Solutions in the Workplace April 10-12, 2012Walt Disney World Swan Resort
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.
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.
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
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.
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
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
Past Year Initiates of Specific Illicit Drugs among Persons Aged 12 or Older: 2010
Past Month Illicit Drug Use among Persons Aged 18 or Older, by Employment Status: 2009 and 2010
Amount of Prescription Painkillers Sold Per State Per 10,000 People (2010)Source: Automation of Reports and Consolidated Orders System of DEA, 2010
Drug Overdose Death Rates by State Per 100,000 People (2008)Source: National Vital Statistics System, 2008
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
Substance Dependence or Abuse in the Past Year, by Age and Gender: 2010
Persons Receiving Most Recent Treatment in Last Year for Pain Relievers
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
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)
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
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."
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.
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 WTSP.com, February 3, 2011
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
RX Drugs Sold From an Ice Cream Truck 39 year old Woman arrested Allegedly selling Soboxone
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
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.
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
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.”
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
Methods of Drug Diversion - PharmacistNY video
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.
Problems With State PMPs• Not Real-Time• No Interoperability between states• Doctors don’t use them• Pharmacists don’t use them
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.
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.
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
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
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
No One is Immune and Some Costs are Unimaginable…
Costs to Industry• Workdays missed • Likely to injure self or others • Workers compensa/on claims ﬁled • Decreased Produc/vity ($129B) • Increased Healthcare Costs
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)
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
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
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
Rates of ED visits per 100,000 population involving nonmedical use of pharmaceuticals, by age and gender, 2008
Can You Afford Not To Havea Substance Abuse Program?
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
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
SAP Balancing Act• Balance employee’s privacy rights and employer’s ability to detect • Balance treatment and enforcement • Balance safety and employee’s rights
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?
SAP Considerations• Will drug abuse assistance be available? • How can employees seek treatment? • Return to work amer treatment? • Who will be enforce the policy?
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
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
Employee Education and Awareness Program Topics• SAP • EAP • Scope of epidemic • How it aﬀects workplace • How it aﬀect employee’s family • Guest speakers
Employee Assistance Program• Why an EAP? • You need employees • Employees have drug problems • Beaer to assist exis/ng employees than replace them
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
Employee Assistance Program Benefits to Employee• Iden/ﬁes problems • Somewhere to turn • Increases employee trust/loyalty • Family atmosphere • Counseling • Follow up services
Employee Assistance Program• What kind? • Scope? • Cost? • Conﬁden/ality? • Return to Work?
Employee Assistance Program Start-up• Your company alone? • Consor/um of small companies? • Outside Vendor? • Union? • Trade Associa/on?
Employee Assistance Program• Not a quick ﬁx • Long Haul • Most companies ﬁnd proﬁtable • Employee apprecia/on • Community reputa/on
Drug Testing Program• Purpose? • Enforcement of SAP and EAP • Consequences • Clearly communicated to employees
Drug Testing Program Who Tested• Employees? • Applicants? • Owners? • Only those in sensi/ve posi/ons? • DOT/Aircram • Union
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
Drug Testing Program What Tested For• Alcohol • Marijuana and Cocaine • All Illicit Drugs • Prescrip/on Drugs • Costs
Drug Testing Program Consequences- Applicant• Permanently disqualiﬁed • Retes/ng immediately • Wai/ng period – retes/ng • Inform applicant of reason for non-‐hire
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
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
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
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
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
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
Questions? Alix C. Michel amichel@cbslawﬁrm.com (423) 757-‐0223 David J. Ward dward@cbslawﬁrm.com (423) 757-‐0233
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.