So our next speaker today is Dr. Michael Decker. I got thrown for a loop here when I started looking at this. Well, Dr. Decker is related to Dr. Decker. And so this is in the tradition of long, long ago, apparently this is a family business. So Dr. Decker, Dr. Anthony, Dr. Michael Decker, sorry, who is here right now, was born and raised in the south side of Chicago and is the son of Anthony Decker. Dr. Decker trained at Nova Southeastern College of Osteopathic Medicine and Banner Good Sam, he did a psychiatric residency program and then at Boston University, an addiction psychiatry program. He's dedicated to the treatment of addiction disorders and underserved populations, patient and provider education and the advancement of the treatment of addiction disorders. Dr. Decker is currently the associate regional director for NAF care, did I say that right? For NAF care. And I think we're ready to go for his talk. We're almost ready to go. Dr. Decker. Today's topic is implications of high potency cannabis for employers. And so this topic is particularly interesting because the reality is that cannabis is becoming more and more commonplace, particularly with so many states allowing medical use, so many states allowing recreational use. And then just recently, Germany approved recreational use of cannabis as well. So I mean, we're not alone in this development, but it certainly is relatively new. Today's learning objectives are to appreciate the medical effects of high potency cannabis. So we're gonna be focusing not so much on the mild effects of it, but on the serious effects of it. We're gonna evaluate for acute cannabis use versus chronic use, the clinical signs and symptoms, interpreting lab results, impairment versus use, which is an important factor because we can't necessarily say metabolite equals impairment in this day and age. We need to state the concerns for employers with regards to employee cannabis use, both acute and chronic use factors. So the medical legal environment is actively changing. So to get an accurate idea in the United States, I actually went to NORML, to kind of, I know, the National Organization for Reform of Marijuana Law to see which states are medically legalized and which states are recreationally legalized. 38 out of 50 states, the District of Columbia and five US territories have legalized medical marijuana. 24 states, the District of Columbia and three US territories have legalized recreational use of marijuana. Most recently, American Samoa. There are some significant risks to employers and businesses. The loss of potential employees, particularly if operating under the drug-free workplace policy, you're gonna lose out on a tremendous amount of qualified individuals, merely because they use cannabis, okay? So the VA, case in point, they even changed their policy so that you may not use, you may not use while you're off-duty, but if you say you're in with treatment or you have been tested and you're negative, okay, now we'll take you, but not while you're actively using, not off-duty. It's disallowed. The risk of injuries, accidents from impairment are paramount when we're talking about cannabis. Risks of absenteeism, so employees not showing up to work, and worse, presenteeism, where they are at work, but they are intoxicated. Risk of motor vehicle accidents, both acutely impaired and there is an increased number of motor vehicle accidents, even if they're sober, but they still have a metabolite in their system, okay? The need for cannabis-specific policies is ever-changing, and as a workplace, in your business, you're going to have to really make policy changes to accommodate, either to make a strict line in the sand saying, no, it's not allowed, or deciding, you know, where exactly do I bend? And then the need for medical review officer involvement in a lot of these cases, because, in fact, I'll show you. So the exposure to litigation is increasing. So as the laws change, there's more retaliatory litigation towards employers who terminate employees for cannabis use off-duty, but still test positive on metabolite-based testing, okay? So currently, several states provide protections, but the state Supreme Court rulings have differed state by state. So in Colorado, our national leader in cannabis, for example, in Coates v. Dish, this guy was a paraplegic janitor. So he's in his wheelchair, he's sweeping, he has to do a drug test, he's positive on the drug test, and then they terminated him. This is the Dish Network. This is not a safety-secure, sensitive position. This is janitorial work. And he sued Dish Network, and the Colorado Supreme Court said, because it's illegal federally, the Dish Network is not doing wrongful termination, even though he's protected by state rights. Now, in contrast, in Pennsylvania, the Scranton Quincy Clinic Company versus a medical assistant palmeter. Basically, the medical assistant was using medical marijuana, she had her medical marijuana license, she failed a drug test, and then they fired her for that, and then she sued them, and she brought a claim of discrimination and wrongful discharge in violation of the law, and won against the employer. So it's not consistent state to state. So what I'm trying to say here is, in both of these cases, as a physician, the first one would be a clear, yes, you can keep your job. The second one would be, now wait a second, you're a medical assistant. You are in a safety-sensitive position. I don't really want you using cannabis, but she sued and said it was wrongful termination, and she won. So this is where it really becomes confusing on the reality of cannabis and employers, because I can draw a firm line in the sand and say, well, when you came on board, you signed an agreement not to use cannabis, or they said, hey, listen, you've got your medical marijuana certificate, that's okay, but then to fire her. So the question really becomes state by state, you're gonna get different answers, and it really boggles my mind. So let's look at some cannabis use statistics. These are collected from the NSDUH data. This is the 2022 data, okay? So we've got maybe like 30 states that approved cannabis use. 43% of Americans have tried marijuana at least once in their lifetime. 