Is that okay? Okay, the next lecture will be presented by Dr. Ansky-Decker. It is the Loren Hatch Memorial Lecture in Occupational Medicine. This lecture is given each year in honor of Loren Hatch, D.O., Ph.D., F.A., O.C., O.P.M., a founding member of the College and the Division of Occupational and Environmental Medicine. He served as President of the College in 1981. He was designated a fellow in 1985 and a full professor under the faculty status in 1998. Dr. Hatch has served as a member of the American Osteopathic Board of Preventive Medicine. Dr. Hatch was affiliated with NIOSH, where he served as an occupational medicine consultant to the Division of Technical Services. He was a prolific lecturer and author and accomplished much to advance the field of occupational and environmental medicine. Established in 1991, this prestigious lecture is presented each year to an individual member or non-member who has demonstrated a desire to see occupational and environmental medicine excel for the public good. Dr.'s lecture will be on Toxicology, False Testing, and Substance Abuse in the Workplace. Dr. Decker is the Medical Director of the East Anthem Cottonwood and Flagstaff in the Rural Clinics in Page, Holbrook, Tuba City, Polka, Chinle, and Cayente for the Northern Arizona VA Healthcare System. He provides primary care and telemedicine services to veterans in mid and northern Arizona areas. He is also active in the evaluation and treatment of veterans with chronic pain and addiction disorders. From 2010 to 2015, Tony was the Director of the Department of Addiction Medicine at the Fort Belvoy Community Hospital, which was one of the replacement hospitals for the Walter Reed Army Medical Center. He served in the Indian Health Service from 1998 to 2010 in Arizona when he was the Acting Director of the Office of Health Programs at the Phoenix Area Office supervising 15 health departments in Nevada, Utah, and Arizona. He was also the Associate Director of the Phoenix Indian Medical Center and the Director of Ambulatory Care and Community Health from 1998 to 2008. Born and raised in western Michigan, he graduated from Hope College in Holland, Michigan. He completed his osteopathic education at Michigan State University in 1978. He completed his internship and family medicine residency at Chicago College of Osteopathic Medicine and an adolescent and young adult medicine fellowship at Rush Presbyterian St. Luke's Medical Center in Chicago. As a public health service scholar, he served Chicago's south side for 14 years. He was Professor and Chair of Family Medicine at the Kansas City University of Medicine and Biosciences. Dr. Decker is board certified in family practice and osteopathic manipulative treatment, adolescent and young adult medicine, addiction medicine, and pain medicine. He is a fellow in numerous professional societies. His areas of expertise include addiction medicine, chronic pain syndromes, informatics, high-risk youth, domestic violence, and behavioral health. Please welcome Dr. Decker. Well, greetings everyone. My name is Tony Decker and I'm going to be talking today on the evaluation of substance use in the workplace. This is for the American Osteopathic College of Preventive Medicine. I have no financial or professional conflicts of interest to disclose. The contents of this lecture are for educational purposes only. I do not represent any federal or state organization despite just retiring from 37 years in the federal government and taking a new job with the state of Arizona. My opinions are simply my opinions for this educational program. I currently am the Chief Medical Officer for the Division of Developmental Disabilities, the Department of Economic Security for the state of Arizona. I graduated from Michigan State University College of Osteopathic Medicine in 1978. I did my internship in family medicine residency at the Chicago College of Osteopathic Medicine and completed a two-year fellowship in adolescent young adult medicine at Rush Presbyterian St. Luke's Medical Center in Chicago. I was a public health service scholar and I served on Chicago's south side for 14 years in the U.S. Public Health Service. I was professor and chair of family medicine at the Kansas City University and clinical professor at George Washington University at the Arizona Andrew Taylor Still University in Mesa and at the Burrell University. I'm board certified in osteopathic family practice, osteopathic manipulative treatment, adolescent young adult medicine, addiction medicine, and pain medicine. I should disclose also that I do not plan to use any brand name medications or medications for non-designated use by the FDA. Our objectives today are to identify body fluid and substances for toxicologic evaluation in the workplace. There are several options at this point in time. Let's see advantages and disadvantages for each different evaluation, both the screening and the confirmatory testing, and to recognize incidental exposures that could affect the results of body fluid and body structure results. One of the great challenges that we have today in American medicine is the chronic pain factor. The Institute of Medicine identified in 2011 that the financial burden of chronic pain exceeds those of cancer and heart disease combined. In 2019, the National Health Interview Survey published in 2020 identified that 20.4% of adults had chronic pain. In 2019, 7.4% had high-impact chronic pain, defined as chronic pain, frequently limited life or work activities. The groups with higher rates of high-impact chronic pain include women, those over 65, non-Hispanic white adults, and those in rural locations. When we look at the veteran population, we do realize that there's an increase of death due to overdose, and there were a little over 6,400 veterans who received care of the VHA who died from an opioid overdose between 2010 and 2016, and that rate was increasing each year during that period. In 2016 alone, there were 1,271 deaths in the VA system, or 3.5 per day from opioid overdoses. This is one and a half times greater than the general population for opioid overdose mortality, and 62% of veteran overdoses involved opioids. You see a little graph there looking at the 2010 to 2016 data, and all opioids causing the red line on the top showing an increase. Now, when we look at the pyramid that's commonly used in dealing with opioid overdose deaths, for every one prescription or a little bit more than one prescription, for