Prescription Drugs in the Workplace
Meeting the Challenge
David K. Roberts, Ph.D.
Legacy Laboratory ServicesMetroLab Toxicology
July 12, 2012
Why are Prescription Drugs a Challenge?
OK
Not OK
Legally prescribed
Diverted, spousal use
Used responsibly
Abused
Can cause impairment- accident risk
Can cause addiction
• Performance problems
• Absenteeism issues
• Increased health care costs
Prescription drugs with abuse potential are the challenge!
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Prescription Drugs with Abuse Potential –
The Usual Suspects- part 1
Drug Class
Trade Name
Generic Name
Amphetamines
Adderall
Amphetamine
Ritalin
Methylphenidate
Xanax
Alprazolam
Klonopin
Clonazepam
Valium
Diazepam
Ativan
Lorazepam
Restoril
Temazepam
Medical marijuana
Pot
THC
Nonbenzodiazepine hypnotic
Ambien
Zolpidem
Benzodiazepines
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Prescription Drugs with Abuse Potential –
The Usual Suspects part 2
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Drug Class
Trade Name
Generic Name
Opioids
Suboxone
Buprenorphrine
Duragesic
Fentanyl
Lortab
Hydrocodone
Dilaudid
Hydromorphone
Dolophine
Methadone
MS Contin
Morphine
Oxycontin
Oxycodone
Opana
Oxymorphone
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US Center For Disease Control- Summary
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Other Prescription Drug Issues
 Prescribed by a trusted professional
 Typically over prescribed- 30 days instead of 3
 Widely prescribed
 Pharmaceutically pure
 No street drug stigma
 Active orally
 Potent
 Legitimate needs vs abuse potential
Abuse potential of prescription drugs, particularly
opioids, is having significant societal issues!
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Opioid Prevalence
(DAWN)
Emergency Dept Visits Involving Opioids
120,000
visits
100,000
Codeine
80,000
Hydrocodone
60,000
Fentanyl
40,000
Hydromorphone
20,000
Methadone
Morphine
0
2004
2005
2006
2007
2008
Oxycodone
year
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Illegal Drug Prevalence
(DAWN)
Emergency Dept Visits Involving Illegal Drugs
200,000
visits
150,000
Heroin
Cocaine
100,000
Marijuana
Meth/amphetamines
50,000
0
2004
2005
2006
2007
2008
year
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Benzodiazepine Prevalence
(DAWN)
# visits
Emergency
Dept Visits involving Benzodiazepines
120,000
100,000
80,000
60,000
40,000
20,000
0
Alprazolam
Clonazepam
Lorazepam
Diazepam
Temazepam
2004
2005
2006
2007
2008
year
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Drug Prevalence Comparisons
(DAWN)
Drug ED Visits Comparison
# visits
350,000
300,000
250,000
Illegal Drugs
200,000
Opioids
150,000
Benzodiazepines
100,000
50,000
0
2004
2005
2006
2007
2008
year
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Prescription vs Illegal Drugs: ED Visits
Drug Class ED Visits
600,000
# visits
500,000
400,000
Prescription Drugs
300,000
Illegal Drugs
200,000
100,000
0
2004
2005
2006
2007
2008
year
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In Oregon
Prescription Drug Deaths > Traffic Deaths
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Hydrocodone (with acetaminophen)
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Hydrocodone- the Most Prescribed Opioid
 Hydrocodone is absorbed and then metabolized to
Hydromorphone
 Hydromorphone is 7 – 10 times more potent than morphine!
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Oxycodone
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Oxycodone- “Hillbilly Heroin”
 Oxycodone is absorbed and then metabolized into Oxymorphone
 Oxymorphone is ~10 times more potent than morphine!
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Opioid Addiction
Opioids indirectly enhances dopamine
Excess dopamine can cause intense pleasure
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Drug Addiction
A Behavior Disorder
 Chronic
 Relapsing
 Complex cascade of neurochemical events
 Result in Compulsive drug seeking behavior
 Persists even if the face of negative consequences
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Meeting The Prescription Drug Challenge
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Step
Issue
Comments
1
Policy
Policy always comes first- don’t forget a legal
review!
