffering. That is our unmet need. Next. So now I'm going to turn this over to Dr. Doug Martin. Thank you. Thanks very much, Dr. Mandel. Welcome, everybody. So I am serving as ACOM's president currently. My typical day job is as medical director for occupational health for Unit Point Health here in Sioux City, Iowa. I have been primarily a clinician-based occupational medicine doctor for 28 years, although I do wear many different hats. And what I'd like to do is to start this off by giving you a very increasingly common scenario that I deal with in my clinic. So if I could have the next slide, please. So here's typically what I'm challenged with. I have a person that's in my office. They're a 47-year-old manufacturing worker, and they've had an injury to their foot. This particular injury is a Liz Frank injury from a pallet jack injury. In my part of the world, this is a very common thing for me to see. Typically, when an individual has this sort of thing, they're going to undergo conservative-based care initially. Oftentimes, they're put in a walking cast or a cam boot. Typically, we're going to start physical therapy. But oftentimes, these injuries are actually seen initially either in an urgent care or an emergency room type of environment, where because of the acute injury, they are given typically an opioid pain medication, in this case, hydrocodone. And unfortunately, the prescription was continued for three to four weeks because that was the first time that the individual could get into anybody for a follow-up out of the emergency room. But when you eventually do have the opportunity to see this individual, you do note that although the injury is recovering and weight-bearing is becoming easier for the individual, that the patient does disclose to you that they've been taking CBD, cannabidiol, which is a common thing for individuals to now obtain, not necessarily via prescription, but oftentimes over the counter or through individual state dispensaries. And when you start to dive into the history a little bit further regarding the individual worker that you have in front of you, you also find out that the patient's mother was in an addiction program 15 years ago, which illustrates one of the very important things with regards to the whole issue of addiction. And there does seem to be some strong associations with co-family members who have had similar problems with this as well. So can I have the next slide, please? So as an occupational medicine doctor that is tasked with managing this injury with a focus on return to work safely, as quick and as efficiently as possible, there are several different concerns that obviously come up. One of which is an obvious one, and that is the concern about does this individual now have signs of addiction to opioids? You recognize that they have been given this prescription for hydrocodone, they've been using it for several different weeks. You start to have questions about the cannabinoid use or the CBD use as a supplement to treat the pain. And then further concerns is with regards to the use of CBD. Some of these products do have THC as part of their concentration. And does that play now a role into additional concern about addiction and all of its negative potential side effects? And oh, by the way, if you happen to be in a community the size of Sioux City, which is big enough to need an occupational medicine doctor to do everything but not big enough to need more than one, congratulations, you also happen to be the medical review officer that gets to review this individual's post-accident drug test. And of course, in doing so, you might notice that there could be some other potential positive things that are on that drug test and it makes you start asking more questions about the history that this individual has, the life experiences that they have had. Do they fall into Dr. Mandel's description of individuals who have increasing concern for various different substances, both perhaps illegal prescription or even over-the-counter? What do those interactions mean and what do we do with this individual with that information? A continuing concern amongst many of us is what happens in the urgent or emergency care environment. And I'm not here to try to pick on emergency room doctors or urgent care providers, that's not my point. My observation is that in many of these situations, because of the role that is typically followed or matched by the emergency room or urgent care provider, there seems to be somewhat of a dichotomy of perspective. Either those individual patients who have these types of injuries are given several different medications to try to help with the pain, and it's not uncommon for myself to see a combination approach, perhaps opioids, maybe even a muscle relaxer, perhaps even a benzodiazepine that's being utilized for sleep control. And what does that mean from the standpoint of the polypharmacy, especially from the perspective of addiction and recovery? Or the other end of the spectrum is that the individual goes into the emergency room with these injuries and they receive no prescription medications. They're told to simply use over-the-counter preparations, and because of the pseudo addiction that Dr. Mandel has talked about, perhaps those individuals will then seek additional drugs because they feel as though that they have not been prescribed appropriately. And then, of course, the last thing is the lack of early follow-up intervention. I don't think I have to tell everyone how critically important that is, especially in the face of a workplace injury. Those of you who follow the different guidelines that we have in occupational medicine understand that early follow-up and early intervention with regards to not only injury care, but also to