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Solutions in the Workplace
National Rx Drug Abuse Summit 4-11-12

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  1. 1. Solutions in the Workplace April 10-12, 2012Walt Disney World Swan Resort
  2. 2. Accepted Learning Objectives:•  1. Describe the scope of the prescription drug diversion problem with a focus on understanding the costs to both the employer and employee.•  2. Explain what should be included in an effective prescription drug diversion policy for the workplace.•  3. Define the roles of employers and employees in creating a safe and healthy workplace.
  3. 3. Disclosure Statement•  All presenters for this session, Hon. Alix C. Michel and Hon. David J. Ward, have disclosed no relevant, real or apparent personal or professional financial relationships.
  4. 4. Prescription Drug Abuse is an Epidemic•  The toll our nation’s prescription drug abuse epidemic has taken in communities nationwide is devastating…we all share a responsibility to protect our communities from the damage done by prescription drug abuse. Gil  Kerlikowske  
  5. 5. Prescription painkiller overdoses are a public health epidemic•  Prescrip/on  painkiller  overdoses  killed  nearly  15,000  people   in  the  US  in  2008.  This  is  more  than  3  /mes  the  4,000  people   killed  by  these  drugs  in  1999.    •  In  2010,  about  12  million  Americans  (age  12  or  older)   reported  nonmedical  use  of  prescrip/on  painkillers  in  the  past   year.    •  Nearly  half  a  million  emergency  department  visits  in  2009   were  due  to  people  misusing  or  abusing  prescrip/on   painkillers.      •  Nonmedical  use  of  prescrip/on  painkillers  costs  health   insurers  up  to  $72.5  billion  annually  in  direct  health  care   costs.  
  6. 6. Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older: 2002-2010Substance Abuse and Mental Health Services Administration, Results from the 2010 National Surveyon Drug Use and Health: Summary of National Findings
  7. 7. Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2009 and 2010    Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey onDrug Use and Health: Summary of National Findings
  8. 8. Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2010
  9. 9. Past Month Illicit Drug Use among Persons Aged 18 or Older, by Employment Status: 2009 and 2010
  10. 10. Amount of Prescription Painkillers Sold Per State Per 10,000 People (2010)Source: Automation of Reports and Consolidated Orders System of DEA, 2010
  11. 11. Drug Overdose Death Rates by State Per 100,000 People (2008)Source: National Vital Statistics System, 2008
  12. 12. Top Ten Most Medicated States
  13. 13. Certain Groups Are More Likely to Abuse or Overdose on Prescription Painkillers•  More  men  than  women.  •  Middle-­‐aged  adults.  •  People  in  rural  coun/es.  •  Whites  and  American  Indian  or  Alaska  na/ves  are  more  likely   to  overdose  on  prescrip/on  painkillers    About  1  in  10  American  Indian  or  Alaska  na/ves  aged  12  and   older  used  prescrip/on  painkillers  for  nonmedical  reasons  in   the  last  year,  compared  to  1  in  20  whites  and  1  in  30  blacks  
  14. 14. Substance Dependence or Abuse in the Past Year, by Age and Gender: 2010
  15. 15. Persons Receiving Most Recent Treatment in Last Year for Pain Relievers