43, yes, admitted, 43% admitted. In 2022, marijuana was the most commonly used illicit drug with 22% of people aged 12 or older using it in the past year. That's 61.9 million people in the United States. The percentage was highest among young adults aged 18 to 25, followed by adults aged 26 or older, and then adolescents aged 12 to 17. Now, of these three groups, you're the 13.3 and the 45.7 million, those are our eligible employment groups. So the problem becomes now, if I'm a drug-free workplace, I can't use any of those people, regardless of whether they're qualified or not. Of the 61.9 million people aged 12 or older who used marijuana the past year, 19 million had what was classifiable as a marijuana use disorder. So most of them, 55.1% had a mild use disorder. That's some mild development of withdrawal, tolerance, things like that. Not necessarily impacting their work or their ability to function in day-to-day life. However, 17% had a severe disorder. And when you break down the numbers, that means that one out of 100 people will have a severe marijuana use disorder in the general population, not just those identified with marijuana use, but of every 100 employees, one of those people should statistically have a severe marijuana use disorder. So let's talk about cannabis use disorder or marijuana use disorder. The DSM-5 changed things quite a bit when it came from addiction and dependence and abuse. So we changed. And so with this, more people were identified with marijuana or cannabis use disorder merely because you only need two to three of these criteria in order to test positive for a cannabis use disorder. But the ones that we're most concerned with, with the severe use disorder are number five, which is recurring cannabis use resulting in a failure to fulfill a major role obligation at work, school, or at home. So this is the absenteeism, the presenteeism. And then the other one that's even a larger concern is cannabis use in situations in which it is physically hazardous. I'm driving a semi, I'm performing an operation today. These are the kinds of things where it's terrifying to think that somebody may be impaired while they're doing it. You know, they're driving around 40,000 pounds. That's just a nightmare. I'm performing, or as the old anti-marijuana TV ads goes, they show a surgeon who's smoking a joint and the patient comes in for tonsillitis and the surgeon's high and keeps saying, oh, you must have appendicitis. I'm gonna start my operation right now. And that's the kind of thought process behind the terrifying nature of cannabis use disorder because for some, it's not a big deal. They're not impaired while they're at work. For others, it is absolutely nightmare inducing. So let's talk about how marijuana has changed. So in the 1970s, cannabis THC concentration, THC is tetrahydrocannabinol, as you all well know, and that is the primary intoxicating ingredient in cannabis. The THC concentration in marijuana was only like around 2%, and that was considered good weed in the 70s. In the 80s, they got a little bit stronger as people learned how to manufacture it better. And then in the 90s, it got a little bit stronger again. And then in the 2000s, we had a big jump up to 10%. And then in the 2010s, we went from 10 to 17%. These are averages. So one might be 30% and one might be cannabis americanus, which is only 1% THC. And then you average out to 10 to 17%. So what most cannabis users want though is what's called sensamia, which is without seed. So this is an unfertilized female cannabis plant that produces the highest quantity of THC. Now the plant produces the THC predominantly to protect itself from dry conditions. Okay, and that's what the THC is developed for. So what did growers do? They selectively killed the male plants and then dried out the grow rooms where these things were. And that's how they got the concentrations up to around 30% in living plants. That's about as much as the plant can actually produce realistically. Then when that wasn't enough, in the states where the cannabis was legal, these other things started. So hash was the old one where people would collect, you know, the actual concentrated trichromes is where the THC actually exists. And they would put it together in butter or hash oil. But nowadays what they do is they take a big long glass tube and they stuffed the cannabis flowers in there. And then they use butane, like the butane that you use to like cook things. And they push it through the butane tube. And at the bottom, it produces an oil in which the tetrahydrocannabinol and other cannabinoids are actually dissolved into that slurry. And that slurry is butane hash oil. And then if you concentrate that further, you can also what's called dabbing, which is you have a glass nail and you put a bit of this butane hash oil on there and then use a torch to heat it up and then inhale those vapors. Now, the problem though is those concentrations can reach THC levels of over 90%. Yeah, so when we talk about impairment, this is tremendous ability to become impaired. Cannabis effects are broad ranging. So there was a study that just came out saying that, you know, everybody says, oh, but marijuana doesn't kill, right? It's harmless. Well, not precisely. If you're a cardiologist, you may have noticed this a lot sooner than the addictionologist did. But the reality is cannabis causes some interesting things to go on with the heart. Myocardial infarctions, coronary artery disease. So chronic use, coronary artery disease. Acute use, we run risks of myocardial infarctions because of an arrhythmia that occurs, most normally a supraventricular tachycardia. And then when people are chronic users, what ends up happening is you have 88% higher odds rate of myocardial infarction versus normal people, like non-users. Then there's also 81% higher odds ratio of stroke. So we can't say marijuana is harmless anymore. The arrhythmias