every one prescription or illicit opioid overdose death in 2015, there were 18 people who had a substance use disorder involving heroin, 62 people who had a substance use disorder involving prescription opioids, over 377 who misused their prescription opioids in the past year, and nearly 3,000 people who used a prescription of opioids in the past year. Now, when we look at unintentional overdoses versus suicides, in the population with chronic pain, you can see that we have a gradual rise in suicide, but a significant rise in overdose unintentional deaths, and they seem to be related to the morphine milligram equivalent, or MME, that is prescribed on a daily basis. Now, this is data from Bonert and Giamma 2011. We're going to go through this process to talk a little bit about how people who are prescribed opioids are at high risk, but people who are on chronic opioids and are forced to stop those opioids are even a higher risk of opioid overdose deaths or suicides. So, there is a suspicion that people who have chronic pain syndrome have a higher rate of mental health comorbidities. We also know that the pharmacy drug monitoring programs have identified multiple providers, early refills, high dosages, or dangerous combinations such as benzodiazepines with a higher risk for overdose. Typically, we recommend that you have the PDMP checked at least once every three months, and I personally will check once a month when I see my patients run chronic opioid or buprenorphine treatment. You want to practice caution with out-of-state patients or limited access scenarios, and you want to make sure that if you have someone who's on chronic opioids, you do participate in medication counts, the PDMP monitoring, and urine toxicology screenings. Now, the DEA in late 2021 had identified several drug combinations that are causing more problems with our working population, and they have a variety of street names. I just wanted to make sure that you're aware of these combinations. It's unusual for a person to have an overdose who has only a single drug in their system. The typical scenario for an overdose situation today is going to be a synthetic opioid such as fentanyl, which is illicitly obtained, along with a stimulant, so methamphetamine, cocaine, or the cathinones, which are also known as bath salts. The holy trinity is an opioid, a benzodiazepine, and soma. It causes a heroin-like euphoric high. The stimulant trinity is an opioid, a benzodiazepine, and a stimulant, which would be similar to methamphetamine or all of the other amphetamines, Adderall being included, or cocaine, or the cathinones. The GABA trinity is opioid, benzodiazepine, and gabapentin. It causes a euphoric high. The zolpidem trinity is opioid, benzodiazepines, and zolpidem ambien, and that causes a downer or depressant type effect. And the speedball, which is an opioid, a stimulant, sometimes called a hardball if the stimulant is a methamphetamine. So it's a combination of heroin or fentanyl and cocaine, or typically it would be a pill-form fentanyl and cocaine and or methamphetamine. It causes a more intense long-lasting high, significant reward from the nucleus accumbens with dopamine stimulation. Polypharmacy cocktails or potentiators of opioid use include alcohol, albuterol inhalers, Adderall, albuterol, and sleep deprivation, Adderall, Lexapro, and cannabis. The other medications that can be used to potentiate the reward experience would be Abilify and Seroquil, which is called jailhouse heroin. Soma and codeine, the soma coma, gabapentin, and oxycodone, which is called stacking. Gabapentin and Seroquil, which is ground up and snorted, it's quetiapine, called Quell or Suzy Q. Gabapentin and Tegretol, Morantin. Seroquil, Zyprexa, Ativan, alcohol, cocaine, being a, again, speedball type arrangement. Some of the HIV protease inhibitors, the highly active antiretroviral medications, along with Percocet, can also cause a significant reward. And then caffeine, high doses, 300 milligrams or more, keeping in mind a regular cup of coffee has 80 milligrams, with ethanol, and an eyeball, which is going to be alcohol with an opioid. Now, whenever you're doing testing for toxicologic evaluation, you want to know the workplace policy and procedures for toxicologic testing. I do know that there have been significant litigation in the area of toxicologic testing that go beyond initial toxicologic screening for job employment. But further evaluations, you want to make sure that your policy is clear. You want to communicate openly what the test is for. Don't ever take a urine sample or a hair sample for a different reason, and then do the testing for toxicologic evaluation without the person knowing about it. Have an understanding attitude. Listen actively. Make sure you understand what the patient is taking as far as prescribed medications. Treat the patient with dignity and respect. Reassure the patient regarding confidentiality of medical records, and have a straightforward, non-judgmental, matter-of-fact, non-confrontational approach in explaining the reasons for the drug testing and any subsequent treatment. Explicit consent for drug testing is not required in primary care settings. However, there are reasons why practitioners should inform patients before drug testing. So, the federal five are typically amphetamine, which includes amphetamine and methamphetamine, cocaine metabolites, echinolamine, marijuana metabolites, typically THC, opioid metabolites or opiate metabolites, codeine morphine, and now 6-monoacetylmorphine, which is the pathopneumonic finding of heroin use, and phencyclidine, PCP. Keep in mind, there's a lot of testing here that is not on the federal five. So, the thing to remember is that in your testing, know if this is a screening test, radioimmune assay typically, or a confirmatory test, which is typically going to be gas chromatography with tandem mass spectrometry or liquid chromatography with tandem mass spectrometry. Sensitivity and specificity are two concepts that really need to be reviewed here. Sensitivity indicates the proportion of positive results that a testing method or device correctly identifies. For drug testing, it's the test's ability to reliably detect the presence of a drug or metabolite at or above the designated cutoff concentration, which is called the true positive rate. Specificity is a test's ability to exclude substances other than the analyte of interest or its ability not to detect the analyte of interest