  16. 16. Florida Legislature voted in the 2012 session to create the Statewide Task Force on Prescription Drug Abuse and Newborns.•  Task  force  will:    -­‐  analyze  data;      -­‐  evaluate  strategies  for  treatment  and  preven/on;    -­‐    iden/fy  federal,  state  and  local  service  programs    -­‐  detail  costs  for  trea/ng  expectant  mothers  and  newborns  suffering  from   withdrawal;  and      -­‐  determine  how  to  increase  public  awareness  •  Between  2005  and  2011,  the  NICU  at  Lee  Memorial  Hospital  saw  an  800%   increase  in  the  number  of  babies  born  addicted  to  prescrip/on  drugs      
  17. 17. Most Frequently Abused Drugs•  To  relieve  pain:    opioids  like  OxyCon/n®  and  Vicodin®  •  To  relieve  anxiety:    seda/ves  like  Valium®  and  Xanax®  •  To  boost  aaen/on  and  energy:    medicines  that  speed   up  physical  and  mental  processes  like  Ritalin®,   Adderall®  and  Dexedrine®  •  To  improve  athle/c  performance:    steroids  like   Anadrol®  and  Equipoise®  •  Painkiller  Opana,  new  scourge  of  rural  America   (Reuters  3/27/12)  
  18. 18. Rise of Oxycontin•  Oxycodone  developed  in  1916  •  Oxycon/n  approved  by  FDA  in  1995  •  Oxycon/n  introduced  in  U.S.  in  1996  •  Best  selling  non-­‐generic  pain  reliever  in  U.S.  by   2001  
  19. 19. The Rise of the "Pill Mills"•  "Pill  mills"  have  flourished  in  Florida  •  According  to  the  Florida  Aaorney  Generals  office,   clinics  are  omen  cash-­‐only  enterprises  employing   doctors  who  write  prescrip/ons  for  painkillers   without  examining  pa/ents.  •  Highway  patrol  officers  rou/nely  stop  vanloads  of   people  with  fresh  stockpiles  of  prescrip/on  drugs.  •  Flights  on  discount  airlines  between  Hun/ngton,  W.   Va.,  and  Fort  Lauderdale,  Fla.,  have  been  dubbed  the   "Oxycon/n  Express."  
  20. 20. Souths Deadly "Pill Mill Pipeline"•  Kentucky  Governor  Steve  Beshear  and  Florida   Governor  Rick  Scoa,  whose  states  anchor  each  end   of  the  "pill  mill  pipeline,"  tes/fied  in  April    in   Washington.    •  "Let  me  be  frank.  Our  people  in  Kentucky  are  dying,"   Beshear  said.  "82  people  a  month.  More  people  in   Kentucky  die  from  overdoses  than  car  wrecks."    •  98  of  the  top  100  doctors  in  the  country  dispensing   oxycodone  are  in  Florida.  "More  is  dispensed  in   Florida  than  the  rest  of  the  country  combined,"  Scoa   told  the  panel.    
  21. 21. Florida Attorney General Moves to Crack Down on Pill Mills•  Its  es/mated  seven  Floridians  die  every  day  because  of   prescrip/on  drug  abuse.    •  Jacksonville  Sheriffs  Office  says  drug  dealers  are  making  big   profits  on  prescrip/on  drugs.  "Theyre  coming  from  all  over   to  the  state  of  Florida  to  obtain  these  pills  and  to  take  them   back  up  to  be  sold  wherever  theyre  from  and  these  pills,  the   oxycodone  30  milligram  pill,  can  be  sold  up  in  Kentucky  for   anywhere  from  $25  to  $50  apiece."  •  "In  a  six-­‐month  /me  span  in  Palm  Beach  and  Broward   coun/es,  doctors  dispensed  more  than  nine  million   oxycodone  tablets…"    •  More  pill  mills  than  McDonalds  in  Broward  and  Palm  Beach   CounMes, February 3, 2011
  22. 22. You Deal, They Die, You’re Done
  23. 23. Migration of Pill Mills•  Started  in  Florida  •  PMP  ini/ated  in  Florida  •  Migrated  to  Georgia  •  PMP  ini/ated  in  Georgia  •  Now  in  Tennessee  and  Kentucky  
  24. 24. Drug Seeking Scams•  Fic//ous  pa/ents  –  stolen  pads    •  Altered,  legi/mate  prescrip/ons    •  Phoned  prescrip/ons  by  drug  seeker    •  Copies  of  legi/mate  prescrip/ons    •  Not  usual  dosage    •  No/wrong  abbrevia/ons    •  Different  inks/handwri/ng    •  Large  quan//es   Websites:  alt.drugs.hard  or  