discuss the preventive aspects of addiction becomes critically important. So can I have the next slide, please? So more challenges. So in the course of being a clinician, and when we're talking about our 47-year-old individual here, these are some of the challenges that I see. As a clinician, you oftentimes need a referral to someone who is more specialized in the areas of addiction and recovery, and referral to counselors oftentimes is what I want, but in the work comp environment oftentimes is difficult. When you contact a human resources representative or a workers' compensation coordinator at a clinic, oftentimes I try to get people back to work with transitional duty recommendations or work restrictions, but oftentimes the response I get is, well, we really aren't interested in taking that individual back to the workplace unless they're 100%. Well, what does that mean? Frankly, I'm not that good as a doctor. Rarely am I going to be able to get someone back to 100%. My goal might be 90% or 95%, and trying to get individuals to understand that becomes problematic. You throw the issue of addiction into that particular timeframe and perspective, and it becomes even more challenging. Another challenge, when you're a clinical provider nowadays, you're expected to be efficient and to improve the bottom line. I don't think I have to tell everybody what the current state of the whole healthcare system is in the United States with regards to finances and economics, just to suffice to say it's not great. If you see 25 patients a day and you would love to spend more time with our injured worker here from the perspective of maybe doing some intervention, some counseling, some discussions about different things, you find that that's a challenge because maybe you only have 10 minutes or 15 minutes to meet with that individual within the parameters of your clinic environment. Oftentimes, within the whole milieu of being a workers' compensation care provider, there are a whole host of outside influences, some of which are employer-related. You have hospital expectations as a clinician. You have to meet certain RGU levels. You have to meet certain expectations of how many people you see in a day. You oftentimes know that individuals like our fellow here that has this injury needs extra time. They need more discussion, more of a listening ear, more of a time for history taking and listening and counseling with regards to these issues. You simply don't have enough time to do that, and there are pressures that are placed on the clinician to try to move those people through the system, which oftentimes is not helpful. Then the last question is, and don't forget, one of the responsibilities of an occupational medicine physician is to make sure that you're returning that individual to work but in a safe manner, not only with the individual's perspective of safety being important, but also making sure that you are not jeopardizing the safety of others that also are in the workplace. This becomes a very critical, important piece of information, especially when we're dealing with the individual that is confronted with a potential addiction. Next slide, please. With that introduction of the individual and the clinical parameters and thought processes that I'm faced with, I'd now like to turn it over to Dr. Hageman. Hi, I'm Kurt Hageman, and thank you for this opportunity to speak with you. I'm the Center Director for the Rocky Mountain Center for Occupational Environmental Health, one of the 18 Education Research Center sponsored by NIOSH, and I'm also the chair of the ACOM Practice Guidelines. Most of what I'll be talking about is more from the practice guidelines standpoint. I'll add that a number of the pearls in this series of talks are at odds with what a lot of people in the clinics are doing. One of my challenges is to train excellent residents who come in with great backgrounds, but they're taught interesting things at odds with the evidence. So it's a little bit of a challenge, and I suspect we're all involved in that in one way or another. Next slide. First, we'll go over some data, which I think are rather important in this conversation to keep in mind. The first graph here has our U.S. These are drug overdose deaths, and this is by year, and you can see that in 2020, the beginning of the pandemic, there is a sharp increase. We certainly have gone way past what I think any of us thought would happen when we started bringing attention to the opioid excesses in the 20-teens, 2010 timeframe. And what we don't know, of course, is, and we'll know in another few months when they finalize the 2021 data, is to what extent are we going to be able to tail this down? And then it was pandemic-related versus, no, this is a different issue altogether, and the pandemic was just an interesting but relatively unimportant piece of evidence. So we'll find out eventually. Next slide. So the next graph has a little bit more detail in terms of the drugs themselves, also up to the year 2020. And, of course, everybody's going to draw attention to the spiking data that are primarily fentanyl-based. They started up in the mid-20-teens, 2014-2015, and has just rocketed up since. But if we move past this, the other thing that's appearing in diagnostics is the issue of polypharmacy and other drugs in these deaths is also rising. So if you take a look at each of the data, especially the amphetamines, which is the next gray line there. Now, the other thing to note is the orangish-brownish line is relatively at a plateau for some years now. And so, to some extent, one could argue that we have been doing a okay job, if you will, at not increasing the deaths from prescription opioids. And so, obviously, this begets many other questions. Regardless, we