when it is below the cutoff concentration, a true negative rate. It indicates the proportion of negative results that a testing method or device correctly identifies. So, screening tests, the most common, are automated immunoassay, either alone or as a point-of-care test or as an initial screen for a two-step testing procedure. The results from immunoassays are qualitative. In other words, the drug or this metabolite is either donated or is denoted as either present or absent. It does not have a quantity reported. In the two-step approach, the screening test immunoassay is followed by a confirmatory GC-MS or LC-MS, and most of these are done now with tandem mass spectrometry. The most common technologies used to perform the confirmatory tests are gas chromatography or liquid chromatography. Now, keep in mind, gas has to be heated to make it into a gaseous form, and some chemicals do change in that process. That's the reason why liquid chromatography will be used for certain entities. Tandem mass spectrometry is the standard of care right now. Other testing methods are used to detect adulteration or substitution. Advantages and disadvantages of urine testing. Well, first off, it's a very easy test to do. The patient usually is able to provide us with a urine sample. It's higher concentrations of the parent drugs and or the metabolites than in the blood. Availability at point-of-care testing is highly advantageous, especially in the workplace, but keep in mind, those are screening tests. These are well-researched, and the documentation is very strong. Now, the disadvantage is that you have a short or intermediate window of detection with many chemicals. It's easy to adulterate or to substitute the sample. In other words, a person could go into the bathroom, and they could flush the urinal, and then just take some water into the cup, or they could dip the water out of the commode. That's one of the reasons why we many times will have the patient give a sample inside of a toilet with a stool and dye the water to prevent the participant from giving us dilute or contaminated samples. Now, there's a variety of substances that people can put into the sample, such as a variety of enzymes, such as enzymatic detergent. There's a lot of things that people will drink, thinking that it will cause either a dilute urine, but that's going to be measured. Typically, we will get a specific gravity on these samples, so if you're down below a 10.02 specific gravity, most places will not accept that as a valid sample. Some people also have what's called a shy bladder, and so your typical protocol, and go by your policy, is give the patient at least 500 cc of water, wait for another 15 minutes, and have the patient give a sample at that point in time. Some patients will say they cannot make urine, and that can become a challenging situation. Oral fluid testing. It's a sample that has become very popular in the age of COVID, and there's a variety of companies that now use oral fluid testing. So, it's a non-invasive specimen collection. It is easy to collect. Typically, there's a reduced risk of adulteration because it's from the mouth. It's a directly observed specimen collection, either with a video recording or a live bi-directional call in which the individual identifies himself, shows proof of identification on the video, gives the sample, seals the sample, and then signs off on the sample and seals it again, and then puts it into the mail carrier envelope all on the video. Then they can upload the video, and that can be seen as a secure identification for that sample. The parent drug, rather than the metabolite, can be tested in the assay. Cocaine is a good example of that, where the parent drug could get into the nasal pharyngeal area and contaminate the mouth, whereas normally with a urine drug screen, we would test for ecanolamine, which is a metabolite of cocaine. We're able to detect same-day use in some cases. It's available at point-of-contact testing or in the home testing with the video. There is the problem of detecting some residual drug in the mouth when this testing is being done. Now, the disadvantages of oral fluid testing is that you'll have a limited specimen volume. There's a possibility of contamination of residual drug in the mouth that cannot be correlated with a blood concentration. There's a short window of detection. It requires supervision of the patient for 10 to 15 minutes before they sample and salivation reduced by stimulant use may make it difficult to obtain enough salivary solution. There's a need for elution or extraction of the solvent to efficiently remove drugs absorbed to the collection device. And cannabidoids in oral fluid have been shown to arise from contamination of the oral cavity rather than excretion of saliva from the blood flow. So a person who has been taking either edibles or has been smoking a marijuana substance that can be in their oral cavity just from contamination of the oral cavity. Sweat evaluations, it detects recent use typically fewer than 24 hours with a sweat swipe, allows for accumulation testing with a sweat patch which people can wear for seven to 14 days. It's non-invasive specimen collection. It's difficult to adulterate. It requires little training to collect the specimen. Keep in mind that for urine drug testing and for most other drug testing, including phlebotomies, you have to have a certified attendant for that. And it may be an economical alternative to urine. The disadvantages are few facilities and limited expertise for the testing, risk of accidental or deliberate removal of the sweat patch collection device, unknown effects of variable sweat excretion among individuals, only a single sweat collection patch available so multiple analyses cannot be done if needed. For instance, if you have more than one positive test on your initial evaluation, it may be affected by external contaminants and it requires two visits, one to apply the sweat patch and one to remove it. The advantages and disadvantages of blood evaluation, it typically detects recent use and established laboratory test method must be followed. These are typically expensive with the exception of ethanol testing levels. There's a limited window of detection for most chemicals. It's invasive because you have to have a venipuncture. The risk of infection does exist. And if you have a patient who's a injection drug user, there may be a suspicion that a infection such as an endocarditis