that occur with this atrial fibrillation, atrial flutter, they are, well, let me put it this way. If I had a patient who was older, like say a veteran who's in their 60s, and they're telling me, oh, I'm using cannabis for PTSD. Okay, that's great. What happens when you use the cannabis? Well, you know, I breathe real hard, my heart pounds, and you know, I think it helps. Well, why don't we go talk to the cardiologist and see what EKG says? Because you might be putting yourself in some serious harm's way. So the reality is there are some serious effects that can occur from cannabis. And it's not, you know, a young person smoking marijuana, I'm not as worried about this. But as the use gets, you know, more entrenched in society, and our aging population is using this, reality is that it becomes far more dangerous. Cannabis does have broad ranging effects in the pulmonary system, acute irritation of lung function. Now, what's interesting though, is for people with asthma, it actually helps a little bit with the bronchoconstriction. Whereas with you don't have bronchoconstriction, it, sorry, if you don't have asthma, it will actually precipitate an asthma irritation type effect. Meta analysis showed that the cough, the sputum production and the wheezing were associated with marijuana smoke. And the chronic use does ultimately develop into COPD. Concentrates, we saw a rash of deaths a few years ago from cannabis vaping. And what happened was, it was actually the slurry that they made, they tried to cut it with vitamin E acetate. Well, when you vaporize vitamin E acetate, it is enormously damaging to the alveoli. And we actually saw deaths because of that. And that was the rash of illegal cannabis vape pens that were going around. So the vape pens, what's in those is actual butane hash oil. And then what happens is people will vaporize that, but then these were illegally created ones where somebody had so much oil and then decided to cut it with vitamin E acetate to make more volume. And then when that occurred, people died because of it. Cannabis also causes something new, which was the hyper emesis syndrome. Emergency rooms started reporting like, oh my God, what is going on here? People are saying they're using marijuana, but normally marijuana reduces nausea, not in massive amounts, 90 plus percent concentrations actually reverse that action in the brain in the appetite center and then cause a hyper emesis syndrome, which initially we found that hot showers would calm down the effect of this. We don't, we still don't know why that is, but hot showers seem to work. But then also large amounts of benzodiazepines in the ER were also effective to stop the emesis syndrome, which again, I'm not sure the mechanism of that action, but I would probably recommend the hot shower over the massive amounts of benzos. Reproductive effects. So, one joint every so often is not gonna lower your sperm count, but if you're smoking 90 plus percent every single day, yeah, your sperm count's gonna go down. So this is an interesting argument for young men in their 20s trying to form a family. Well, we may have a reason why you can't form a family. No, it does not cause much of a dysfunction in terms of the sex hormones, but it does seem to lower the sperm count. And it also causes some interesting things with females, preterm birth, small for gestational age, perinatal mortality, all go up with these super powered cannabinoids. Ophthalmically. So everybody's familiar with the picture of the stoner where they've got the bleary eyes, the injected conjunctiva, it's known. The transiently decreased intraocular pressure. So remember when they first were trying to medicalize marijuana and they said, oh, it's good for glaucoma. Well, it's good for a couple hours. The eye drops actually work all day long. So the question becomes exactly why are you using it for glaucoma? It's transient. Nystagmus is noticeable. So like on a sobriety test, if somebody's high on cannabinoids, 90 plus percent, you can actually get the eyes to produce in the stagmas. Hallucinations can occur. Reduced tear production is generally common, especially with the higher potency cannabinoids. The clinical picture physiologically when somebody is acutely intoxicated are the red eyes, the nystagmus, and ataxia with the higher-potency forms, slurred speech, dry mouth, increased appetite, tachycardia, increased blood pressure, increased respiratory rate. The psychiatric picture becomes far more complicated with high-potency opioids. We have an abnormal range of mood from euphoric to dysphoric. So basically, you know, we think of somebody high being happy, kind of dopey, you know, smiling, laughing. That's not necessarily true with these higher-potency forms. So what you might see is people angry, violent, aggressive. The range of anxiety where some people may have decreased anxiety, some people may have increased anxiety to the point of sheer paranoia. And with the higher-potency forms, some of the concentrated forms can actually produce frank psychosis. That's okay. Basically, what I was going to say was that Farrer at North Carolina showed that there's a high association with actually schizophrenia, frank schizophrenia. Yes, absolutely. All of the things you have on there. So these are acute, whereas the schizophrenia findings were when we have kids aged 12 to 13 using cannabis on the regular, especially these high potency forms, we do see an increased incidence of schizophrenia and other schizophrenic form illnesses. In addition to mood disorders, anxiety disorders, a variety of psychiatric findings that in addiction there's several different theories on how addictions occur. And there's several theories on how schizophrenic form illness occurs. And one of those theories is the two-hit hypothesis. You were predisposed for it, but without another trigger, you're not going to develop it. Well, this is that other trigger. Because of how it works, it seems to precipitate those psychotic symptoms. Long-term chronic users will develop tolerance to the acute effects of cannabis. So