Workplace Issues and Strategies

1. Workplace Issues
and Strategies
Presenters:
• Jennifer Fan, PharmD, JD, Pharmacy Advisor, Center for Substance Abuse
Prevention, Substance Abuse and Mental Health Services Administration
• Laurie Cluff, PhD, Workplace Health and Safety Research Psychologist,
RTI International
• Scott Novak, PhD, Senior Developmental Epidemiologist, RTI
International
Prevention Track
Moderator: J. Kevin Massey, MS, Business and Program Development
Specialist, Weitzman Institute, Community Health Center, Inc., and
Member, Rx and Heroin Summit National Advisory Board

2. Disclosures
Laurie Cluff, PhD; Jennifer Fan, PharmD, JD; Scott
Novak, PhD; and J. Kevin Massey, MS, have disclosed no
relevant, real, or apparent personal or professional
financial relationships with proprietary entities that
produce healthcare goods and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– John J. Dreyzehner, MD, MPH, FACOEM – Ownership
interest: Starfish Health (spouse)
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center

4. Learning Objectives
1. Outline the challenges Rx drug abuse poses in
the workplace.
2. Identify principles underlying workplace
strategies to prevent and intervene early in
substance use disorders.
3. Describe the workplace prevention and
response programs and tools available through
the SAMHSA Prevention Prescription Abuse in
the Workplace technical assistance center.

5. Prescription Drug Misuse in the
Workplace, Consequences and
Approaches for Prevention
Deborah Galvin, Ph.D. SAMHSA
Jennifer Fan, Pharm.D., J.D., SAMHSA
Laurie Cluff, Ph.D., RTI International
Scott Novak, Ph.D., RTI International

6. Session Objectives
• Examine the scope, variation and
consequences of prescription drug misuse in
the workplace.
• Describe effective and research-based
strategies workplaces, unions and related
organizations use to prevent prescription
drug misuse in the workplace.
• Acknowledge current and future critical issues
for workplace prevention programs.

7. Presentation Overview
• Workplace prescription drug misuse issues
and scope
• Medical marijuana use among workers
• Strategies for employers to consider
• SAMHSA’s Preventing Prescription Abuse in
the Workplace (PAW) Technical Assistance
Center
• Programs addressing prevention of
prescription drug misuse

8. Workplace Prescription Drug Risks
• Health Problems: Unpredictable interactions and
negative physical and behavioral reactions.
• Accidents: Can interfere with cognition and
memory.
• Addiction: 2 months of continued use can lead to
increased risk of addiction and need for
treatment.
• Legal Trouble: Possession without a prescription
is illegal and can be prosecuted or lead to job
loss.

9. What Workers Need to Know
• Federal law prohibits the use or possession of
someone else’s prescription drugs.
• Federal law prohibits distributing medications
without a medical license.
• Someone else’s prescription drugs may lead to
complications with your current medications
or medical conditions; serious side effects; or
allergic reactions.

10. What Workers Need to Know
• You could be legally responsible for a
coworker’s injuries if they take your
prescription drugs with or without your
permission.
• Workplace injuries from prescription drug
misuse may result in monetary losses to an
employer and to those who were involved in
the related incident.

11. Impact of Prescription Drug Misuse
on the Workplace
• Increased likelihood of accidents and injuries
• Reduced productivity
• Increased tardiness and sleeping on the job
• Increased absenteeism & sick leave
• Increased turnover
• Decreased morale of co-workers
• Illegal activities at work with increased theft
and security issues

12. Why Prevention in the Workplace?
• 23% of the U.S.
workforce has used
prescription drugs non-
medically1.
• The estimated cost of
this misuse to
workplaces is $26
billion2.
1 SAMHSA’s 2013 National Survey on Drug
Use and Health,
2 Birnbaum, et al. (2011). Societal costs of
prescription opioid abuse, dependence, and
misuse in the U.S. Pain Medicine, 12, 657-667.

13. Rates of Prescription Drug Misuse
Among Workers
• In 2014, 6% of workers aged 16-64 misused a
prescription drug in the past year. Prescription
pain relievers were the most commonly
misused.
Type of Prescription Drug Misused in the Past
Month
Any Prescription Drug 2.5%
Pain Relievers 1.6%
Sedatives and Tranquilizers 0.8%
Stimulants 0.6%

14. Types of Rx Abuse: Opioids
Potent pain relievers
Very addictive--misuse of opioid painkillers is
the fastest growing drug problem in the
United States
80% of Worker’s Compensation injury claims
include at least one opioid pain reliever
Do nothing to heal the cause of pain
Used to treat acute injuries, diarrhea, cough,
and pain

15. Opioid Abuse and Work
Opioids used to treat acute and chronic
pain.
Need to monitor employees who are on
opioids and also returning to work after
short/long term disability.
If opiates are used, there are safe ways to
use them while monitoring patients to
keep them safer.
For those who have developed addiction,
effective treatment is available
Employee Assistance Programs—Valuable
Resources