could have been caused by a venipuncture when in reality it was from injecting chemicals. It requires training to collect the specimen and may not be an option for an individual with poor venous access, a common event in patients who have a history of injection drug use. Advantages of hair and nail analysis. This has the longest window of detection. You may be able to detect changes in drug use over time from seven to 10 days before the hair or nail extraction to three months depending on the length of hair being tested or the length of the nail being tested. It's a directly observed specimen collection. It's for the most part non-invasive unless the patient has shaved all their hair and that you have to obtain either pubic hair or hair in other areas that would be considered private. Four tests can cover a year because you can have three months of data in each extraction. It's easy to store and easy to transport. It's difficult to adulterate or substitute and it's readily available from the standpoint of getting a sample depending on the length of hair or the length of nail that's being obtained. Now, the disadvantages is that typically it does not detect use within the previous seven to 10 days. It is difficult to interpret results. It is costly and time consuming to prepare the specimen for testing. Few labs are available to perform the testing. There's no point of care testing currently available for this. It's difficult to detect low use such as a single use episode. It may be biased with hair color. Dark hair contains more of some basic drugs such as cocaine, methamphetamine and opioids due to an enhanced binding to the melanin in the hair. The possibility of environmental contamination including occupational exposures exists. Now, this is one of the interesting things about cocaine. Benzolecanine is a metabolite, but hair is a protonaceous substance from the body and cocaine can metabolize with topical application. So a person who works around individuals with cocaine use and has contact with their hair because they touch their hands to their hair, they could have not only the primary drug cocaine, but they could also have the metabolite, benzolecanine in the hair shafts without any ingestion. Specimens can be removed by shaving or clipping and that's one of the reasons why pubic hair may be obtained. Breath analysis. Well, it's well established method for alcohol testing which is the alcohol breath analyze. It's readily available. It's used only for alcohol and other volatiles. It has a short window of detection and it may be difficult to obtain an adequate sample especially with patients who are very intoxicated or uncooperative. It's uncommon to use in the clinical setting. So this is something that can be used as a screening test or if there's an event in the workplace in which you need to have testing done. Advantages and then we'll go over disadvantages of meconium testing and this would be in the neonate. We can detect maternal drug use and abuse and fetal or infant exposure. There's a wide window of detection, the third trimester of gestation. Non-invasive collection from a diaper is generally a adequate specimen amount. Keep in mind that meconium can be elicited spontaneously but a patient who is in a neonate that is in distress has a higher likelihood of meconium being excreted while the baby is still in preuteral. Disadvantages, a narrow collection window that can be missed especially in babies with low birth weight. Testing is not available in all labs. It requires some extra steps including weighing and extraction and confirmatory assays are more difficult than for urine. Now let's move to alcohol biomarkers. Biomarkers such as gamma glutamylpepsidase, carbohydrate deficient transferrin, aspartate aminotransferase are all measured in the serum. Erythrocyte mean cell volume, MCV, may confirm a suspicion of long-term alcohol use because of macrosites. Typically the MCV would be greater than 101 for someone to call that and that's because of vitamin deficiencies in the chronic alcohol user. Ethylglucuronide, which is ETG and ethyl sulfate, ETS, are direct metabolites and can be used to test people for up to 72 hours for alcohol exposure. COVID has been a challenge and my job as a medical review officer typically has identified patients who have dramatic exposure to hand sanitizer, meaning 150 to 200 washes per day and respiratory therapists working with ventilator care for patients with COVID infections and some nursing staff that are seeing 150 to 200 washings per day. There was a study from Yale University which identified in the laboratory detectable levels of alcohol in the bloodstream and in the urine with heavy exposure to inhaled alcohol. However, another study that came out of University of Florida tested people in the lab. In other words, it was live action employees working with hand washing up to 30 to 40 times per day and they were not able to get positive ETG or ETS. I think the jury is still out on this in regard to unusual exposures of 150 washings per day. That is unusual in most clinical practices, but it is possible with some of our nursing staff and our respiratory therapy staff. Testing for ETG is becoming more common to monitor alcohol consumption for people who have been ordered to abstain. So providers and staff who are in a monitored program and they are not allowed to drink alcohol could be tested for this. This could also be the case for individuals who are in the transportation industries that need to be monitored if they have agreed for such testing. So ETS and ETG typically will be positive for about 72 hours after a significant exposure. So let's talk about exposure. A serving of alcohol, 12 ounces of regular beer, 5%, five ounces of regular wine, 14%, and 50 mLs of 40 proof, I'm sorry, 50 mLs of 80 proof or 40% alcohol would be considered a serving. The serving is 14 grams of ethanol. So a 14 gram ethanol exposure, if you took three of them, you'd be close to 44 grams of ethanol. Path or phosphatidyl ethanol is a minor metabolite, biomarker of alcohol use. And anytime a person would imbibe in more than 44 grams of ethanol over about 48 to 72 hours, that test will be positive at a threshold of 20 nanograms per deciliter for approximately three to four weeks. Now, if a person drank a glass of beer and then waited for five days, drank another glass of beer, 12 ounce, 5%, typical 14 gram exposure, that person would not test positive for phosphatidyl ethyl. But