if you have somebody who's using 90% THC every day, you're not going to see bleary eyes. You're not going to see ataxia. You're not going to hear slurred speech. You're not going to see nystagmus. However, it's very similar to how chronic alcoholics are. So what happens is your brain rapidly builds a tolerance to any type of chemical that's altering its homeostatic balance. Cannabis upsets that homeostatic balance, and then the development of tolerance is really the person's brain trying to accommodate for those extra chemicals. So when we talk about cannabis, impairment is where the most concerning thing is when it comes to employers and work. So psychomotor impairment emerges immediately after acute cannabis use, even in regular users, but decreases significantly one hour post-use, where you may not see a frank ataxia. The actual testing of people under acute cannabis use showed results. So there was some impaired balance function, increased body sway, but not frank ataxia, but something that was measurable. Reduced proprioception or postural tracking, slower response times, increased simple reaction time, reduced selective attention, reduced sustained attention, and reduced divided attention. So let's say for an example, the box sorter at the Amazon warehouse, where they have to quickly determine like, okay, the box need to go here, the box need to go there. They're going to miss boxes. And Amazon tracks those things down to a microsecond. So you're going to appear on the manager's warning screen, like, hey, this guy, let's get him out of here. The reduced reaction speed in driving simulations was across the board, even for chronic users. And even after they sobered, they still had a little bit slower reaction than a non-user. So when it comes to cannabis and vehicles, I'm anxiously awaiting when AI takes over our driving from us, and the government says, that's why nobody gets to drive anymore. Then they can legalize everything, of course. High potency cannabis effects, greater than 90% in frequent users, the arm extension tasks where basically, so how these work is, they have a variety of actions where you're measuring the response speed. And one of those is to reach out and grab something. One of them is to pull your leg back, like something's going to smash your leg. And then another one is postural sway with eyes open, and then of course, with eyes closed. And so what happened was 15% slower immediately after use, but after one hour, they regained their speed back again. The leg withdrawal task was slowed by 6 to 7% immediately, and one hour, I'm sorry, the arm extension task was impaired both one hour later, and the leg withdrawal task were impaired immediately and one hour later. With the postural sway, it was slowed by 4% acutely, okay, so not ataxic, but it's there. But it recovered one hour post-use in chronic users. With eyes closed, they had a much harder time not swaying, but even after one hour, they came back to normal, okay. So the arm extension and leg withdrawal tasks were not recovered one hour later, whereas the postural sway was recovered one hour later. So when using concentrates, the blood levels were double that of FLOWER users, okay. So FLOWER is up to 30%, concentrates is up to the 90%. However, one interesting thing that they found was when given free range on how to use their cannabis, these users would titrate the dose for their blood to about the same levels. So the same levels of intoxication were achieved by all the different users, okay, typically above 5 nanograms per deciliter. And that's serum levels. So delayed verbal recall performance was impaired after use, which impairs memory. Heavy users of cannabis were resistant to many of the impairment effects that were observable amongst naive users. The exception was the degree of balance impairment. So balance impairment in this study was 11% worse than baseline. And that's consistent with the blood alcohol level of 0.5 to 0.1%. So that's legally drunk, okay. This was present even in frequent users and is a valuable sign of acute use or impairment. So while you or I may be able to look at somebody with frank attacks and say, okay, something's wrong with them, this is 11% worse than baseline. So it takes a keen eye to really catch this. There's something called SPICE, which is a synthetic cannabinoid one receptor agonist. The difference between tetrahydrocannabinol, which is a partial agonist at the CB1 receptor and SPICE, which is a full agonist at the CB1 receptor. So what this study shows is that so versus the placebo, the dotted line that goes up at a sharp angle, that's the SPICE. And then the solid line is the THC studies. And so what happened is when you put a full agonist in there, and these are psychotic symptoms on the side here, derealization, depersonalization, and then amnesia all increase. So what happens is that the more activity there is at the CB1 receptor, the worse these psychotic symptoms and the worse amnesia and other neurological effects can occur. And of course, what you see on the right-hand side there is just kind of the difference between a full agonist and the partial agonist. Thank God they really outlawed that one. Typically, testing for cannabis use is via a urine immunoassay. We're looking for 11-nor-9-carboxy-delta-9-tetrahydrocannabinol. And that's typically what we're looking for on the immunoassay tests. Typically, via urine, it's going to turn positive two to five hours past consumption, and then highly variable about how long the metabolite will remain positive due to the chronicity of cannabis use. In an infrequent user, you'll go positive in two to five hours, and you may stay positive for maybe a week, maybe. If you're a really healthy person, you can get out of your system in a couple of days. If you're a big guy like me, and you use every single day, it'll stay positive for months. It's lipophilic. So what happens is it deposits in the fat cells, and then if someone stops, then what you're waiting for is the, oh, what's it called, pyrolysis. And that's what releases it back into