  25. 25. PaMents  Healthcare  Providers   Pharmacists  
  26. 26. Methods of Drug Diversion - Patient•  Pa/ents  as  a  source  of  drug  diversion   –  Changing  wri/ng  on  prescrip/ons   –  Obtaining  prescrip/ons  for  a  single  drug  from   mul/ple  doctors  concurrently   –  Forcing  or  influencing  physicians  to  write   prescrip/ons   –  Using  decep/ve  prescrip/ons   –  Pa/ents  ac/ng  like  physicians  
  27. 27. Methods of Drug Diversion - Patient
  28. 28. RX Drugs Sold From an Ice Cream Truck          39  year  old  Woman  arrested   Allegedly  selling  Soboxone  
  29. 29. Methods of Drug Diversion - Doctor•  Healthcare  professionals  as  a  source   –  Lacking  skills  and  failing  to  recognize  diversion  •  Physicians  as  a  source   –  Using  the  wrong  drug  for  diagnosis   –  Not  having  the  ability  to  make  good  decisions   –  Addicted  to  drugs  affec/ng  mental  health   –  Engaged  in  illegal  drug  trafficking  ac/vi/es  
  30. 30. Why Do Healthcare Providers Get Addicted?•  Job  stress.  Long  hours/stress  related  to  caring  for  the   sick/dying.    •  ICU,  ER,  OR,  or  anesthesia  have  the  highest   prevalence  of  substance  abuse  and  are  considered   VERY  high  stress  work  sesngs    •  Workaholic  personality  leads  to  other  addic/ons.  •  In  general,  providers  take  care  of  others  first  and   themselves  last.    
  31. 31. Engaged in Illegal Trafficking Activities• Chicago  Doctor  Given  Four  Life  Sentences  • Convicted  of  causing  the  deaths  of  four    pa/ents  who  overdosed  on  pain  pills.   February  14,  2012  
  32. 32. California “Doctor Feelgood” Charged With 3 Murders •  Wrote  more  than  27,000  prescrip/ons  in  a  three  year  period •  “If  my  pa/ent  decides  to  take  a  month  supply  in  a  day,  then  there’s   nothing  I  can  do  about  that.”
  33. 33. Methods of Drug Diversion - Pharmacist•  Pharmacist  as  a  source   –  Not  checking  for  the  accuracy  of  physicians  DEA  number   –  Receiving  phone  orders  and  dispensing  or  giving  out   medica/ons  based  on  incomplete  informa/on  on   prescrip/on   –  Not  detec/ng   •  Misspellings   •  Dosage  mistakes   •  Inappropriate  refills   –  Rogue  Pharmacists  
  34. 34. Methods of Drug Diversion - PharmacistNY video
  35. 35. Prescription Pill Epidemic Fuels Pharmacy Robberies Across The Country•  "Last  year,  pharmacy  robberies  were  up  18,000  in  the   en/re  country,"  (Knoxville  P.D.  spokesman  D.  DeBusk,   7/8/11)    •  Robbers  come  in  24/7  to  demand  prescrip/on  pills,   especially  OxyCon/n,  and  make  a  quick  getaway.  •  Innocent  employees  and  customers  at  risk.  
  36. 36. Pharmacy Robberiesvideo
  37. 37. Pharmacist’s Response•  Refusing  to  carry  Oxycon/n  •  Time  release  safes  •  DNA  spray  •  Call  ahead  prescrip/ons  •  Other  op/ons  
  38. 38. Other Pharmacist’s Responses
  39. 39. Other Pharmacist’s Responses
  40. 40. Responses to Prescription Drug Abuse•  Na/onal  •  State  •  Local  •  Employer’s  
  41. 41. National Response
  42. 42. •  Educa/on  •  Tracking  and  Monitoring  •  Proper  Medica/on  Disposal  •  Enforcement  
  43. 43. States’ Responses•  PMPs  •  Pill  Mill  legisla/on  •  Requiring  Physicians  to  View  PMPs  •  Law  Enforcement  Task  Forces  •  Strengthening  Pharmacy  Protec/on
  44. 44. How Are the Controlled Substance Databases Being Used?