can see there's a number of interesting pieces of data in this one graph. Next slide. And so the next slide shows you that this is not just a U.S. issue, although we certainly sadly lead both in terms of time frame and extent, but we have a propensity for consuming rather large quantities of opioids. There are fatalities in other countries that are also have rocketed up, so this is not merely an American experience, sadly. Next slide. And this is the last of my graphs coming up, and this one I think has a number of interesting facets to it. First of all, for those old enough to remember, we were taught to use weak opioids. That was always the first thing to do. If you notice the case that Dr. Martin gave you, he gave what is a typical case. The person had a minor injury and they're prescribed a strong opioid. Right away that's at odds with common guidance on opioids, but it is what is out there in practice routinely and also for molars being pulled and all sorts of other stuff going on. And you can see that the big blue to the left is codeine. That's the week opioid falls down. If you're curious about tramadol, it came out in 1995. But tramadol coming out does not, you know, even if it was up to those levels of codeine, what you can see is the spiking numbers of high potency opioids on the right half or right one-third of this graph. And that's fairly important in terms of, in my opinion, explaining some of the issues that we've seen in the data and some of our problems with opioids. Next slide. So what we're going to transition now is the ACOM practice guidelines. We are, as Dr. Mendel noted, in the process of updating, doing a comprehensive update of our opioids guideline. And to date, and this is also at odds with common teaching, there is just not quality evidence that other medications are inferior to opioids, which begets the whole question of why are we starting out with strong opioids or weak opioids or any opioids for most injuries. And that's true of multiple trials, randomized controlled trials, double blinded with anti-inflammatories and other treatments. And of course, most people would intuitively know the safety profiles are worse for the opioids. And we have very little in the way of functional benefit, which has been shown. So there's little in the way of quality evidence to support initial treatment of injuries with opioids. Next slide. And I will not read all of these, but these are the indications in our guidelines. I'm doubtful, but we will see what the experts think regarding whether these will change materially in our update. But we've emphasized function for quite some time going back about 10 years now. At the time that was pushing the edge a little bit, it's not so pushing the edge anymore. It's pretty much mainstream that that should be the emphasis in pain management, and other more efficacious treatments should have failed. The one thing I'll note, and I'm not going to read the rest of this, you can read fast and I can talk. But I will note that in reviewing records and reviewing patients, it is pretty routine from what I see that once you dig into it, prior treatments actually were not trialed. Because when you dig into it, you find out, oh, they didn't really have an exercise program, they had a gentle stretching program and some passive modalities with therapy. Well, that does not meet the criteria for back pain management. So my caution and my teaching for the residents is you surely need to dig into things. And don't just accept the simple I've already had that answer. Next slide. And now this is the prior. Thank you. And I think this is my last slide. But these are a few of the things in our opioids for chronic pain algorithm. And again, the emphasis on function. And once you go through this algorithm, and you go to the bottom of it, the short answer is most patients are not a candidate for chronic opioids. That's the real punchline. There's just too many flags, too many things not done. Too many intolerances of the medications themselves and so forth. So there's many, many issues. That doesn't mean that you don't have candidates. That's a different question. But the majority of the entire population with chronic pain would not pass through an algorithm to get chronic ongoing maintenance with opioids. Next slide. And next we will transition to Dr. Czarnecki. Thank you. I am Fabrice Czarnecki, the chief medical officer for the Transportation Security Administration, U.S. Department of Homeland Security, and the chair of the AECOM Public Safety Medicine section. Next slide, please. So I do not have slides. So you have to listen to me. I'm going to talk to you about what AECOM has to offer for employees who are working in public safety, such as police, fire, EMS. But this is general advice that you can probably use for most of your employees. First, I have to give you a disclaimer that as a federal employee, what you're hearing here are my opinions, my opinions only, and not the opinion of the federal government or TSA. So at AECOM, we have a document, an online document called the medical evaluation guidance for the medical evaluation of law enforcement officers, and we are expanding that to EMS. We have a chapter on substance use disorder. We are already working on the third version. So the second version is published. And so if you have a law enforcement officer with diagnosed substance use disorder, what we are recommending before return to work is for you to differentiate abuse and dependence. And we are using here the DSM-IV-TR criteria. That was just a choice because we thought that the return to work criteria were better. So if you are dealing with abuse, we want to see four steps before we return the employee. And we're talking here full duty, so with a firearm