the bloodstream. So even though somebody stops using, the pyrolysis still releases the active metabolite back into the system. And so basically, they are still impaired for a while. Now that's not to say that, you know, if they're thoroughly tolerant to it, the level of impairment will be less and less and less measurable. So when considering the occupational harms of high-potency cannabis, impairment is primary concern. Use is not the big deal. Impairment really is. The impairment associated with cannabis use is sort of precipitated by the neurological and cognitive changes. The impairment from marijuana varies greatly with the THC concentration or dose, the route of administration, the user's experience with or tolerance to the drug. You know, if somebody works in a head shop and they smoke weed 10 times a day, that's not really safety sensitive. If somebody's doing something that is safety sensitive and, you know, they stop in Colorado, it's legal in Colorado, they go buy a 90-plus percent cannabinoid product, and then they use it, now, you know, you might be impaired more than just the time period that you're intoxicated. So while the presence of the metabolite does not equate to impairment, the positivity of the metabolite testing can remain positive long after the acute intoxication phase ends. So in post-workplace injuries, when an employee tests positive for cannabis, there are severe implications. So typically, or I should say traditionally, if somebody got hurt at work, they go to the they go get drug tested, they're positive for marijuana, well, no workman's comp, you were intoxicated at work, you know, that's right out. Today it's a different story. So did they have a medical marijuana license? Did they, were they in a state where recreational use is legal? Well, now it's tougher, because unless I have a drug-free workplace, I can't stand on that ground anymore, you're intoxicated, you had a positive metabolite test, you don't deserve any workplace workman's comp. So now you need both the presence of the positive metabolite test and objective proof of intoxication or impairment at the time of injury to deny compensation benefits. Extremely, extremely difficult to determine. And so that's where we're at right now. We're kind of like at a precipice where the laws of the land have changed, but the legalities of these things have not really caught up yet. And that's why, that's why I talked about the court cases, where you have clearly two different scenarios where one should have gone this way, one should have gone that way. But then the courts decided opposite of that, against medical direction, I guess. So, you know, we we get in debates a lot with our with our children and and other folks and what what hurts me as a as a as at least a supporter of the medical profession is the notion that that this is a medical marijuana and, you know, everybody took either the osteopathic oath or the Hippocratic Oath and yet you have colleagues of yours that are prescribing a substance of which they're really prescribing you to have carte blanche access to a whole class of substances without being able to regulate the dosage without having any knowledge of the purity of it, or the toxicity of it. And for those that are smoking and inhaling it to think we're not going to have the same long term cancer type effects that we experienced with a different herb that we smoked tobacco is ludicrous. Yet I see nothing in the public health space or within, you know, from the Bureau of medical licensure boards, really cracking down as a profession on prescribing this and you know, I mean, we live in Oklahoma City and there's when I go to St. Anthony Hospital, if I take a particular route down Penn Street, I passed 13 dispensaries, two of which have a sign spinner on the highway, you know, trying to get me to stop. And they have creative names like cannabis and, you know, all these wonderful things. But but the thing that's so offensive to me is the fact that we're allowing it to be termed medical marijuana and we're legitimizing it by actually prescribing it. And what you've shown is that it is harmful. And that in every case that you're prescribing marijuana for, there are other properly regulated, appropriately approved through the FDA rigorous process, medicines that will do a better job. So I don't know if there's a caboose on the end of my train of thought or not. But my question to you is, what are we doing as a medical profession to self regulate? Because I've always been proud of the House of Medicine and that y'all do peer review and self regulate. So I'll answer. Okay, let me let me just answer that. What is the medical profession doing about this? Not enough. What I was going to say was in Georgia a few years back, they made it legal for medical marijuana is legal. However, it is not legal for any physician licensed in the state of Georgia to prescribe. Notice, you don't have to be a physician located it. You have to be if you're even licensed, then you can't prescribe medical marijuana at all. And it remains illegal to transport it across the state line into Georgia. So how you get that? Basically, it just shows up on a on a map that it's legal. Yeah, and so that's the thing. So when we say medical marijuana, typically, that's not physicians prescribing anything. This is the they might go to a special like in Arizona, how it works is you need to be a naturopath or osteopath or an allopath. And you have to recommend that this patient has a condition that meets the requirements of the law in order to be approved for medical marijuana. That's not prescribing. And that does give carte blanche kind of, you know, so here's the thing. If I prescribe somebody propranolol, does that mean you can go to the grocery store and buy, you know, 5000 doses of it? No. So that's that's what where we currently are with cannabis. It's not regulated in any type of realistic medical manner. It is purely commercial product. So basically, this is the same way laudanum and cocaine was before the 1914 act. So it's just it's on this. It's on