1. A Prescription for Safety Presented by Diana Byrnes, CUTR

2. Prescription Trends NTSB, ONDCP, SAMHSA and other government agency studies indicate that abuse and misuse of prescription controlled substance medications is more prevalent than “illicit” drug use. Dramatic increase in past decade in use of medications for chronic pain, anxiety, sleep disorders,and attention deficit disorders Inappropriate use of medications takes several forms: –Misuse –Abuse –Physiological dependence –Psychological dependence

3. Definitions Misuse: not following prescribed dosage levels, frequency of use, or use for a purpose other than for which it was prescribed- (non-medical use also) Abuse: when the pattern of use leads to clinically significant impairment or distress that manifests itself in the individual’s behavior Physiological dependence: when the individual experiences increasing tolerance for a drug and experiences withdrawal when the medication is discontinued Psychological dependence or addiction: when the individual experiences an overall loss of control, seeks medication compulsively, and continues use of the medication in spite of negative consequences

4. Prescription Stats Most frequently reported Rx medications in drug-abuse related ER cases (as reported by DAWN): – Benzodiazepines and Opiates More than 6.3 million Americans reported use of Rx drugs for non-medical reasons in 2003 –According to National Institute on Drug Abuse 40 million in 1991 vs. 180 million in 2007 –The increase in # of opiate prescriptions written

5. DOT Prohibited Drugs Amphetamines Cocaine Marijuana Opiates PCP –DOT Drug testing panel limited to Schedule I and II drug classes

6. What’s Missing? Largest class of painkillers, synthetic opioids, are not detected in DOT urine drug testing: –Vicodin, Oxycontin, Roxicontin (hydrocodone, hydromorphone, oxymorphone, methadone) Benzodiazepines, barbiturates, and propoxyphene are also not detected in DOT testing –Xanex, Ativan, Clonopin, Vicodin (diazepam, alprazolam, clonazepam, and lorazepam)

7. Video Clips from Media Outlets Hydrocodone and Xanax

8. FL Transit System Accident Sept. 2007 Accident –Employee had been involved in two accidents within one month –Employee passed all DOT drug and alcohol testing that was conducted after each accident

9. FL Transit System Accident Cont. Law enforcement conducted independent blood tests –Results revealed two forms of benzodiazepines and methadone in driver’s system –Employee terminated for failure to report the use of Rx medication as required by employer policy –Operator later arrested for felony DUI and careless driving

10. Federal Transit Administration’s Position

11. Directives Nine years ago the NTSB issued a directive to FTA to do the following: –Educate transit systems on potential safety risks associated with the use of Rx and OTC meds –Create a reporting mechanism to determine the role Rx and OTC meds play in accidents –Recommended rail transit agencies require employees to report use of any OTC or RX med and implement a medical review system

12. FTA Response FTA issued a “Dear Colleague” Letter –Asks (not requires) grant recipients to review policies regarding Rx and OTC meds –Asks (not requires) grant recipients to develop a training program to address the safety risks of Rx and OTC med use while performing safety sensitive functions

13. FTA Response Continued Rx and OTC Medication Toolbox 2003 –Policy templates –Procedures –Training Aid –Post Accident Procedures FTA includes an article in each issue of the Updates newsletter concerning Rx and OTC meds FTA is currently collecting data from transit systems. The survey is available at: http://transit-safety.volpe.dot.gov/Survey1/Default.aspx

14. FTA Rx and OTC Toolkit Three policy approaches –Employee self evaluates fitness for duty Not recommended as the only policy or procedure –Employer requires employee to obtain a signed medical authorization (and involvement of MRO in determining safety concerns) Recommended –Employer supplies a list of Rx and OTC meds that are “approved” or “disapproved” for use Okay, but not the best method

15. Best Practices for Policy Development Best Practices for Rx and OTC Policy –Stand Alone- not part of D&A policy –Medical Authorization required –Form supplied that includes description of safety-sensitive job functions –Strong training module –Attendance policy for Rx and OTC use