and with a car. So first, they are under the care of the right person, a addictionologist, or as we wrote it, a knowledgeable clinician. Then, that they meet the DSM-V, so we switch here criteria for early remission of the substance use disorder, which means no criteria for that disorder for three months, at least three months, except craving. And then abstinence, one to three months, with the range to be decided by the occupational medicine provider. And finally, ongoing drug or alcohol testing, as determined by the knowledgeable clinician. For somebody who meets the dependence criteria, you want to cover the same steps and add the completion of an addiction treatment program and an abstinence here for at least three months. We also have another document that could be useful to the audience. We have a medication chapter. I think that one has already been revised about three times. So it's a list of almost every medication on the market in the US. And they are flagged by the consequences on the fitness for duty, again, with specific attention paid to public safety, but that would also work for transportation. The point here being that if you have an employee with treated substance use disorder, be aware that the treatment itself can impair the person. So even if the substance use is not a problem anymore, understand that if your worker is now on buprenorphine or methadone or benzodiazepine, that will cause sedation and you can't have that employee work full duty on these medications if they have a safety-sensitive occupation. Thanks. Yes, next slide. Hi, everyone. I'm Dr. Alexandra Straetner. I am a psychologist at Straetner and Associates and also an assistant clinical professor within the Mount Sinai Health System. We can flip to the next slide. So as if all of the things we've talked about so far were not enough to be thinking about when considering folks you're working with who have substance use disorders and questions about work-related assessments, we're going to talk a little bit about the psychological considerations, which are extremely important but also fairly involved. I always like to start by talking about how I would encourage and how I do encourage residents that I work with and students that I work with in psychology to think about individuals who have substance use disorders. Because when somebody comes into your office, how you are treating them has a lot to do with your underlying beliefs about what is a substance use disorder. What does it mean if a person has a substance use disorder about that person? So to begin, many substance use disorders are accompanied by what we call co-occurring disorders. And in my world, we're usually talking predominantly about psychological or mental health disorders. However, of course, this is not exclusively true. We could also be talking about co-occurring medical disorders. Kansian identified what was called the self-medication hypothesis. The notion behind this is that when somebody develops a substance use disorder, it is often not exclusively, but often a way that they are self-medicating underlying concerns. So for example, if somebody comes into your office and you determine that they may have an opiate use disorder, it's possible that they also have underlying depression, underlying anxiety, or another mental health concern that the symptoms of that concern have not been properly managed effectively in the past. This person has not sought mental health care because of stigma around mental health. And somewhere along the way, perhaps they were prescribed an opiate medication or in some other manner, they came to begin using these substances and they discovered, as ineffective as it may be to the objective observer, that this helped them manage what might've felt like an overwhelming emotional experience. So keep in mind that you are often looking at people who may be dealing with really significant distress. Along those lines, it's important that we emphasize compassionate, non-moralistic care. Perhaps the biggest barrier to early treatment and to treatment at all is stigma and internalized stigma in thinking about substance use disorders. Historically, we have treated substance use disorders as being a matter of personal choice. Personal choice. We know that that is not true. We know, and there is a substantial body of research to indicate that these disorders are disorders, that they are illnesses that have a brain component. And other folks would speak to the fact that they also often have components within other areas in the body. So it's important that we treat these disorders like disorders, that we don't make people feel shamed or blamed. That's different from asking people to be accountable. We don't have to shame or blame people for having symptoms. If you have a patient who comes in who has diabetes, you're not going to shame or blame them for the fact that you've diagnosed them with diabetes, but you are going to ask them to take responsibility for their treatment, including the aspects of treatment that would occur outside of your office, blood sugar monitoring, medications as needed. And the same is going to apply here. I also always encourage people to think about cultural competency and cultural humility. I won't go into the distinction between those two terms. Needless to say, there are courses, much of the information I'm speaking about involves, many people take many years of courses on these topics, but it's important to be thinking about cultural factors. And I include in that workplace cultural factors. Just before our presentation, Dr. Mandel was talking about different risk factors for people in different occupations. It is distinctly possible that the individuals that you are seeing may have come to develop a substance