  45. 45. As of: July 31, 2008Drug Product: METHADONEPrescriber State: TN Rank Prescriber Name Office Zip Scripts Filled Cash Scripts Filled 1 XXXXXX Nashville-372 33 16 2 XXXXXX Nashville-372 32 32 3 XXXXXX Nashville-372 29 11 4 XXXXXX Nashville-372 29 27 5 XXXXXX Nashville-381 18 5 16 XXXXXX Nashville-374 10 10 Source: Tennessee Prescription Drug Monitoring Database
  46. 46. Problems With State PMPs•  Not Real-Time•  No Interoperability between states•  Doctors don’t use them•  Pharmacists don’t use them
  47. 47. Tennessee Pill Mill Law•  Allows  the  licensing  boards  to  inspect  the  pain  clinic   and  inves/gate  complaints  •  Prohibits  owner  from  being  convicted  of  a  felony  or   an  illegal  drug-­‐related  misdemeanor    •  Requires  that  all  pain  clinics  must  be  operated  by  a   medical  director  who  is  a  physician  and  prac/ces  in   this  state  under  an  unrestricted  license.    •  The  medical  director  must  be  in  the  clinic  at  least   20%  of  the  /me  the  clinic  is  open.  
  48. 48. Tennessee Pill Mill Law•  Establishes  procedures  to  revoke  or  suspend   cer/ficates  issued  by  the  department.    •  Requires  clinic  to  post  cer/ficate  in  a   conspicuous  loca/on  that  is  clearly  visible  to   pa/ents.    •  Prohibits  cash-­‐only  transac/ons  except  for  co-­‐ pays,  deduc/bles  and  co-­‐insurance  payments.
  49. 49. New York Proposed Legislation I-­‐STOP  Internet  System  for  Tracking  Over-­‐Prescribing•  Connects  prescribers  to  a  centralized  online   database  •  Tracks  frequently  abused  controlled   substances  in  real  /me  •  Physicians  required  to  review  pa/ents’   prescrip/on  history  before  they  issue  a   new  prescrip/on  
  50. 50. New York Proposed Legislation I-­‐STOP  Internet  System  for  Tracking  Over-­‐Prescribing  •  Pharmacists  required  to  check  the  database   for  script  authen/city  before  they   dispense  painkillers  •  Mandate  that  doctors  and  pharmacists   report  new  prescrip/ons  every  /me  they   are  wriaen  and  filled  
  51. 51. The Cost of Substance Abuse To Society•  2005  federal,  state  and  local  government  spending  as   a  result  of  substance  abuse  and  addic/on  was  at   least  $467.7  billion  •  Almost  three-­‐quarters  (71.1%)  of  total  federal  and   state  spending  on  substance  abuse  is  in  two  areas:   health  care  and  jus/ce  system  costs    •  Of  the  spending  that  can  be  iden/fied  by  substance,   an  es/mated  $18.7  billion  is  spent  on  illicit  drugs
  52. 52. No One is Immune and Some Costs are Unimaginable…
  53. 53. Costs to Industry•  Workdays  missed  •  Likely  to  injure  self  or  others  •  Workers  compensa/on  claims  filed    •  Decreased  Produc/vity  ($129B)  •  Increased  Healthcare  Costs  
  54. 54. Direct Costs to Industry•  Absenteeism  (1.5  /mes)  •  Tardiness  •  Sick  leave  •  Over/me  pay  •  Insurance/Liability  Claims  •  Workers  Compensa/on (3  ½  /mes  more  likely)    
  55. 55. Hidden Costs to Industry•  Personnel  turnover  (25-­‐200%  compensa/on)  •  Poor  decisions  •  Damage  to  equipment  •  Fric/on  among  workers    •  Damage  to  the  companys  public  image  •  Diverted  supervisory  and  managerial  /me        
  56. 56. Additional Costs to Industry•  Poten/al  overall  cost  of  painkiller  abuse  at  more  than   $70  billion  a  year•  Pill  addicts  who  shop  around  for  doctors  to  obtain   prescrip/ons  cost  insurers  $10,000  to  $15,000  apiece•  The  toll  in  lost  produc/vity:  $42  billion•  The  criminal  jus/ce  bill:  $8.2  billion
  57. 57. ED Visits For Prescription Drug Abuse•  1,244,679  ED  visits  involved  non-­‐medical  of   prescrip/on  drugs,  OTCs  or  supplements  •  Pain  relievers  were  involved  in  47.1  percent  of  visits  •  Medical  emergencies  related  to  nonmedical  use  of   pharmaceu/cals  increased  98.4  percent  from   2004-­‐2009  •  627,291  visits  in  2004  to  1,244,679  visits  in  2009 SAMHSA,  2010
  58. 58. Rates of ED visits per 100,000 population involving nonmedical use of pharmaceuticals, by age and gender, 2008
  59. 59. Can You Afford Not To Havea Substance Abuse Program?