16. “A Prescription for Safety” An Rx and OTC Management Plan

17. Stand Alone Policy Physician Release Form NON DOT expanded testing panel Training Post Accident Investigation Procedures Attendance Policy “A Prescription for Safety”

18. Stand Alone Policy Not part of the Drug and Alcohol Policy Prohibited Behaviors –Using a prescription (Rx) medication that is not legally prescribed for the employee –Using an Rx or over-the-counter (OTC) medication in excess of the prescribed dosage –Using any medication that contains alcohol within four (4) hours before performing safety-sensitive functions –Using any medications that adversely impact the employee’s ability to safely perform his/her safety- sensitive job functions

19. Policy Continued Requires employee to obtain a signed release form from prescribing physician –Medical Disqualification if Rx medication is not deemed appropriate Discuss the use of an alternative medication Utilize accumulated paid time off Request a temporary non-safety sensitive position; (provided that such a position is available) –Employees who fail to report are subject to termination

20. Development of NON-DOT Testing Plan

21. NON DOT-Testing Plan Separate and sometimes in addition to DOT required test Testing for post accident and reasonable suspicion scenarios –Conducted under agency authority –Tests for an expanded panel (beyond DOT 5) –Includes synthetic opiates, Benzodiazepines, Propoxyphene and Methadone

22. NON DOT Testing Circumstances DOT required tests will always take priority NON DOT testing will be conducted under agency authority in the following circumstances: –Employee is involved in an accident or incident resulting in injury to himself and/or another –Employee exhibits signs and symptoms of impairment and is subject to reasonable suspicion testing- under both the DOT and NON DOT testing plans

23. NON DOT Testing Plan Currently available through our statewide contracted TPA; FirstLab –Specific testing panel and pricing can be negotiated –Current contract expires 12/2011 –Please contact Diana Byrnes if interested in initiating an NON DOT testing plan– volume will decrease cost

24. NON DOT Testing Plan Must use a non-federal form (will be provided upon account set up) Must be a separate void –Shipped separately to lab –Reported by MRO as separate result

25. NON DOT Testing Consequences Employee will be subject to termination if a positive test result is reported following an MRO review –Positive means that no legitimate medical explanation exists (no Rx) –A positive lab result that is verified as negative by MRO means that Rx is valid, but result will contain an MRO safety concern –Employees may be subject to termination if result is negative with safety concern and employee failed to report medication use to employer

26. Awareness Education and Training Plan

27. Training Plan Comprehensive Training Plan that includes: –Policy distribution to all covered employees –20 minute training video (available later this year) –Handbook to accompany video will include policy highlights –Posters to be displayed in common areas –Safety-Sensitive ID wallet cards

28. Wallet size employee ID card

29. Awareness Training Emphasis on Fitness for Duty Training will include warning signs of impairment Doctor-Patient communication tips Use of pharmacist as resource when purchasing OTC meds Dangers of combining Rx and OTC meds –Due to differing effects of Rx and OTC meds; there are no “approved” medications

30. Post Accident Investigation

31. Post Accident Procedures Following all accidents –Employees will be asked to list medications (both Rx and OTC) consumed up to 72 hours prior to the event –Employer will record this data on the Post Accident Decision and Documentation Form Updated version is in the works –Employer will use this information to determine if the possibility of the Rx and/or OTC medication use is a causal factor

32. Attendance Policy

33. Attendance Reasons employees do not report medication use: –Employer does not offer temporary non-safety sensitive positions –Employee does not have any accumulated paid time off (sick time) to utilize Employers must consider alternatives in order to ensure effectiveness of program –Paid time off “bank”? –Cross training employees (non-safety sensitive)

34. In Closing Rx meds are the fastest growing substance of abuse DOT drug testing limits detection of the most dangerous Rx meds Employers are strongly encouraged to implement policies and procedures to safeguard against Rx and OTC medication impairment “A Prescription for Safety” will be packaged for use by August 2009

35. Questions? Diana Byrnes byrnes@cutr.usf.edu 813-426-6980