A Prescription for Safety

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A Prescription for Safety

• Presented by Diana Byrnes, CUTR

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Prescription Trends

• NTSB, ONDCP, SAMHSA and other government agency
  studies indicate that abuse and misuse of
  prescription controlled substance medications is
  more prevalent than illicit drug use.
• Dramatic increase in past decade in use of
  medications for chronic pain, anxiety, sleep
  disorders,and attention deficit disorders
• Inappropriate use of medications takes several
  forms
• Misuse
• Abuse
• Physiological dependence
• Psychological dependence

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Definitions

• Misuse not following prescribed dosage levels,
  frequency of use, or use for a purpose other than
  for which it was prescribed- (non-medical use
  also)
• Abuse when the pattern of use leads to
  clinically significant impairment or distress
  that manifests itself in the individuals
  behavior
• Physiological dependence when the individual
  experiences increasing tolerance for a drug and
  experiences withdrawal when the medication is
  discontinued
• Psychological dependence or addiction when the
  individual experiences an overall loss of
  control, seeks medication compulsively, and
  continues use of the medication in spite of
  negative consequences

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Prescription Stats

• Most frequently reported Rx medications in
  drug-abuse related ER cases (as reported by
  DAWN)
• Benzodiazepines and Opiates
• More than 6.3 million Americans reported use of
  Rx drugs for non-medical reasons in 2003
• According to National Institute on Drug Abuse
• 40 million in 1991 vs. 180 million in 2007
• The increase in of opiate prescriptions written
  

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DOT Prohibited Drugs

• Amphetamines
• Cocaine
• Marijuana
• Opiates
• PCP
• DOT Drug testing panel limited to Schedule I and
  II drug classes

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Whats Missing?

• Largest class of painkillers, synthetic opioids,
  are not detected in DOT urine drug testing
• Vicodin, Oxycontin, Roxicontin (hydrocodone,
  hydromorphone, oxymorphone, methadone)
• Benzodiazepines, barbiturates, and propoxyphene
  are also not detected in DOT testing
• Xanex, Ativan, Clonopin, Vicodin (diazepam,
  alprazolam, clonazepam, and lorazepam)

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Video Clips from Media Outlets

• Hydrocodone and Xanax

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FL Transit System Accident

• Sept. 2007 Accident
• Employee had been involved in two accidents
  within one month
• Employee passed all DOT drug and alcohol testing
  that was conducted after each accident

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FL Transit System Accident Cont.

• Law enforcement conducted independent blood tests
• Results revealed two forms of benzodiazepines and
  methadone in drivers system
• Employee terminated for failure to report the use
  of Rx medication as required by employer policy
• Operator later arrested for felony DUI and
  careless driving

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Federal Transit Administrations Position
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Directives

• Nine years ago the NTSB issued a directive to FTA
  to do the following
• Educate transit systems on potential safety risks
  associated with the use of Rx and OTC meds
• Create a reporting mechanism to determine the
  role Rx and OTC meds play in accidents
• Recommended rail transit agencies require
  employees to report use of any OTC or RX med and
  implement a medical review system

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FTA Response

• FTA issued a Dear Colleague Letter
• Asks (not requires) grant recipients to review
  policies regarding Rx and OTC meds
• Asks (not requires) grant recipients to develop a
  training program to address the safety risks of
  Rx and OTC med use while performing safety
  sensitive functions

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FTA Response Continued

• Rx and OTC Medication Toolbox 2003
• Policy templates
• Procedures
• Training Aid
• Post Accident Procedures
• FTA includes an article in each issue of the
  Updates newsletter concerning Rx and OTC meds
• FTA is currently collecting data from transit
  systems. The survey is available at
• http//transit-safety.volpe.dot.gov/Survey1/Defaul
  t.aspx

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FTA Rx and OTC Toolkit

• Three policy approaches
• Employee self evaluates fitness for duty
• Not recommended as the only policy or procedure
• Employer requires employee to obtain a signed
  medical authorization (and involvement of MRO in
  determining safety concerns)
• Recommended
• Employer supplies a list of Rx and OTC meds that
  are approved or disapproved for use
• Okay, but not the best method

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Best Practices for Policy Development

• Best Practices for Rx and OTC Policy
• Stand Alone- not part of DA policy
• Medical Authorization required
• Form supplied that includes description of
  safety-sensitive job functions
• Strong training module
• Attendance policy for Rx and OTC use