a person who drank three drinks on the same evening or spread over three days, that person should test positive at threshold. I've seen patients with phosphatidyl ethyls in the thousands. Many of them will deny that they've been exposed, but the reality is the test is very, very good and highly reproducible. So phosphatidyl ethyl is positive for two to four weeks with an exposure of 44 grams of ethanol over the course of 48 to 72 hours. Intercultural skills becomes an important part of testing for substance use in the workplace. Attempt to understand how the patient's background and culture could affect their treatment and their experience in testing. List the patient's understanding for drug testing. Negotiate a culturally relevant care plan with the patient as a partner. Interpret verbal and nonverbal behaviors in a culturally relevant manner. Acknowledge the patient's role as an active participant in his or her own care. And be sensitive that prior adverse childhood events and sexual abuse may cause genital exposure to be very traumatic. So if the patient has shaved or does not have any significant hair that can be sampled and you decide to go with pubic hair, you need to make sure you have the patient's consent for that type of evaluation and that this is a chaperoned event. Discuss the information and confirm the patient's awareness of all prescriptions and substances consumed or exposed to. Review medications and safety risks. Identify a morphine milligram equivalent assessment. Reinforce the patient's agreement and monitoring needs. Discuss the care with other providers when appropriate and coordinate the goals. Evaluate the possibility of a substance use disorder, substance misuse, substance abuse, or substance diversion. In other words, if a patient is prescribed Alprazolam or Xanax and has a negative benzodiazepine screen, it may be because the use does not reach the threshold event or that the patient is diverting or not taking their medication. Now, there's a whole variety of things that can cause tests to be positive. For instance, in the area of alcohol testing, kombucha is 1% or more ethanol. Kiffer, which is fermented camel's milk that stays thick at room temperature, is used in smoothies, can be 1%. Any fermentation process typically will make alcohol. Apple cider vinegar. It says right on the bottle of Dr. Bragg's apple cider vinegar, it does not need to be refrigerated, but it does have cider in it. And some bottles can start to ferment. There's a whole variety of European desserts, tiramisu, chocolate mousse, rumballs, baked Alaska, anything that's flaming, that comes to the table flaming, and the participant blows out the fire, they could have some remaining liquor that was used to cause the flame still remain on the plate. So now patients should be aware there are certain things they shouldn't use. Listerine and Scope are 58% ethanol. That's 116 proof. Now, a patient who uses gargle typically will use it, swish it in their mouth, gargle, and spit it out. There's still a small amount of absorption. People that are in monitored programs are told not to use anything with alcohol in it. Hand sanitizer is typically required, but now that we have University of Florida's paper that talks about 40 to 50 exposures not causing a positive ETG or ETS, and the Yale study with over 100 to 150 exposures causing it, we need to have a little bit more science to guide us in those areas. Behavioral health support. Anyone who is put through for cause testing is going to be under some significant emotional stressors. A comprehensive pain management program can decrease the physical and emotional impact of chronic pain and better suit the patient care needs. So patients who are on prescribed opioids, and many times for legitimate reasons, when they get screened, they may be hesitant to inform you of the medications. You need to make sure that the patients are able to talk about all their medications in a way that's non-pejorative to the patient. Stress reduction techniques, work with a cognitive behavioral therapist, a relationship counselor, a pain support group. Talking to others in addition to the provider about chronic musculoskeletal pain can help ease the pain symptoms and the anxiety associated with drug testing. With all specimen testing, you want to establish the identity of the patient. That needs to be verified. Typically it's with a state or a government ID. Explain clearly the collection procedure to the patient. Ensure that the collection container is appropriate for the specimen matrix. Label the specimen properly. Collect a sufficient amount of specimen. With urinary testing, typically we need to have at least 30 cc's of urine. Ensure that the specimen collection method prevents substitution, dilution, or adulteration. Typically in a forensic setting, the test is observed. For testing for cause in people who are mandated by law, such as healthcare providers or people in the transportation industries, then you want to have observed urines. This is a big deal in regard to exposing genitalia to create an observed urine. You want to prevent contamination from environmental sources when collecting the specimens. Storing the specimen. Make sure that this is in the manufacturer or laboratory's recommendation. Proper temperature. Maintain the specimen integrity. Prevent loss of or tampering with the specimen by storing in a secure area. Properly record the information and follow universal precautions. Remember with all testing, consider the purpose of the drug test, limitations of the drug test used, the drugs, the drug metabolites being detected, and those that are not being detected. Be aware of potential cross-reactivities. This is less of an issue in regard to the confirmatory testing, but not completely resolved, and the limitation of the selected matrix. I should let you know that the old Vicks nasal inhalers, not the new ones, but the old Vicks nasal inhalers were made from L-methamphetamine. And unless you have a chiral analysis, you're going to pick up a methamphetamine test on someone who is using the old methamphetamine nasal inhalers. L-methamphetamine is a decongestant. D-methamphetamine is a drug of abuse. And chiral analysis is not necessary in everything, but in certain areas, it is. CPT codes, you see the codes here from 80100 to 80102, and that would be for qualitative screening for 100, and that's typically used for the presence of multiple drug classes. For qualitative