2
Panel
You can’t find it if you don’t test for it- make sure
your company is using the right panel!
3
Consistency
Use the same panel for all your testing regardless
of reason- avoid collector errors.
4
Require
Disclosure & Train
Supervisors
Require confidential employee disclosure- policy
(non)compliance may be critical. A trained
supervisor can provide evidence for impairment.
5
MRO
Use a board certified MRO- sorting through
legitimate vs illegitimate prescription medication is
better left to a professional.
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Step 1- No Testing Without a Policy
www.drugfreeworkplace.gov
Always Hire an Employment Lawyer to Review Your Policy
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Step 2- Use the Right Panel.
“Urine 8”- Illegal + Prescription Drugs
.
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Test
Drug Class
Cutoff
Make sure cutoff is appropriate
1
Amphetamines
500 ng/mL New more sensitive DOT cutoff
2
Benzodiazepines
200 ng/mL Need lower cutoff & special
screening test for Alprazolam
3
Cocaine
150 ng/mL New more sensitive DOT cutoff
4
Opiates
300 ng/mL Need low cutoff for Hydrocodone
5
Heroin
10 ng/mL New test included in each panelcan be positive by itself!
6
Oxycodone
100 ng/mL Required to reliably detect
Oxycotin, Percodan, Percocet
7
Methadone
300 ng/mL Increasingly common prescription
drug
8
Marijuana
50 ng/mL
DOT cutoff to exclude passive
exposure
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Other Drug Step 2 Panel Considerations
Out with the OLD screening tests:
Propoxyphene, MDMA, Barbiturates, Methaqualone, PCP,
Amphetamine 1,000, Cocaine 300,
In with the NEW / relevant screening tests:
Oxycodone, Methadone, Benzodiazepines, Heroin,
Amphetamine 500, Cocaine 150,
Out with the OLD confirmation tests:
“DOT Opiates”: Morphine and Codeine only
In with the NEW / relevant “Expanded Opiates” confirmation
tests (will be in DOT panel in 2 years):
Morphine and Codeine 2000
Hydrocodone / Hydromorphone 150
Oxycodone / Oxymorphone 100
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Consistency & Disclosure
Step 3: Consistency helps reduce errors. If you have only one panel
you will avoid “the wrong panel” syndrome. Keep it simple.
Step 4: Important issues if you have a post accident or reasonable
suspicion drug screen.
If a prescription drug is detected and it was legally prescribed- policy
becomes paramount.
The MRO will NOT be able to determine impairment using urine
drug levels.
If the employee failed to disclose a detected prescription drug- you
will have a policy violation.
If a trained supervisor documented objective evidence of
impairment- you have a policy violation.
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Step 5: A Board Certified MRO
Board certified MROs can
•investigate prescriptions without violating HIPAA laws.
•Interview donors regarding their medical conditions.
•Review chain of custody documents.
•Legally provide a safety concern if an employee has a detectable
prescription drug that could cause on the job impairment and result in
increased accident risk
SAFETY CONCERN: A legally prescribed Hydrocodone is detected
in Joe’s urine in a pre-employment drug test for a fork lift operator.
Reported Negative after an interview- no safety concern: A legally
prescribed Alprazolam metabolite is detected in Suzy’s preemployment drug test for a receptionist.
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Prescription Drugs in the WorkplaceMeeting the Challenge Summary
 Prescription drugs represent a significant business threat
 Policy comes first in order to protect your business
 Don’t forget your lawyer
 Make sure your panel covers the main prescription drug threats
Amphetamines
Benzodiazepines
Opioids
 Use the same panel every time- keep it simple
 Communicate your policy and require that employee’s disclose
prescription drugs that could cause impairment
 Train your supervisors to recognize drug impairment
 Use a board certified MRO
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Questions????
Thank you!