use disorder because of the kind of work that they are doing, that they may have certain vulnerabilities or that certain things may be normalized in the industry in which they work. So we need to be thinking about those cultural factors. And finally, I like to think about evidence-based care as a non-moralistic intervention because evidence-based care is grounded in research. So by offering something to our patients that is grounded in research, what we're saying to them is what you are dealing with is real. It's not a personal failing. This is a disease and we're going to help you with it. Among those evidence-based interventions, as were previously mentioned, these include SBIRT, which is screening brief intervention, which is often motivational interviewing and referral to treatment. And as I said, within brief intervention, we're often talking about motivational interviewing. So I do want to touch on that just briefly as I'm attempting to click through. If somebody could click my slides, I forgot that's not me in control. Thanks. I'm not going to speak in depth about motivational interviewing today. Some of you may have had this training, I hope, over the course of residency, fellowship, or perhaps even in medical school. Residents that I work with increasingly are getting this training in medical school, which is great. But I just want to touch briefly on the spirit of MI. If you know that you are working within this spirit, you are doing a motivational intervention. So what do I mean by the spirit of MI? We are talking about care that is collaborative. We are talking about care in which we accept our patients. We recognize that they are autonomous and we have unconditional positive regard for them. We're talking about care that is compassionate and care that emphasizes evocation. In other words, in many instances, although our patients may not be experts on substance use disorders, the best ideas about change are going to come from them because they are more likely to act on and find success with their own ideas for change. If we can be thinking from this framework, and needless to say, there is extensive training availability out there if you're interested in learning more about this, but at a basic place, if you can be thinking from this framework of treating your patients as individuals that you care about and can be collaborative with, we're going to be starting from a very good point in terms of the likelihood that they are going to benefit from the interventions that you are spending so much time on. Next slide, please. So moving on to talking about how we approach the treatment of substance use and co-occurring disorders in the psychological and psychiatric services continuum, there is much that could be said about this. In brief, there is a very wide range of treatment that exists for individuals with substance use and co-occurring disorders, including specialized programs for people who may have particular kinds of substance use concerns, as well as for individuals who may have particular kinds of co-occurring mental health concerns or pain management concerns. And these can range from outpatient services, which are non-intensive, all the way through to residential treatment, which is a more long-term inpatient stay. Ideally, we are offering people opportunities for treatment that best meet their needs in terms of their diagnosis, their functioning, and what we're seeing in our assessment, but we do have to recognize that a significant component of this is also what they have access to financially, and also what they may have access to because of other psychosocial stressors and circumstances in their lives. So it's important to be taking those things into consideration in addition to the diagnoses that we're making. Across all of these kinds of treatment, you will see individual therapy and group therapy, as well as pharmacologic treatment and cautious clinically-minded use, and I always want to make a point of this, of any kind of testing, urinalysis, breathalyzer, or blood testing. Sometimes we don't have a lot of choice in the use of these, but I would encourage you to talk about the use of these with your patients, not because you can necessarily control whether or not they are going to have to undergo drug testing, but because we want to be clear that this is not something that's intended to make our patients feel like we do not trust them. Again, that reinforces a lot of stigma, so we want to use these in a clinically-minded way, and one thing I will just say as a side note, as a psychologist who works with folks with substance use disorders, if you're going to be using these tests, please send them out to labs for confirmation because I have seen a lot of erroneous test results that can really have negative impact on people's lives because of the way that medications, that they're actually prescribed to address certain kinds of concerns, might be metabolized. So the role of the family in treatment is very significant in the treatment of substance use disorders. This might include couples therapy, families therapy, referral to individual therapy for family members, and family systems groups where education might be provided to help families learn about substance use disorders, the disease model of substance use disorders, and how to best support their family members. And as many of you may know, services may be offered within the place of employment in some instances, and they also might be offered by professional organizations, and increasingly, profession-specific care is also available. So we have seen the increasing emergence of the acknowledgement that workplace culture is relevant to treatment, so there are programs specific for nurses, physicians, lawyers, pilots, and many