screening used to detect the presence of only one drug, it's 80101, and then confirmatory tests, it's 80102. Alcohol testing is 82055 for any method other than breath testing, and 82075 for alcohol breath testing. So how did we get here with all the emphasis on trying to identify drugs of abuse in our workplace? Well, first off, the Institute for Healthcare Improvement, Don Berwick was the CEO. He wanted to minimize or eliminate pain in healthcare. The Joint Commission had a policy and procedure for pain that was required to be present in all JCAHO approved facilities. Pain became the fifth vital sign. In 2016, the CDC started guidelines for opioid use. It has gone through two edits, 2019, and as I'm speaking, the 2022 edits have just completed public comment. There's been an increase in opioid prescribing from the late 1990s until 2010 of 400%. Purdue Pharma and other manufacturers and distributors are going through significant litigation today in regard to the knowledge that they had that their substances were causing opioid use disorder and the continued distribution of those medications. Provider education and provider miseducation became the rule. The PDMP, and in the state of Arizona, we call it the Controlled Substance Pharmacy Monitoring Program, but the pharmacy drug monitoring programs are now required in all 50 states. BOMEX, and that's the Board of Medical Examiners here in Arizona, and the licensing boards, the number one reason for a doctor to get in trouble with the Board of Medical Examiners in Arizona is an untoward event and a prescribed opioid. The number two reason for a doctor to get in trouble is the reduction or the termination of chronically prescribed opioids. So you're damned if you do and you're damned if you don't. Relationship of opioid termination and overdose and suicides. Oliva, who is from the Menlo Park VA in California and Yale University, reviewed 1.4 million veterans who had an outpatient prescription for an opioid between 2012 and 2013. Nearly 800,000 had their opioids stopped, which was 57%. There were 2,887 deaths from overdose or suicides, and these were stratified for length of treatment from 30 days, 31 to 90, 91 to 400, and more than 400 days on an opioid. The longer you were on an opioid, the more likelihood you had problems with either suicide or opioid overdose. Laura Schell and Jama published an editorial on opioid tapering. This is in 2021, time for reconsideration. This is going back to the Oliva study. Time on opioids were all split up approximately a third for 30 days or less and a third for greater than 400 days. Only about 9% were between 31 and 90 days and a little over 20% were between 91 and 400 days. The hazard ratio for overdose in men and women who had their opioids terminated, if you were 30 days or less, you had a 1.67 chance greater of a overdose event. But look what happens in those patients, these veterans who were given more than 400 days of opioids and then had their opioids terminated. It became 6.7 fold greater chance of an overdose in that population. Suicide hazard ratios where if you had your opioid stopped in 30 days or less, you're twice as likely, you had a 2.02 odds ratio greater than the population that did not have their opioids terminated. But when you're looking at men and women that had opioids for more than 400 days, it was nearly an eight fold increase in the suicide rates for that population. We started looking at overdose versus suicide outcomes. It's interesting that we had 1,851 overdoses in that population, 1,249 that were suicides, 13 were excluded because of missing data. Remember, it was 1.4 million veterans that were monitored and 800,000 of them had their opioids terminated. Increased risk for men and women who are also on tramadol, increased morphine milligram equivalents, and the number of their other medical diagnoses, including diabetes, cardiac and liver disease, or if they had mental health or a history of substance use disorders, younger males and being single were the higher risks. Now, Agnoli published in 2021 in August in JAMA, tapering was associated with an adjusted incidence rate of 7.6 mental health crises per hundred patient years compared with 3.3. So again, twice as much with those who had tapered opioids in regard to a mental health crisis. And then when we looked at, or when she looked at the rates of people who had overdose events, it went from a relative risk ratio of 1.09 for overdose and 1.18 for mental health crises. Again, there was a significant increase in both of those populations with reduction. So our controversy right now are limitations on morphine milligram equivalents. Many people are trained for medication-assisted therapy, but very few actually prescribe. A person who is on buprenorphine, you have to check with your state law if they're allowed to continue working in at-risk positions, such as physicians. Some states, most of them do not allow a physician with a history of opioid use disorder to practice. And there's no data that the use of buprenorphine causes the person to be destabilized or less safe. Cost and effectiveness of residential treatment has become highly questioned. Effectiveness of sober living homes are highly questioned. Naloxone distribution should be the standard. And if a person has naloxone in their drug test, it would be important to identify, did they have an overdose or an overdose event that had to be treated? Buprenorphine diversion, despite buprenorphine being an excellent medication for opioid use disorder, it is also a drug that is diverted. The Substance Abuse and Mental Health Services Administration, SAMHSA, and the Drug Enforcement Agency dropped the XDEA training requirement. If a person is going to prescribe buprenorphine, they do need to have an XDEA, but you do not need to take the training. And the requirement for a board-certified pain medicine consultation for opioids greater than 90 MME is challenging. The state of Washington did this a few years ago, and the wait time to get a Medicaid patient through the process exceeded 12 months to get a board-certified pain medicine consultation. So where do we go from here? We want to recognize those in need, be culturally aware, recognize that substances in the workplace continue to be a great challenge associated with injuries and absences. We want to support the efforts to increase providers that are able to prescribe medication-assisted therapies. And remember that the XDEA certificate in your