1. Prescription Drugs in the Workplace Meeting the Challenge

2. David K. Roberts, Ph.D. Legacy Laboratory Services- MetroLab Toxicology July 12, 2012

3. Why are Prescription Drugs a Challenge? Prescription drugs with abuse potential are the challenge! July 2, 2015LEGACY HEALTH3 OKNot OK Legally prescribedDiverted, spousal use Used responsiblyAbused Can cause impairment- accident risk Can cause addiction Performance problems Absenteeism issues Increased health care costs

4. July 2, 2015LEGACY HEALTH4 Prescription Drugs with Abuse Potential – The Usual Suspects- part 1 Drug ClassTrade NameGeneric Name AmphetaminesAdderallAmphetamine RitalinMethylphenidate BenzodiazepinesXanaxAlprazolam KlonopinClonazepam ValiumDiazepam AtivanLorazepam RestorilTemazepam Medical marijuanaPotTHC Nonbenzodiazepine hypnoticAmbienZolpidem

5. July 2, 2015LEGACY HEALTH5 Prescription Drugs with Abuse Potential – The Usual Suspects part 2 Drug ClassTrade NameGeneric Name OpioidsSuboxoneBuprenorphrine DuragesicFentanyl LortabHydrocodone DilaudidHydromorphone DolophineMethadone MS ContinMorphine OxycontinOxycodone OpanaOxymorphone

6. US Center For Disease Control- Summary July 2, 2015LEGACY HEALTH6

7. 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! July 2, 2015LEGACY HEALTH7

8. July 2, 2015LEGACY HEALTH8 Opioid Prevalence (DAWN)

9. July 2, 2015LEGACY HEALTH9 Illegal Drug Prevalence (DAWN)

10. July 2, 2015LEGACY HEALTH10 Benzodiazepine Prevalence (DAWN)

11. July 2, 2015LEGACY HEALTH11 Drug Prevalence Comparisons (DAWN)

12. July 2, 2015LEGACY HEALTH12 Prescription vs Illegal Drugs: ED Visits

13. In Oregon Prescription Drug Deaths > Traffic Deaths July 2, 2015LEGACY HEALTH13

14. Hydrocodone (with acetaminophen) July 2, 2015LEGACY HEALTH14

15. Hydrocodone- the Most Prescribed Opioid  Hydrocodone is absorbed and then metabolized to Hydromorphone  Hydromorphone is 7 – 10 times more potent than morphine! July 2, 2015LEGACY HEALTH15

16. Oxycodone July 2, 2015LEGACY HEALTH16

17. Oxycodone- “Hillbilly Heroin”  Oxycodone is absorbed and then metabolized into Oxymorphone  Oxymorphone is ~10 times more potent than morphine! July 2, 2015LEGACY HEALTH17

18. Opioid Addiction July 2, 2015LEGACY HEALTH18 Opioids indirectly enhances dopamine Excess dopamine can cause intense pleasure

19. 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 July 2, 2015LEGACY HEALTH19

20. Meeting The Prescription Drug Challenge July 2, 2015LEGACY HEALTH20 StepIssueComments 1PolicyPolicy always comes first- don’t forget a legal review! 2PanelYou can’t find it if you don’t test for it- make sure your company is using the right panel! 3ConsistencyUse the same panel for all your testing regardless of reason- avoid collector errors. 4Require Disclosure & Train Supervisors Require confidential employee disclosure- policy (non)compliance may be critical. A trained supervisor can provide evidence for impairment. 5MROUse a board certified MRO- sorting through legitimate vs illegitimate prescription medication is better left to a professional.

21. Step 1- No Testing Without a Policy www.drugfreeworkplace.gov Always Hire an Employment Lawyer to Review Your Policy July 2, 2015LEGACY HEALTH21

22. July 2, 2015LEGACY HEALTH22 Step 2- Use the Right Panel. “Urine 8”- Illegal + Prescription Drugs TestDrug ClassCutoffMake sure cutoff is appropriate 1Amphetamines500 ng/mLNew more sensitive DOT cutoff 2Benzodiazepines200 ng/mLNeed lower cutoff & special screening test for Alprazolam 3Cocaine150 ng/mLNew more sensitive DOT cutoff 4Opiates300 ng/mLNeed low cutoff for Hydrocodone 5Heroin 10 ng/mLNew test included in each panel- can be positive by itself! 6Oxycodone100 ng/mLRequired to reliably detect Oxycotin, Percodan, Percocet 7Methadone300 ng/mLIncreasingly common prescription drug 8Marijuana50 ng/mLDOT cutoff to exclude passive exposure.

23. July 2, 2015LEGACY HEALTH23 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

24. 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. July 2, 2015LEGACY HEALTH24

25. 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 pre- employment drug test for a receptionist. July 2, 2015LEGACY HEALTH25

26. Prescription Drugs in the Workplace- Meeting 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 July 2, 2015LEGACY HEALTH26

27. Questions???? Thank you!