the store shelves. Yeah. So we've gone back 100 years in regulation time for cannabis. So serum testing. So serum testing for cannabis is really where the research was conducted as far as impairment. And so what happened was they found that the serum levels of around three point three to four point five were equivalent to about a point oh five alcohol impairment level. OK, so that means that a plasma level of five nanograms per milliliter of THC. Is consistent with legally drunk for alcohol. OK, so five nanograms per milliliter is the plasma level of THC that is required to say that somebody is impaired. You are intoxicated. OK, the problem though is when I send them after a workplace accident, what do we get? We get urine. So unfortunately, I did not find correlating urine numbers for this. So urine is good for the for the, you know, yes or no. You know, it's positive or negative. But really, we need to get serum levels or do direct impairment testing. Got a question. Hold on. So this is really cool. My question is, is there any lab on the planet or at least in the United States that can do a plasma THC level? So could you order this test from West or one of the big companies and get it done? I sure hope so. That doesn't sound like a yes. That doesn't sound like a yes. Now, in the past, I know that the answer was no. I'm just curious if the science has caught up with this, if the labs have caught up with this science, that would be really cool. I would not presume that the generally commercial labs are able to do this type of testing. But this is the number in which the research indicated this is an intoxicated person. So what we need is we need to correlate this to the urine actual percentage and then kind of come across the board that way. But research-wise, this is where it was at. The question is, how long until we have a test that is a test that can be given roadside or at the police station to demonstrate active intoxication from cannabinoids? So, the field sobriety test actually does capture acute intoxication from cannabinoids. As we demonstrated with the numbers, it's just, it's not as profound as an alcohol field sobriety test. It's going to be more in that gray area where the officer's like, well, does it smell like marijuana in the car? Does the kid reek like marijuana? Did I find a marijuana vape pen in the car? Then I would say if the field sobriety test is in that gray area where not quite alcohol positive but still not looking right, that's a DWI, that's a DUI. Whereas for us, it's more difficult because in a workplace environment, accident occurs. They either go to the hospital or the workplace testing environment. And then we're going to do a urine metabolite test. But again, that doesn't tell us, was the employee impaired at the time of the accident? And that's where we got to get better about the testing rigmarole. The reality is impairment level is far more valuable than a positive metabolite test. So here's the nanograms per milliliter. And this was from a relatively recent article. The employers who decide to or are required to accept employees' use of medical and or recreational marijuana consistent with state law must carefully assess risk of impairment from marijuana use, especially for employees in safety sensitive positions. I can't stress that enough. So as it stands right now, I think we have to stand firm on our ground, which is if you can't test negative for a marijuana metabolite, I can't give you a safety sensitive position. I have a input from Dr. Ferguson. Serum THC can be done by labs, but that doesn't mean it is commercially offered by those labs. It is very expensive at the few labs that do it. And they offer it with a long turnaround time. Additionally, there is SAMHSA funded research questioning whether the five nanogram level is too high. Agreed. But again, we're talking about a blood alcohol level of like 0.1. So like equivalency rating. And there is impairment lower than the five nanogram per milliliter, as it as was shown right here. So what happens is it's, you know, a linear style graph, but the impairment showed impairments as low as 3.1, and then all the way up past five for impairments. Another question? So the zero, so the blood alcohol level is 0.05 was equivalent to the 3.3 to 4.5 nanograms per milliliter. So what they were saying is that a 0.08 or legally intoxicated via alcohol was roughly equivalent to five nanograms per milliliter. Yeah, so what happens is if you can say somebody's drunk off alcohol above a 0.08, then you could say that if the marijuana serum, THC serum level was above five nanograms per milliliter, they are legally intoxicated, yeah. So is everybody here an MRO? Nobody, some people are, okay. So a medical review officer is kind of like a gold standard when it comes to employee marijuana related questions. Legal counsel is also strongly recommended if you have somebody who is, I've got a medical marijuana license for the state, you're not supposed to discriminate against me per state law. However, you're doing something that's safety sensitive or it's a drug free workplace because drug free workplace is federal and it supersedes that state law for medical marijuana, especially in federal workplaces. Specific guidelines regarding testing for post-accident and possible impairment assessments need to be developed and explained to employees. Serum testing is recommended if available. Proof of use and impairment are needed to deny claims outright. So if you've got them on video camera and they're like, you know, I see you got a little bit of sway here, that might be enough. Or, you know, you dropped all your stuff and I got 50 days of video records showing that you never dropped your stuff, but today you did. And now you'd had an accident and you test positive for the marijuana metabolite. You have to gather enough evidence to really make a case for impairment. The occupational health professional responsible for providing medical evaluation of employees fitness for duty should establish and consistently apply clear guidelines on the situations