DEA is still required, but you do not have to have training for it. Realize that treating addiction is complex and multidisciplinary. We want to remove the stigma of addiction, keeping in mind that about 10% of the U.S. working population has a drug or alcohol misuse disorder or an addiction. And so we want to identify them to encourage them to get intervention. Decriminalization of the diagnosis of substance use disorder to maximize acceptance of treatment is an important step. Realize that this is a moving target. New substances, new opioids, non-fentanyl opioids are coming down the pipeline that are challenging the lives of many of the men and women that we work with. And we want to enhance the use of community services to encourage those who have a substance use disorder to consider intervention services. The physician health programs run between 92 to 94% effective in returning physicians to full practice. And so we do know that in the professional population, this has had a significant positive impact. As monitoring has become the standard, new and hopefully more accurate testing systems will become available. Clinical testing is very different from forensic testing. Testing should be used to support a patient's recovery. Clinical decisions should not be made based on a screening test and in only one part of the clinical care. Look for reasons to explain the results. Always know prescribed medication and things that could have caused them to become positive and use a patient-centered approach in working with people who are being tested for drugs. References are identified here, and I am more than happy to be available for discussion. And thank you very much for attending this presentation. This is Tony Decker, and I am available if there's any questions regarding this presentation. And Jeff, thank you very much for inviting me to present. Thank you, Dr. Decker. Are there any questions for Dr. Decker? Oh, lots of questions. Hang on, Dr. Decker. Great. Must confuse them. Uh-oh. Dr. Decker, can you hear Dr. Klatka? I did not hear what she said. If she could speak a little louder. I have a question about breathalyzer testing. Yes, go ahead. Yeah, we actually do use it routinely where I work. And so I wondered if you could expand a little bit on that as far as contaminants, mouthwash, what I work with military applicants. So everybody gets breathalyzer tested. Of course, they're told not to drink, not to use mouthwash. 99% come up zero. I guess my question is, is your threshold zero? Or sometimes we get a 0.02 or so. I'm not sure if there's an exact consensus on what we do with that. If that can be, would you attribute that to use of mouthwash or food or some other contaminant? Well, this is a very interesting question because on the base, the level for impaired driving is 0.5 at the Army, Navy, and Marine Corps bases. I was at Fort Belvoir. I also took care of Andrews. And Andrews, if you're Air Force, it's 0.2 is an impaired driver. And obviously, they're trying to make sure that nobody's going to get behind a cockpit while they're impaired. At the same time, the officers club on the base serves alcohol pretty freely. So the thing that's an issue in regard to breathalyzers is one, the patient who had just consumed a distilled spirit, let's say 40% or 80 proof, they're going to have ambient alcohol in their mouth. If they used mouthwash like Listerine or Scope, those typically run greater than 50% ethanol. And I've treated many, many service members and many, many non, in other words, civilians who exercise their alcohol use disorder with mouthwash. It's not the best thing because you end up getting diarrhea and a bunch of other things. But because Listerine, for example, is 58% ethanol, people will go to that. We even had many people admitted to our program at Fort Belvoir who are drinking hand sanitizer, which runs anywhere between 70 and 90% ethanol, also has significant detergent. But the issue is, is the breathalyzer a good screen for acute alcohol exposure? The answer is yes. I mean, it's very portable. It's very available. The technology is simple. It does not detect is the person alcohol dependent or they have an alcohol use disorder. It detects exposure to alcohol that is either present in the mouth or excreted through the salivary system. So the answer is yes, it's a good method. It essentially gives you basic information. It will provide information consistent with impairment, but keep in mind, impairment on the base is very different. If you're driving on US1 in the Northern Virginia area and you get pulled over and you're 0.8, you're not intoxicated. You pull in the Pennscape at Fort Belvoir and you're seen as inappropriate in any way, the guards can go ahead and pull a staff member to come over and to do a breathalyzer test. And if you're above 0.5, you have a DUI. And then you get referred over to me. So the military has different stages. And like I said, the Air Force is 0.2. Now, if a person had alcohol in their system, they should pop up positive. But if they had any alcohol containing substance in their mouth, so for instance, they have a little bottle of Listerine, they gargle and spit it out, that can be detected very easily with a breathalyzer test. So are there any other questions about that? Okay, I'll take any other questions you have, Jeff. I have a follow up question. It appears that I'm assuming that when you are checking for, I think it was phosphatidylethylamine, that you're looking at people who are in abuse recovery. Because to me, one beer per day in which it would be detected as positive would not really always be considered a problem. I'm having a difficult time hearing. Could you speak just a little louder? Yes, you said that one beer per day for three days would be a positive test. Correct. And so, so are you actually checking to see if they are have a drinking problem with that? Or are these people who are supposed to be abused and not drinking at all? I typically tell patients, one beer a day is not a health issue. Correct. A matter of fact, for males, the US Public Health Service will say you can consume up to two alcohol standard servings, 14 grams, which would be two beers a day, and still be considered safe drinking. Now, safe drinking as in a person who does not have an alcohol use disorder. They even say that you can save up one day and drink double that the day before the day after. So they typically say if you're consuming more than 14 servings of alcohol