other professions. Finally, I would encourage people to consider provider credentials. Individuals who have substance use disorders may often be referred to addiction specialists. However, addiction treatment providers may or may not always have training in assessing co-occurring disorders. If you have reason to believe that there are co-occurring mental health concerns, it's extremely important that you refer to somebody or to a program where assessment and treatment that includes co-occurring disorder care can be provided. Next slide, please. As a final note, there are many complementary aspects of care. These include self-help recovery groups, such as 12-step programs, and also alternatives to 12-step programs, such as smart recovery, as well as non-clinical services. Folks may have heard of these. They're sometimes described as sober coaching, sober companioning. In the words of psychologist Irv Yalom, these kinds of self-help recovery groups and supportive services can help with installation of hope. Both the American Society of Addiction Medicine as well as SAMHSA have talked about the importance of the establishment of community in recovery from substance use disorders. These kinds of supports can be extremely helpful to assist with those goals. I do want to note these are not a replacement for clinical care. If we treat them as a replacement for clinical care, we are reinforcing stigma, because you would not send anybody with any other diagnosis to a non-professional to receive treatment and say that that was sufficient. These groups can be extremely helpful, but we also have to make sure we're providing evidence-based care. I think that that's my last slide. So I'll just take a couple of minutes here to summarize what I've heard as some of the challenges and set us up for some question and answer. Go ahead and go to the next slide. I'll say that I'm Les Kerté. I'm a clinical psychologist by training. I have what feels like forever clinical experience. I've spent a lot of time lately for the last 20 years mainly dealing with workplace mental health and looking for ways to provide that and also in the disability and workers' compensation space looking at lost time and how we do something about that. I think one of the questions that we have to ask ourselves that we're really trying to get at, and I heard Dr. Mandel say in the very beginning, to focus on an emotion word that helps you try to save a life. And that's one of the questions we have to ask ourselves a lot is why aren't we doing more around these issues, around addiction and particularly addiction in the workplace? In the workplace, I think one of the challenges that we see is whether or not employees are taking advantage of the services available and whether employers are providing those services and particularly providing accommodations. We know that's a huge piece of helping people return to work. I think in clinical practice, we see healthcare challenges. We see challenges that Dr. Martin spoke about. The delay between the ER visit and getting somebody into further care can be long enough that we really set people up for a significant problem with addiction because they're taking high-dose opioids for longer than they need to be. I think it's really important. I acknowledge the self-medication hypothesis. I think one of the ways that that's been misused in treatment is that we think that treating the co-occurring and presumed underlying anxiety or depression as if that will fix the addiction. And that turns out not to be true. We really need to focus on specifically treating the addiction and the substance use disorder. And I think finally, the last thing that I'll say is that I think it's really important to underline what several of us have said about focusing on function. The addiction itself is not the disability. The underlying disability is caused by the impact of those substances. If it's causing sedation in a safety-sensitive workspace, then that's a reason to hold people out of work. It's not the substance use disorder. It's not the addiction that is the disability. It's our focus on function. And that's something that I think that we're frankly not as good at in providing care as we need to be. Now, this is an occupational medicine audience, so we're probably above average. But nevertheless, that is something that we have to pay attention to. And I lied. The last thing I think I also want to really underline that we've started with and ended with a focus on having a compassionate understanding about what's going on for people and treating people with dignity and as individuals in order to help them regain function. And I'll leave it at that, and we'll turn it back over to Dr. Mandel. Thank you. Thank you. I have actually taken what I thought to be 11 different points of this presentation with more questions than answers. The first being, as Dr. Straitner indicated, not only is there depression as an issue, but we have to be aware of cognitive issues that may impair the ability to treat these individuals. Secondly, family history. Not only family history, but also important legal issues that these people face. Many people are uninsured. They may be insured by companies that exclude mental health and addiction problems. Naloxone. So it's been suggested by a number of people that employees, peer supporters provide naloxone training to recognize among their peers rather than looking towards employers or physicians. So training of employees in naloxone has been carried out throughout the country with some success. We need to include in the drug for drugs in the employee handbook to include specific drugs and alcohol issue and for patients to essentially agree. In terms of treatment programs, as Alex indicated, there are many