for which use of medical marijuana would be considered. It is advisable for medical evaluations to include documentation of state registration, the schedule of use relative to working hours, the cannabis form used, whether somebody's using plant material, edibles, concentrates, the need for any accommodations given the employee's job duties and anticipated duration of use. For instance, let's say I'm a trucking company. There's a big difference between the lady who stays at the office and does the paperwork versus somebody who's operating the vehicle. The guy who's operating the vehicle is under much stringent, much more stringent restrictions on what is acceptable. Whereas the lady working in the office, because she's not operating heavy machinery may be under different level of restrictions. So, and for duration of use is interesting because we're giving people carte blanche. You know, they can go to the store and buy as much as they want and use it for as long as they want. There's no, you know, I prescribed this for 30 days. So like the next 30 days, you're not gonna operate those heavy vehicles. It's nothing like that in cannabis. I can't say like, you know, I gave him a prescription for 30 days and then that's supposed to be that. The occupational health provider should work with site management to assess risk based on safety sensitive natures of jobs. So at this stage in the game, without a clear path to active impairment testing, we don't have a way to say in your safety sensitive job that any level of cannabis use is okay. Even in states where it's legalized for recreational medical use. So considerations of workplace safety in the context of underlying medical condition for which marijuana has been recommended may also be appropriate in some cases for let's say the trucking company with the office worker versus the road worker. The office worker, it may not be a clear cut answer, but your workplace policy has to match that discrepancy. If you're not in a safety sensitive position, it may be more amenable, whereas if you are, absolutely not. So the development of policies pertaining to marijuana are just desperately needed. The purpose, the intent of the program, the employees covered by the policy, whether somebody's okay to have medical marijuana or if they're okay to use recreational marijuana in their off duty time. When the policy applies, is off duty use prohibited or not? Prohibited behavior. If you're using it right before you come to work with the presenteeism, that's not okay. That's like drinking a couple of beers before you show up to work. I mean, this is not Russia where that's acceptable. Whether employees are required to inform their supervisor of medical marijuana prescriptions or drug related convictions. Whether the policy covers searches and the extent of the search allowed. Are you allowed to go look in the guy's car to see if he's got a vape pen stuck in the cup holder? That's, if I saw one as an employer, I'd be pretty upset. It's like, are you doing this while you're driving? Are you nuts? Observable and measurable behaviors indicative of unsafe job performance. Now, this is the year 2024. Technology has come forward a little bit with regards to impairment testing. But we're still not there yet. I'll talk about the technology here in just a minute. I think one more, yeah, one more, couple more slides. Oops, let me go backwards. Referral mechanisms for unsafe work performance. That's, you know, he's a medical marijuana patient, but I'm not so comfortable with how he's been working lately. Performance is failing or some other type of issue with his job performance. Requirements for drug testing with input from the medical resource officer. Consequences for policy violation, whether return to work agreements are needed after an absence related to substance abuse. It's like I stayed up all last night and ate cookies until 3 a.m. and so I can't come in today. That's not gonna fly. It's like you're still absent from work for substance abuse related reasons. Measures to protect employee confidentiality. Measures for policy enforcement, because here's the crazy part. They go to get the medical marijuana license, okay? That's a public license, okay? But as soon as we identify marijuana use disorder, 42 CFR Part 2, you guys familiar with that? Okay, so CFR 42 Part 2 is, if somebody has substance use disorder, you can't disclose it to anybody without the patient's permission. Yet they're gonna be telling everybody, I have a medical marijuana card. You see the problem with that? So now what they do is they handcuff us so that we can't say anything like, hey, I'm worried. You know, so that's a big deal too. The measures of policy enforcement, the steps to communicate policy to employees, supervisors, occupational health professionals, management, union management when applicable, and contractors and their employees. So unions are very interesting. Let's say you're a carpenter. That is somewhat of a safety sensitive position, particularly because you're working on structural integrity. And then you're up dangling in places where you could fall and hurt yourself in a serious manner. Some unions protect their workers on medical marijuana. So now it's not only you the employer versus the patient, it's you versus the patient and their union who's gonna be protective of, hey, but he has a state sanctioned marijuana license, and he fell on your work site, so you need to pay his workers compensation. So you see where there's a lot of problems with the current system as it currently stands. And then the other thing is this also brings up the reality of if somebody's got a problem with cannabis, again, that one out of 100 people of all 330 million of us, one out of 100 is gonna have a serious cannabis use disorder where it's gonna cause problems. As employers, do we refer to treatment? And the reality is that there has to be a consideration at this point in time. And who's gonna treat cannabis use disorder, right? Certainly not the dispensaries. Employers should consult with legal counsel. And