per week, you could have a problem. Now, there's high variation in regard to effect of alcohol on individuals and there's high variation in regard to metabolism. The PEP, the phosphatidylethyl test is a blood test or a blood spot test. And that test will identify if a person has been exposed to more than 44 grams of ethanol over a 72 hour period during the past two to three weeks. So I had a physician, I do MRO services for 10 states. And I had a physician yesterday in Kansas who had a PEP of 79. And he initially said that it was because he was using Listerine mouthwash, but he spits it out, but he chokes every once in a while. I said, well, it would be highly unlikely for the Listerine to cause the positive PEP test at 79. It's not a linear relationship from 20 and above, but the base is 44 grams of ethanol, which is about three servings. Then he called me back about 20 minutes after we talked to say, you know, I think I was at a party and I don't remember everything that happened at the party and I may have consumed alcohol. That's usually my line, Tony. There's one more question in the chat briefly. Go ahead. Okay. And then Dr. Baltresaitis has a question too. But the chat question is, how do you manage a chronic pain patient with a positive UDS for an illegal substance? Okay. So the term illegal substances is difficult because in the state of Arizona and in, I believe, 43 states, we now have medical marijuana and or recreational use marijuana. So that would not be considered an illegal exposure. However, it depends on the opioid. Let's say you have a person on a hundred mic per hour patch of fentanyl, and they can't remember if they took their patch off or they put a new patch on because of the use of THC. So my issue is, this is a variable response answer. One, you don't want anyone who's on chronic opioids to use medications that will accelerate or complicate their use. The second thing afterwards is that there's definitely certain medications that are, to me, no-goes. So you have a person on chronic opioid therapy, but they're positive for ecanolamine or they're positive for cocaine metabolites. They're positive for methamphetamine, and you know it's the D-methamphetamine. They're positive for other illicit substances that put them at risk of misuse, abuse, or diversion. Now, this is all discussed before you prescribe your first dose of opioid. So the patient is aware of your approach. I don't really like my veterans or my patients using marijuana when they're on higher dose opioids, above 30 morphine milligram equivalents, because if they can't remember if they took their meds and they took a second dose of meds, there may be a complication. So it's how you wish to practice. I think some people, the reason we got into trouble back in the late 2000s and the early 2010s was because people decided that, you know what, this is actually safe enough. You decide how much pain medicine you want to use. And we became very liberal in our prescribing. That was a huge mistake. Now we have the problem of people that are on opioids. And some doctors, a significant number, more than 50% of the primary care physicians in the United States between 2010 and 2022 have stopped prescribing schedule 2 opioids. There's a reduction of availability. So my answer to your question is not sure what, I mean, everybody's different. You have to decide your relationship with your patients. Like I said, I don't think the DEA is hiding behind bushes waiting to pounce on you as you walk by, but I do know the DEA is watching all the PDMP monitored systems. If you're a heavy prescriber of opioids in your community, you can assume the DEA is watching you. The other question? Yeah, one more and then we'll be on a brief break. Hi, Tony. You mentioned that EPGs could possibly be positive for someone who's excessive use of hand sanitizer. My question is about like a false positive test for a PEP test. Okay. You said 44 grams of alcohol in 72 hours will cause a positive phosphatidyl ethanol test. Are there any false positives? Is there anything else that will cause a positive PEP test? Well, okay. So in the process of evaluating a person who has a positive phosphatidyl ethyl, you know that they had at least 44 grams or three drinks. But let's say you have a person who came down with COVID and they were sick, sick, and they went down to Walgreens and bought the typical two-pack, 12-ounce two-pack of NyQuil. NyQuil is 10%. So they have 12 ounces times two, 24 ounces. Each bottle of NyQuil has approximately three servings of alcohol in it. So if they drank two bottles in two days, they could have a positive PEP. Now that's that's a challenge for all of us because we're trying our best to avoid incidental exposure. And most people, like when I work with physicians and nurses, they're given clear printed instructions that they cannot consume cough medication that has alcohol in it. And so they have to sign off an agreement. I still have people who drink 32 ounces of kombucha. Now that should not cause a PEP positive, but that will cause per day. So they're drinking a large bottle of fermented tea every day, which can have one to 2% ethanol in it. And so that person will have a positive ETS and ETG, but should not have a positive PEP. So PEP is a very reliable threshold of 20 nanograms per deciliter, which would indicate 44 grams of exposure. Now, there are some people who have chronic diabetes with chronic yeast cystitis. This is especially a problem in our female patient population. They make their donation on a Friday afternoon. It sits on the counter in the lab over the weekend. And when the technician picks it up, there's all kinds of bubbles inside the sample. They are auto-fermenting. That's another possibility. So that's a urine drug test, not a PEP, but that could be positive. And you have cells in their urine. So you would have the ability to metabolize some of that alcohol, which could cause ETS or ETG positive. There's lots of little curveballs that we have in the area of medical review officer activities. So it's something for us all to remember. Okay, thank you, Dr. Decker, very much for your lecture. I know you'll remain in the chat. So feel free to continue to do Q&A with Dr. Decker that way. Dr. Balthasitis has a few housekeeping notes.

Occupational Medicine

Workplace Toxicology

Substance Abuse

Chronic Pain

Addiction Therapy

Toxicology Testing

Opioid Crisis

Veterans Healthcare

Provider Education

Substance Detection