Solutions in the Workplace National Rx Drug Abuse Summit 4-11-12

1. Solutions in the
Workplace
April 10-12, 2012
Walt Disney World Swan Resort

2. 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.

3. 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.

4. 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

7. 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.

8. Past Month Nonmedical Use of Types of Psychotherapeutic Drugs
among Persons Aged 12 or Older: 2002-2010
Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey
on Drug Use and Health: Summary of National Findings

9. 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 on
Drug Use and Health: Summary of National Findings

10. Past Year Initiates of Specific Illicit Drugs among Persons Aged
12 or Older: 2010

13. Past Month Illicit Drug Use among Persons Aged 18 or Older,
by Employment Status: 2009 and 2010

14. Amount of Prescription Painkillers Sold Per State Per 10,000 People
(2010)
Source: Automation of Reports and Consolidated Orders System of DEA, 2010

15. Drug Overdose Death Rates by State Per 100,000 People
(2008)
Source: National Vital Statistics System, 2008

17. Top Ten Most Medicated States

19. 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

20. Substance Dependence or Abuse in the Past Year, by Age and Gender: 2010

21. Persons Receiving Most Recent Treatment in Last Year for Pain
Relievers

23. 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

25. 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)

26. 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

27. The Rise of the "Pill Mills"
• "Pill
mills"
have
flourished
in
Florida
• According
to
the
Florida
Aaorney
General's
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."

28. South's 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.

29. Florida Attorney General Moves to Crack
Down on Pill Mills
• It's
es/mated
seven
Floridians
die
every
day
because
of
prescrip/on
drug
abuse.
• Jacksonville
Sheriff's
Office
says
drug
dealers
are
making
big
profits
on
prescrip/on
drugs.
"They're
coming
from
all
over
to
the
state
of
Florida
to
obtain
these
pills
and
to
take
them
back
up
to
be
sold
wherever
they're
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

30. You Deal, They Die, You’re Done

31. Migration of Pill Mills
• Started
in
Florida
• PMP
ini/ated
in
Florida
• Migrated
to
Georgia
• PMP
ini/ated
in
Georgia
• Now
in
Tennessee
and
Kentucky

32. Drug Seeking Scams
• Fic//ous
pa/ents
–
stolen
pads
• Altered,
legi/mate
prescrip/ons
• Phoned
prescrip/ons
by
drug
seeker
• Copies
of
legi/mate
prescrip/ons
• Not
usual
dosage
• No/wrong
abbrevia/ons
• Different
inks/handwri/ng
• Large
quan//es
Websites:
alt.drugs.hard
or
DEALookup.com

33. PaMents
Healthcare
Providers
Pharmacists

34. 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

35. Methods of Drug Diversion - Patient

36. RX Drugs Sold From an Ice Cream Truck
39
year
old
Woman
arrested
Allegedly
selling
Soboxone

37. 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

38. 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.

39. 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

40. 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.”

42. 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

43. Methods of Drug Diversion -
Pharmacist
NY video

44. 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.

45. Pharmacy Robberies
video

46. Pharmacist’s Response
• Refusing
to
carry
Oxycon/n
• Time
release
safes
• DNA
spray
• Call
ahead
prescrip/ons
• Other
op/ons

47. Other Pharmacist’s Responses

48. Other Pharmacist’s Responses

49. Responses to Prescription Drug Abuse
• Na/onal
• State
• Local
• Employer’s

50. National Response

51. • Educa/on
• Tracking
and
Monitoring
• Proper
Medica/on
Disposal
• Enforcement

52. States’ Responses
• PMPs
• Pill
Mill
legisla/on
• Requiring
Physicians
to
View
PMPs
• Law
Enforcement
Task
Forces
• Strengthening
Pharmacy
Protec/on

54. How Are the Controlled
Substance Databases
Being Used?

56. As of: July 31, 2008
Drug Product: METHADONE
Prescriber State: TN
Rank Prescriber Name Office Zip Scripts Filled Cash Scripts Filled
1 XXXXXX Nashville-372 33 16
2 XXXXXX Nashville-372 32 32
3 XXXXXX Nashville-372 29 11
4 XXXXXX Nashville-372 29 27
5 XXXXXX Nashville-381 18 5
16 XXXXXX Nashville-374 10 10
Source: Tennessee Prescription Drug Monitoring Database

57. Problems With State PMPs
• Not Real-Time
• No Interoperability between states
• Doctors don’t use them
• Pharmacists don’t use them

59. 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.