  60. 60. What Should an Employer Do?•  Wriaen  substance  abuse  policy  (SAP)  including   prescrip/on  medica/on  •  Employee  educa/on  and  awareness  program  •  Employee  Assistance  Program  (EAP)  •  Drug  tes/ng  program,  where  appropriate    •  Train  supervisors  
  61. 61. What Should Written SAP Do?•  Communicate  that  substance  abuse  of  any  kind  is  not   allowed  •  Define  prescrip/on  drug  abuse  or  diversion  as   substance  abuse  •  Explain  purpose  of  policy  (workplace  safety,   produc/vity,  employee  health)  •  Communicate  consequences  of  policy  viola/on  •  Encourage  employees  to  seek  treatment  
  62. 62. SAP Balancing Act•  Balance  employee’s  privacy  rights  and   employer’s  ability  to  detect  •  Balance  treatment  and  enforcement  •  Balance  safety  and  employee’s  rights  
  63. 63. SAP Considerations•  When  does  policy  apply?  •  To  whom  does  policy  apply?  •  What  is  the  goal  of  the  policy?  •  What  ac/vi/es  are  forbidden?  •  Does  policy  include  drug  tes/ng?  •  How  will  privacy  rights  be  protected?  •  What  will  the  consequences  be  if  your  policy  is   violated?
  64. 64. SAP Considerations•  Will  drug  abuse  assistance  be  available?  •  How  can  employees  seek  treatment?  •  Return  to  work  amer  treatment?  •  Who  will  be  enforce  the  policy?  
  65. 65. Other SAP Considerations•  Communicate  policy  to  all  employees  •  Procedures  to  inves/gate  alleged  viola/ons  •  Due  process  and  opportunity  to  answer   allega/ons  •  Conforming  to  federal/state  laws  •  Conform  to  union  contracts  
  66. 66. SAP In Place, Now What?
  67. 67. Employee Education and Awareness Program•  Explain  purpose  of  SAP  •  Create  buy-­‐in  •  Educate  on  dangers  of  all  drugs,  including   prescrip/on  drugs  •  Ques/ons/answers  
  68. 68. Employee Education and Awareness Program Topics•  SAP    •  EAP  •  Scope  of  epidemic  •  How  it  affects  workplace  •  How  it  affect  employee’s  family  •  Guest  speakers  
  69. 69. Employee Assistance Program•  Why  an  EAP?  •  You  need  employees  •  Employees  have  drug  problems  •  Beaer  to  assist  exis/ng  employees  than   replace  them  
  70. 70. Employee Assistance Program Benefits to Employer•  Reduce  accidents  •  Reduce  absenteeism    •  Raise  produc/vity  •  Reduce  health  insurance  costs  •  Reduce  workers’  comp  claims  •  Increases  employee  trust/loyalty  
  71. 71. Employee Assistance Program Benefits to Employee•  Iden/fies  problems  •  Somewhere  to  turn  •  Increases  employee  trust/loyalty  •  Family  atmosphere  •  Counseling  •  Follow  up  services  
  72. 72. Employee Assistance Program•  What  kind?  •  Scope?  •  Cost?  •  Confiden/ality?    •  Return  to  Work?  