programs, some of which are successful, many successful only short term, but they include the community, digital, telehealth, and also for many, which I have found spiritual in terms of faith-based institutions. People will go towards their clergy, will talk to their spiritual counselor where they may feel some connection. When we talk about supportive employment, as Doug indicated, there is what is our recovery management checklist. After the person has recovered or presumably gone into remission, is that the end? Do we have any more responsibility? Les pointed out his view of disability, and not all of us would agree. Is addiction a brain disease? And therefore, is that in itself a disability? Finally, do we use opioid assessment tools? Are the tools to be used for every employee for a company? Or do we look for those that we have a suspicion? Or only after an accident? Or after, we assume, returning to work? And finally, is workman's comp and opioid treatment considered workman's compensation? Especially, as Doug indicated, if the initial injury is a documented work-related injury. Someone commented in the chat, in the question and answer, whether the Lisfranc injury is considered a severe injury. To that individual, it was sufficient to the degree that according to the treating physician, medications were prescribed appropriately or inappropriately. And the last thing I'll indicate is that Kurt and I work on guidelines. The guidelines give evidence-based medicine, but guidelines are to be used as a guide. They don't necessarily always indicate the best medical practice. Guidelines are frequently outdated. They're updated, which take long periods of time. So I have two questions based upon all those comments in the minutes remaining. Someone asked, is any marijuana, THC, cannabis allowed in the workplace? Someone takes a break in their afternoon break, and they may smoke a cigarette. Is any cannabis allowed? Do we use the federal guidelines for what is sufficient to where they would face consequences? Does the level, in fact, interfere with their ability to work? And is there a correlation? So maybe each person can comment on how do you manage now marijuana, either medically prescribed or recreational use, for individuals who are working? And what's the liability of the physician knowing that they are on marijuana, especially when it may be followed by the need for narcotics in addition? So maybe Fabrice, why don't you start, and then let's go around with that. And please comment on any of those issues that I mentioned. Fabrice? I'm sorry. I was typing an answer in the chat box. So what's your approach in the population you serve to any level of marijuana? Well, we are federal employers, so it's not a medical issue. That's my easy answer. Now, we do have a medical guidance for Marinol, but as far as positive THC metabolite tests, they don't even come to me. Doug, comments? Yeah. So what an interesting question, multifactorial, which I think I try to break down my answer to this based upon which hat I'm wearing at any particular time. So as a medical review officer, my advice to employers is to make sure that all of these questions are addressed in company policy, whether that's drug testing policy, HR policy, or what have you. Most employers that I'm aware of do not allow THC use on the premises or during working hours. Some of them also talk about it off-use hours as well. Having said that, also as a medical review officer, I will tell you that in the non-federal drug testing world, there is a definite trend to not test for THC anymore, especially in states where there is either medical use that's allowed or recreational use allowed, because it is sidestepping the issue of if you have a positive test, how is this interpreted? What do you do about it? Is there any discipline, et cetera, et cetera? And this is not an MRO webinar, so those issues I think are probably fodder for a different webinar. As far as fitness for duty is concerned, of course it makes a difference. But the problem is, is that we struggle identifying whether there is true impairment with any particular level of marijuana use, either it can be measurable or that is known. And of course, this is the reason why it's difficult, right? Because for marijuana, it doesn't follow the pharmacokinetics like, for example, alcohol does, where we have fairly good data and information about what happens with a person's level of impairment based upon their blood alcohol concentration. No such thing exists for marijuana. You can have people that are chronic users and have very little impact on how they cognitively behave. And other people, it takes minimal amounts and they're all over the map with things. So it becomes more of an individual type of assessment. And then of course, we get into all those wonderful wonky ADA issues, which is the legal hat that sometimes that I get involved with as far as what do we do with an individual that has a legitimate diagnosis where the utilization of marijuana is appropriate, whether it's chronic cancer or maybe some other thing that the state marijuana board has listed on their approved list for utilization of medical marijuana. And we can all debate whether there's science behind that or not. In many cases, there isn't. So how do we deal with that sort of thing from a legal perspective? So those are lots of things to think about. And I will tell you is usually based upon the specifics of where that individual is in geography, state statute, and what their employer has to say about it. So I have a question that Les actually asked me to address. And Kurt, maybe you could address this. How can physicians better interact with employers in terms of accommodation and why should they? Kurt? Okay, I'll go first. Well, so