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A Prescription for Safety

• An Rx and OTC Management Plan

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A Prescription for Safety

• Stand Alone Policy
• Physician Release Form
• NON DOT expanded testing panel
• Training
• Post Accident Investigation Procedures
• Attendance Policy

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Stand Alone Policy

• Not part of the Drug and Alcohol Policy
• Prohibited Behaviors
• Using a prescription (Rx) medication that is not
  legally prescribed for the employee
• Using an Rx or over-the-counter (OTC) medication
  in excess of the prescribed dosage
• Using any medication that contains alcohol within
  four (4) hours before performing safety-sensitive
  functions
• Using any medications that adversely impact the
  employees ability to safely perform his/her
  safety-sensitive job functions

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Policy Continued

• Requires employee to obtain a signed release form
  from prescribing physician
• Medical Disqualification if Rx medication is not
  deemed appropriate
• Discuss the use of an alternative medication
• Utilize accumulated paid time off
• Request a temporary non-safety sensitive
  position (provided that such a position is
  available)
• Employees who fail to report are subject to
  termination

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Development of NON-DOT Testing Plan
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NON DOT-Testing Plan

• Separate and sometimes in addition to DOT
  required test
• Testing for post accident and reasonable
  suspicion scenarios
• Conducted under agency authority
• Tests for an expanded panel (beyond DOT 5)
• Includes synthetic opiates, Benzodiazepines,
  Propoxyphene and Methadone

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NON DOT Testing Circumstances

• DOT required tests will always take priority
• NON DOT testing will be conducted under agency
  authority in the following circumstances
• Employee is involved in an accident or incident
  resulting in injury to himself and/or another
• Employee exhibits signs and symptoms of
  impairment and is subject to reasonable suspicion
  testing- under both the DOT and NON DOT testing
  plans

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NON DOT Testing Plan

• Currently available through our statewide
  contracted TPA FirstLab
• Specific testing panel and pricing can be
  negotiated
• Current contract expires 12/2011
• Please contact Diana Byrnes if interested in
  initiating an NON DOT testing plan volume will
  decrease cost

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NON DOT Testing Plan

• Must use a non-federal form (will be provided
  upon account set up)
• Must be a separate void
• Shipped separately to lab
• Reported by MRO as separate result

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NON DOT Testing Consequences

• Employee will be subject to termination if a
  positive test result is reported following an MRO
  review
• Positive means that no legitimate medical
  explanation exists (no Rx)
• A positive lab result that is verified as
  negative by MRO means that Rx is valid, but
  result will contain an MRO safety concern
• Employees may be subject to termination if result
  is negative with safety concern and employee
  failed to report medication use to employer

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Awareness Education and Training Plan
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Training Plan

• Comprehensive Training Plan that includes
• Policy distribution to all covered employees
• 20 minute training video
• (available later this year)
• Handbook to accompany video will include policy
  highlights
• Posters to be displayed in common areas
• Safety-Sensitive ID wallet cards

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Wallet size employee ID card
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Awareness Training

• Emphasis on Fitness for Duty
• Training will include warning signs of impairment
• Doctor-Patient communication tips
• Use of pharmacist as resource when purchasing OTC
  meds
• Dangers of combining Rx and OTC meds
• Due to differing effects of Rx and OTC meds
  there are no approved medications

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Post Accident Investigation
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Post Accident Procedures

• Following all accidents
• Employees will be asked to list medications (both
  Rx and OTC) consumed up to 72 hours prior to the
  event
• Employer will record this data on the Post
  Accident Decision and Documentation Form
• Updated version is in the works
• Employer will use this information to determine
  if the possibility of the Rx and/or OTC
  medication use is a causal factor

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Attendance Policy
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Attendance

• Reasons employees do not report medication use
• Employer does not offer temporary non-safety
  sensitive positions
• Employee does not have any accumulated paid time
  off (sick time) to utilize
• Employers must consider alternatives in order to
  ensure effectiveness of program
• Paid time off bank?
• Cross training employees (non-safety sensitive)

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In Closing

• Rx meds are the fastest growing substance of
  abuse
• DOT drug testing limits detection of the most
  dangerous Rx meds
• Employers are strongly encouraged to implement
  policies and procedures to safeguard against Rx
  and OTC medication impairment
• A Prescription for Safety will be packaged for
  use by August 2009

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Questions?

• Diana Byrnes
• byrnes_at_cutr.usf.edu
• 813-426-6980