1. Fitness to Work & Safety Sensitive Occupations Chris Stewart-Patterson MD Occupational Physician Program Director Harvard Medical School

2. Safety Sensitive? Danger to self Danger to work mates Danger to general public Pre-placement examination Periodic examinations Fitness to return to work

3. Safety Sensitive Fitness to Work Demonstrate normal or adequate function –Good health after acute condition –Chronic disease in remission –Chronic disease with documented period of medical stability No immanent relapse potential No risk of sudden incapacitation –1% guideline?

4. Safety Sensitive Work Assessment Know the medical aspects of the industry 1.Ideally job site visits 2.Job descriptions 3.Job demands analysis 4.Bonafide occupational requirements? 5.Specific medical fitness guidelines –Exclusionary diagnosis? –Exclusionary treatment or medications?

6. NFPA Essential Duties 1.Firefighting tasks… 2.Wear SCBA 3.Exposure to toxic fumes 4.6 or more flight of stairs 5.Wear fire personal protection ensemble –50lb (+20 to 40 lb tools) 11. Complex problem solving 13. Sudden incapacitation can result in death

7. VFRS JDA Maximal values for active fire suppression Lift 50 kg Carry 50 kg Push 100 kg Pull 100 kg Time pressure constant Attention to detail constant

8. Occupational Medicine Guides Industry –Railway Association of Canada –CMA Driver’s guide 7 th Ed –NFPA occupational medicine guides –ACOEM LEO medical evaluation guides –U.S. DOT Commercial Driver Medical –AAPL Practice Guideline Psychiatric Disability –Fitness to Work: The Medical Aspects 4 th ed K Palmer et al –AMA Guides to the Evaluation of Work Ability & RTW

9. ACOEM LEO Medication Guides Medication categories Acceptable– unlikely to adversely impact job functions. Temporary – consider restrictions at the beginning of treatment to assess possible side effects Shift – may be taken while off duty with adequate time before returning to duty. Restricted – known to have an effect that will very likely adversely impact safety or performance of job functions Diagnosis – the diagnosis for which the medication is prescribed may require evaluation

10. Seizures, Diabetes & CAD Fitness to Work References & resources: RAC CMA Driver’s guide 7th Ed NFPA guides U.S DOT commercial drivers ACOEM LEO (not seizures yet…)

11. Hardest FTW Assessment? A valued safety-sensitive worker Finishes residential treatment “I’ve stopped using/drinking” But fit to work….? 1) Chronic limitation? 2) What is risk of relapse? 3) Co-morbid conditions? 4) Denial?

12. Hidden Substance Use Disorder Impairment Undiagnosed comorbid conditions Denial is a part of dependence Unrecognized severity of impairment –Cognitive –Sleep disruption –Adaptation Active deception: Faking well? Co-workers or family cover up?

13. Chronic Alcohol Use Disorder Comorbidity Psychiatric comorbidity Dependence/abuse comorbidity Medical comorbidity –Hepatitis & Cirrhosis –Wernicke’s encephalopathy & Korsakoff’s amnesia –Cardiomyopathy –Peptic ulcer disease –Many more ….. Comorbid conditions contraindicated?

14. Cognitive Testing Screening Mental status examination Trail Making Tests A & B Online neuropsychological screening Review safety protocols If abnormal results…. –Still abstinent? –Full neuropsychological testing battery?

15. Trail Making Test B

16. SUD RTW Cases Early Wernicke’s encephalopathy Alcoholism & post CVA Anoxic brain injury # 1 Anoxic brain injury # 2

17. Confirm SUD Treatment Monitoring with unannounced testing? Ongoing treatment 1.Primary substance use disorder 2.Psychiatric comorbidity 3.Medical comorbidity Relapse prevention plan –Social support –Avoid environmental cues –Sleep management plan!!!!

18. Physician Relapse Study Retrospective cohort study of 292 MD/PAs 25% had at least 1 relapse in 10yrs Relapse risk after the first relapse: HR 1.69 A family history of an SUD: HR of 2.29 Major opioid use with coexisting psychiatric disorder: HR of 5.79 All 3 factors — major opioid use, dual diagnosis, and family history: HR of 13.25 –Domino K.B et al. JAMA. 2005;293:1453-1460

19. RAC SUD Medical Guides Individuals with DSM IV Substance Dependence must: Have documented abstinence for 3 months Complete an intensive addiction treatment program Agree to participate in a Monitoring Process Comply with a Relapse Prevention Agreement for at least two years Demonstrate total abstinence as long as they remain employed in a safety critical position

20. Assessing Fitness for Safety Sensitive Work Diagnosis & impairment Capacity & limitations? Risk & restrictions? Fit to work? Review industry RTW SUD guidelines +/-Follow up review of performance & attendance +/- Follow up occupational medical evaluation

21. If in doubt… Second Occ Med opinion Specialist review Return to non-safety sensitive work trial –Attendance reports –Performance reports Re-assess Supervised RTW