again, even the legal counsel will tell you that some of these areas are gray and nebulous. And the reality is the court could go either way. It could protect the patient, it could protect the employer, and there's not really a good way to estimate unless you have clear data. Hey, this guy was impaired, and he came to work, and he knew that he was not supposed to be impaired at work, and he got hurt. So that brings us to advancements. Okay, innovations in impairment testing. Have you all seen the, so in professional monitoring programs where doctors and lawyers and other professionals get in trouble for substance use, there's a variety of advanced testing measures that we can utilize. Some of those are breathalyzers that plug into smartphones, and you can actually, it videotapes you while you blow into the breathalyzer, and then it immediately transports the results to the monitoring physician, okay? In cannabis, we don't have a way to do a chemical analysis other than a metabolite test at this point in time. Serum testing or more precise quantitative urine testing obviously is important, but with these, so what happens is these guys used AI to develop a system on the smartphone where it observes the nystagmus of the eyes. And then it asks them to do a rapid response, like a response time study on the phone itself and can actually determine with relatively, about 88% accurate whether somebody is impaired at this point in time. The catch is you need a baseline reading. So as an employer, this presents an interesting piece of technology because if people come in with drug testing, they're sober, let's get a baseline level on these apps. And then if they have an accident in the workplace, I'm gonna run the app right there, right then and now, like, hey, we're gonna test to see if you're impaired right here, right now, and then get a result. And then if you are, I mean, and you have a positive metabolite, that's proof of metabolite and impairment at the time of the accident, okay? So safety sensitive positions, I think what you're gonna start seeing is these workplaces are gonna start running around with a tablet that's got some cameras and such on it and then run them through a impairment program and see if they're impaired at the time. So that's right up on around the corner. I'm actually meeting with some of those guys tomorrow to actually see a live demonstration of it, so. Thank you. Oh, yeah, tremendously, tremendously helpful. The reality is, like, the answer for these types of questions, we can technologically find an answer, but, you know, or we could get more precise urine testing, you know, with quantitative results instead of going all the way to GC-MS or LC-MS. How about more questions? So you mentioned the device that looks at nystagmus. There were devices in the past that were looking at sway and things. There was one was called Canary is the one I remember. Is any of that proving out? And my question is, even those people, the workplaces that they, if they get this app to work really well, are they ready to go to court with you? And that's the big question. So with the research results, you're only 88% accurate. We need to get more accurate than that. So what I think will happen is they'll have, so the question was, are these impairment testing devices and methodologies capable of going to court and standing up in court and saying that this guy was impaired at this point in time? And so the reality is, with research, these methodologies will become more accurate over time. And especially with AI advances and things called deep learning, where what it does is it evaluates not just, you know, a thousand samples, but a million samples to try and get a baseline reading and then to understand where exactly neurologically somebody is impaired. I think what you'll see is you'll see, you'll start to see specialized devices that specifically will look for these types of things. Like it'll probably look like a tablet with some other additional pieces of hardware on it. And you'll get a baseline reading on somebody when they come in for a job. And then if there's ever an accident or something, or even in situations where somebody needs to be extremely precise, like in Arizona, we have a new microchip factory. In those microchip factories, it's called a forge actually, they have these very precise tolerance tests. And like, you have to be just almost like a robot and you're in a space suit because there can't be any contamination. What you might see from these companies is that immediately prior to shifts, they'll be tested for impairment. Did you not sleep last night? Did you have too much coffee this morning? And then you have a little tremor. All of these things could be tested on a instant basis. And so what I think we'll see moving forward is even like when you hop in the car, the car might do an impairment level testing on you. The reality is this is the direction that we're probably headed. It's gonna move away from metabolite testing and more towards an active impairment level testing. And the implications for use of that are just tremendous. So. Correct, some cars already identify, like if you start to leave your lane a little bit, it'll let you know like, hey, yeah, pull over. It's like something's wrong with you. And were there any, and let me just do a conclusion here. So the effects of high potency cannabis medically in naive users are quite impairing. However, in chronic users, their tolerance may mask some acute symptoms and intoxication. So you can't always tell. Blood serum levels of THC have more correlation to acute impairment than the presence of metabolites in urine assays. The serum level of more than five nanograms per milliliter are generally indicative of impairment in both naive and chronic users of cannabis. And the employers in states where cannabis use is medicalized or legalized should strongly consider consulting with an MRO and legal counsel in development of cannabis related policies. So those are the big key points. Thank you.

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