Saturday, September 28, 2013

Addiction Medicine and Occupation Medicine

The Interface of Addiction Medicine and Occupational Medicine
-your patient’s safety in the workplace

Sept. 27, 2013

Dr. Paul Sobey
Dr. Paul Farnam

Presentation from the Canadian Society of Addiction Medicine Annual Meeting, Vancouver, BC 2013.  These are two amazing clinicians with excellent training and impressive clinical experience.  The presentation was fully attended and highly appreciated. I hope my rough notes will give a sense of the depth and breadth of information available.

Learning objections
-safety issues
-potential negative impact
-duty to notify

Employer and employee responsibilites

In US there’s a major omnibus bill and occupational medicine is a huge industry
In Canada less legislative issues - more decided by precedent

Risk sensitive
-safety critical
-safety sensitive or person of public trust

 Health Professions Act
Who is subject?
Duty to Report - Section 32.2 and 32.3
-32 (2) (1) A registrant must report in writing - reasonable and probable grounds, believes that the contued practiced of a designated health profession might constitute a danger to the public
32 (3) (1) - admission to a hospital or a private hospital as defined in the Hospital Act , for psychiatric care or treatment, or treatment for addiction to alcohol or drugs the other person is unable to practice

Employers are worried
  • Substance Use Disorders don’t stop at the gate
  • illicit drugs
  • -Also alcohol , marijuana and prescription drugs
  • problems with attendance, performance

Worksafe BC 
4.20 Impairment by alcohol, drug or other substance
“a person must not enter or remain at any workplace while the person’s ability to work is affected by alcohol, a drug or other substance”
“the employer must not knowlingly permit a person to remain at anyworkplace while the person is impaired”

Substances and Diagnosis
-medical marijuana
-methadone and suboxone
Issues when SSP use of these medications 
Suspicion or clear evidence

Canada - world’s second largest per capita consumer of prescription opioids
-750 mg/year/person of morphine (2010)

Risk sensitive fitness considerations
-no addiction disorder
  • addiction diagnosis = increased complexity
  • may not be a candidate for COT
    Chronic stable, reasonable dose with b3nefit
  • literature supported diagnosis
  • psychiatric and medical issues in remission

Medical Marijuana
-this is a huge conundrum
-from occupational consideration it’s not approved

Marijuana is not a medication
Not HPB approved
  • like all other medications
Medical Marijunaa Access Act
-I don’t havea clue what the exemption looks like
-approve usages may exclude occupying a Safety Sensitive Position

-pam and z drugs
-limitted research and prescribing data
-memory and other cogntive impairment
-rarely primary drug of choice
-in background - predictive of other subtance abuse?
-alcohol and opioids problem
high rate of abuse in OAT population
-withdrawal compicates treatment

When I’m doing a withdrawal will the withdrawal period exclude them from work

Methadone and Bup?Nal
Chronic Cancer and Noncancer Pain
-methadone only
-means failure of typical opioids
-There fore must question fitness for work

Oipoid Agonist Therapy (OAT)
-Means Opioid Dependence
-All patients are ‘polydrug dependent’

Take Homes 
-a valid prescription does not mean “no impairment’
-no valid prescription does mean impairment

Is the medical conditions related to their having a Safety Sensitive Position
Failure to progress or loss of level of function
What would a panel of my peers say?

Dr. Paul Farnum

Healthquest Occupational Health Corporation
Alliance Medical Monitoring

For 7 years directed physician health program of BC - “that was an interesting population”

Workplace and Addiction

Progressive worsening in work - identification then intervention then comprehensive assessment - primary treatment - “after care” - Medical Monitoring - Return to work 

“Identification” - Attendance, performance, behaviour
  • the employer is getting becoming aware
  • Intervention “the difficult conversation”
  • Occupational-Addiction Medicine Assessment
  • Comprehensive “Independent” assessment
  • Biopsychosocialspiritual assessment
  • -biological testing, collateral information, ‘understanding job demands’

Addicted MDs - what di we learn?

-need good assessment and good treatment
“using comprehensive monitoring, coordinated by an experienced Physician Health Program, reports demonstrate that over 70% of addicted physicians achieve five years of sobriety, are able to return to work and resume a functional lifestyle”
Medical Monitoring

“Relapse Prevention Agreement”
Between patient and experienced Monitor
Duration - 2 years/5 years /indefinite
No mood altering potentially addictve drugs
Approved recovery activities eg Mutual Support Meetings (AA/NA, SMART etc)
Unscheduled Lab work (Urine/Blood/Saliva/Hair)
Regular contact with monitor
Regular Reporting to “Oversight body”

Contingency Behavioural Management
-ties compliance to benefits (employment) through accountability
-contingency -if you don’t follow thorugh - job on line

Safety Sensitive RTW considerations
-Safe and Sustainable Return to Work
-Comprehensibel Occ/Add Evaluation
-recommended primary treatment 

Re-evaluation for fitness to work
-stable remission, enough for occupation
-workplace consideraation - restrictions, limitations
-accomodations required

Commuynicating with the employer
as patient’s md you are their advocate
As IME assessor or MRO you act independently
-know who you are communicating with and ask about the employer’s procedures
-no occupational health department
-fitness to work considearation only

Employer and employee responsibilities
  • emploeyer - duty to accomodate disability
  • -recognised medical condition
  • -how far does it extend
  • -no duty to accomodate employee with ‘abuse’
  • Employee and Union - duty to facilitate the accomodation

Duty to Accomodate
-Fraser Lake Sawmills - Hybrid Approach - defining case
may be degree of ‘non culpableness”  or hybrid or culpable

Treatment Resistance and “Last Chance Agreements”

Key Messages
Safety, safety, safety
Understand Standard of CAre - ‘stable abstinent remission’
-Understand guidelines and employer’s rights

Don’t treat and keep secret!

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