60. 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.

61. 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

62. 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

63. 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

64. No One is Immune and Some
Costs are Unimaginable…

65. Costs to Industry
• Workdays
missed
• Likely
to
injure
self
or
others
• Workers'
compensa/on
claims
filed
• Decreased
Produc/vity
($129B)
• Increased
Healthcare
Costs

66. 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)

67. Hidden Costs to Industry
• Personnel
turnover
(25-­‐200%
compensa/on)
• Poor
decisions
• Damage
to
equipment
• Fric/on
among
workers
• Damage
to
the
company's
public
image
• Diverted
supervisory
and
managerial
/me

68. 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

69. 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

70. Rates of ED visits per 100,000 population involving nonmedical use of
pharmaceuticals, by age and gender, 2008

72. Can You Afford Not To Have
a Substance Abuse Program?

73. 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

74. 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

75. SAP Balancing Act
• Balance
employee’s
privacy
rights
and
employer’s
ability
to
detect
• Balance
treatment
and
enforcement
• Balance
safety
and
employee’s
rights

76. 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?

77. SAP Considerations
• Will
drug
abuse
assistance
be
available?
• How
can
employees
seek
treatment?
• Return
to
work
amer
treatment?
• Who
will
be
enforce
the
policy?

78. 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

79. SAP In Place, Now What?

80. 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

81. Employee Education and Awareness
Program Topics
• SAP
• EAP
• Scope
of
epidemic
• How
it
affects
workplace
• How
it
affect
employee’s
family
• Guest
speakers

82. Employee Assistance Program
• Why
an
EAP?
• You
need
employees
• Employees
have
drug
problems
• Beaer
to
assist
exis/ng
employees
than
replace
them

83. 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

84. Employee Assistance Program Benefits
to Employee
• Iden/fies
problems
• Somewhere
to
turn
• Increases
employee
trust/loyalty
• Family
atmosphere
• Counseling
• Follow
up
services

85. Employee Assistance Program
• What
kind?
• Scope?
• Cost?
• Confiden/ality?
• Return
to
Work?

86. Employee Assistance Program Start-up
• Your
company
alone?
• Consor/um
of
small
companies?
• Outside
Vendor?
• Union?
• Trade
Associa/on?

87. Employee Assistance Program
• Not
a
quick
fix
• Long
Haul
• Most
companies
find
profitable
• Employee
apprecia/on
• Community
reputa/on

88. Drug Testing Program
• Purpose?
• Enforcement
of
SAP
and
EAP
• Consequences
• Clearly
communicated
to
employees

89. Drug Testing Program
Who Tested
• Employees?
• Applicants?
• Owners?
• Only
those
in
sensi/ve
posi/ons?
• DOT/Aircram
• Union

90. 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

91. Drug Testing Program
What Tested For
• Alcohol
• Marijuana
and
Cocaine
• All
Illicit
Drugs
• Prescrip/on
Drugs
• Costs

92. Drug Testing Program
Consequences- Applicant
• Permanently
disqualified
• Retes/ng
immediately
• Wai/ng
period
–
retes/ng
• Inform
applicant
of
reason
for
non-­‐hire

93. 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

94. 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

95. 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

96. 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

97. 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

98. 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

99. Questions?
Alix
C.
Michel
amichel@cbslawfirm.com
(423)
757-­‐0223
David
J.
Ward
dward@cbslawfirm.com
(423)
757-­‐0233

100. Disclaimer
This
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.