a couple of things. This is a very common problem. You brought up the statistics at the beginning to ignore something that's that prevalent is generally not a good idea. I think that that's one category of the problem. Now, from the standpoint of do you, however, accommodate people into safety critical work? Well, that's a different issue. You know, you've got public safety concerns and so forth. There's no reason to believe that CBD is safe. This experiment so far, and it's early in the experiment, you know, it's a natural experiment. Going on with Colorado, Oregon, and other states is not working very well. We're not seeing reductions in crime. We're not seeing reductions in the number of deaths. We're not seeing reductions in crime. We're not seeing we're seeing flooding ERs. We've got all kinds of issues going on. So you have to assume that this is not going to work very well. So that begets the issue of why would one think that this is going to be reasonably safe in the workplace? And should we, you know, increase such use or encourage increase of said substances? And you know, at the current time, I'd have to say, doesn't look like it. And if you're the doc, and having somebody travel from one location of a company to another, and you knew about it, and they wrecked the car and killed somebody. Well, I, you know, that's one of those, I wouldn't want to be on the answering. And why did you do that? So I have the last question. I'll ask, Alex, Alex, where do you fit in? Do we basically you utilize your services? When there is a problem? How can you educate us from a psychological perspective, as a person who deals with addiction and mental health, to sort of preempt or early intervention? Where can we make a difference? So psychologists certainly can play a preventative role in the way that we can also play a role at the point at which intervention is necessitated. But certainly, psychologists can play an important role in terms of education. It's my hope, and I'm always reluctant to talk about silver linings with this pandemic, because that just doesn't feel quite right to me doesn't sit right with me to talk about how we we needed this to get here. But it's my hope that what has happened over the past few years, has led to a cultural shift in which employers in trying to assess, well, why, why don't folks want to come back to the workplace, or maybe looking at workplace wellness a little bit more, and what might be mediating mental health struggles that are associated with work. So psychologists can play a role in that in terms of educating the public, educating the workforce. I also, and this is not, this is preventative in a different way. But I also think it's incredibly important that psychologists and all healthcare providers educate families, educate people who may not be coming to your offices yet. Addiction is a family disease, substance use disorders have a genetic component. If you have somebody that you're seeing who has substance use concerns, let them know that their family, their kids may be at risk for this too. Understanding and letting people know it's not something that they need to feel ashamed of talking about, that this may just be a part of what their family might experience goes a long way. So let me close with the following. To emphasize what Alex just indicated, is that addiction is a family illness. It's not only within an individual. One area which we haven't addressed, but I think it's important to point out is cultural competency. Cultural competency among the healthcare providers and recognizing the healthcare disparity that may exist within many portions of our community. So I would say the opposite of addiction is community. Without the family or healthcare team, there is loneliness, depression, which could lead to disability and death. This webinar is a call to action for everyone on this call to be engaged. We may not be able to solve problems, but it is our responsibility and an obligation to try. So I'd like to thank everyone on the panel. I'd like to thank Harry, Danielle, Heather, for the background team that's made this possible. I hope this is not a one-time event, but a start of a discussion and action to move forward. So Danielle will tell us a little about the continuing education, and from the bottom of my heart, I want to thank everyone for being participants. Thank you, Dr. Mandel, and thank you to our amazing panelists today. We truly appreciate you sharing your information, your knowledge with everyone here. To all of our learners, CCM and CME credit, within 24 hours of the conclusion of the webinar, everybody that registered for the webinar will receive a link to the archive recording, as well as webinar slides, handouts, any sort of resources. Those who attended the webinar live will be able to claim either CME or CCM credits via a link to a survey. The survey will be open for 30 days to allow people to claim their credits, and then it will be added to their transcript typically within 14 days after the close of the survey. A CCM certificate will be emailed to those that attended the live webinar and complete the online survey within one week after the webinar. To claim these CEs, log into your CCM dashboard at www.ccmcertification.org. So finally, we'd like to thank everybody. This has been a very important meeting, which I hope will lead to further conversation, community, and family. Thank you very much. Here are additional resources, which will be provided to you within the PowerPoint presentation. Thank you. And thank you, everybody, for participating today.

addiction

healthcare crisis

prescription drugs

illegal drugs

overdose deaths

workplace challenges

brain disorder

family support

evidence-based treatment

substance use disorders