  73. 73. Employee Assistance Program Start-up•  Your  company  alone?  •  Consor/um  of  small  companies?  •  Outside  Vendor?  •  Union?  •  Trade  Associa/on?  
  74. 74. Employee Assistance Program•  Not  a  quick  fix  •  Long  Haul  •  Most  companies  find  profitable  •  Employee  apprecia/on  •  Community  reputa/on  
  75. 75. Drug Testing Program•  Purpose?  •  Enforcement  of  SAP  and  EAP  •  Consequences  •  Clearly  communicated  to  employees  
  76. 76. Drug Testing Program Who Tested•  Employees?  •  Applicants?    •  Owners?  •  Only  those  in  sensi/ve  posi/ons?  •  DOT/Aircram  •  Union  
  77. 77. Drug Testing Program When Tested•  Upon  employment  •  Every  Physical  examina/on  •  Amer  all  accidents  (some/mes  required)  •  Amer  some  accidents  •  Poor  work  performance  •  Abnormal  behavior  •  Random  
  78. 78. Drug Testing Program What Tested For•  Alcohol  •  Marijuana  and  Cocaine  •  All  Illicit  Drugs  •  Prescrip/on  Drugs  •  Costs  
  79. 79. Drug Testing Program Consequences- Applicant•  Permanently  disqualified  •  Retes/ng  immediately  •  Wai/ng  period  –  retes/ng  •  Inform  applicant  of  reason  for  non-­‐hire  
  80. 80. Drug Testing Program Consequences- Employee•  Refer  to  EAP  if  available  •  Refer  employees  to  counseling  and  treatment   amer  the  first  posi/ve  but  fire  amer  the  second  •  Mul/ple  aaempts  through  EAP    
  81. 81. Drug Testing Program Procedure•  Who  will  perform  tes/ng  •  How  reported  to  employer  •  If  posi/ve,  repeat  confirmatory  test  •  Confiden/ality  •  Who  will  communicate  results  to  employee  •  Medical  review  officer  
  82. 82. Drug Testing Program Considerations•  Statutory  or  regulatory  requirements  •  Disability  discrimina/on  provisions  •  Collec/ve  bargaining  agreements  •  Federal/State  Legisla/on/ADA  •  Any  other  requirements  in  effect
  83. 83. Train Supervisors•  Key  to  success  of  SAP  •  Direct  contact  with  employees    •  Supervisors  detect  performance  problems  /   substance  abuse  •  Documen/ng  unsa/sfactory  work   performance  or  behavior      
  84. 84. Train Supervisors•  Understand  the  substance  abuse  policy    •  Be  able  to  explain  SAP  to  employees  •  Know  when  to  take  ac/on  •  Look  for  signs  of  substance  abuse  and  what  to   do  once  they  find  them    
  85. 85. DOT Drug Abuse Regulations 49 CFR Part 40•  Airline  industry  •  Railroad  industry  •  Commercial  carriers  •  Operate,  maintain,  or  emergency-­‐response   func/ons  on  a  pipeline  or  liquid  natural  gas   facility  •  Commercial  vessel  licensed    by  USCG  
  86. 86. Questions?                        Alix  C.  Michel                        (423)  757-­‐0223                          David  J.  Ward                          (423)  757-­‐0233  
  87. 87. DisclaimerThis  presentaMon  is  provided  with  the  understanding  that  the  presenters  are  not  rendering  legal  advice  or  services.    Laws  are  constantly  changing,  and  each  federal  law,  state  law,  and  regulaMon  should  be  checked  by  legal  counsel  for  the  most  current  version.    We  make  no  claims,  promises,  or  guarantees  about  the  accuracy,  completeness,  or  adequacy  of  the  informaMon  contained  in  this  presentaMon.    Do  not  act  upon  this  informaMon  without  seeking  the  advice  of  an  aSorney.        This  outline  is  intended  to  be  informaMonal.    It  does  not  provide  legal  advice.    Neither  your  aSendance  nor  the  presenters  answering  a  specific  audience  member  quesMon  creates  an  aSorney-­‐client  relaMonship.