16. Types of Rx Abuse: Stimulants
Examples: Ritalin, Concerta, Dexedrine,
Adderall, Vyvanse
How they work: Enhance brain activity
by increasing the activity of brain
excitatory chemical messengers, such as
norepinephrine and dopamine, leading
to mental stimulation.
Generally prescribed for:
◦ ADHD
◦ Narcolepsy
◦ Depression that does not respond to other treatments
◦ Asthma that does not respond to other treatments

17. Types of Rx Abuse:
Sedatives/Hypnotics
The sedative-hypnotic classification includes sedatives,
benzodiazepines, and other related compounds
The sedative category includes: barbiturates, also called
‘barbs’ or ‘downers’
Commonly abused barbiturates are secobarbital
(Seconal®) and pentobarbital (Nembutal®)
A few sedative-hypnotics do not fit in either category.
They include methaqualone (Quaalude®), ethchlorvynol
(Placidyl®), chloral hydrate (Somnote®, Aquachloral® &
Supprettes®), and meprobamate (Miltown®, Equanil®,
and Meprospan®)

18. Tranquilizers/Sleep
Aids
• Common benzodiazepines (BZDs), the “minor tranquilizers,”
include: lorazepam (Ativan®), oxazepam (Serax®) clonazepam
(Klonopin® and Rivotril®), alprazolam (Xanax®), diazepam
(Valium®), and chlorazepate (Tranxene®).
• BZDs used as sleep aids include zolpidem (Ambien®), eszopiclone
(Lunesta®): and zopiclone (Imovane®).
• Sedative-hypnotic drugs are commonly shared, as they are
perceived by the user as less dangerous than other types of
medications.
18

19. Which Industries are Most Affected?
2014 Past Year Non-Medical Use of Any Prescription Drug (NSDUH)

20. What Employers Are at Risk?
• The industries with the highest rates of
prescription drug misuse include:
accomodations and food services;
construction; arts, entertainment, recreation;
and information services.
• Service and construction occupational
categories have the highest rates.
• No industry or occupation group is risk-free.

21. Occupational Risk Factors
• High injury rates (e.g., mining, transportation)
• High stress (e.g., law enforcement)
• Variable working hours/shifts that disrupt
sleep patterns
• Easy access to medication
• National estimates are limited to self-reported
misuse.

22. Factors Contributing to Rise
Availability
• Effective marketing by pharmaceutical companies
• Easy access: > 50% of nonmedical users obtained the
Rx drugs from a friend or relative.
Reduce pain
• Misperceptions about prescription drug safety
• Lack of education on effective pain management
Multiple motivations
• Relieve anxiety and stress
• Reduce sleep issues
• Enhance cognition
• Increase stamina

23. Misuse Can Become Addiction

24. Common Risk Factors & Signs
Portenoy and Payne's Aberrant Behavior
1. Selling prescription drugs
2. Forging prescriptions
3. Stealing drugs
4. Injecting oral formulations
5. Obtaining prescription drugs from non-medical sources
6. Concurrently abusing alcohol and illicit substances
7. Escalating doses on multiple occasions despite warnings
8. "Losing" prescriptions on multiple occasions
9. Repeatedly seeking prescriptions from other providers
without informing the provider or after warnings to desist
10. Evidence of deteriorating function due to drug use
Portenoy & Payne, Substance Abuse: a comprehensive textbook, 3rd Ed., 1997

25. Medical Marijuana
23 States and
DC have
medical
marijuana
4 States have
retail marijuana
(CO, WA,
OR, AK)

26. Workers’ Use of Marijuana
• Among 2014 National Survey of Drug Use and
Health participants aged 18-64, 61% indicated
their employment status was full-time.
• About 1 in 13 full-time workers reported using
marijuana in the past month.
• Marijuana users working full-time used it an
average frequency of 15 days in the past
month.

27. Absenteeism Among Full-time Workers

28. STRATEGIES FOR EMPLOYERS TO
CONSIDER

29. What Can Employers Ask?
• Pre-Employment Inquiries
– Can applicant fulfill all stated job duties?
– Applicant is required by law to notify employer of any medication that
can affect job duties.
• Post-Job Offer Inquiries
– If applied to all employees with same job status, employer can ask
health-related and medication questions.
– Can require medical examination
• During Employment
– Generally, employers cannot ask about prescription drug use unless
side effects directly affect job function, or employers have reliable
information leading them to believe job functions are impaired or
there are safety risks.

30. Options for Employers
• Identify potential advantages of adopting/enhancing
employee wellness programs to include prescription
drug misuse.
• Adapt or modify drug-free workplace programs to add
prescription drug misuse prevention.
• Structure benefits packages to enhance prescription
drug misuse prevention efforts.
• Enhance return-to-work programs following
prescription drug disorders.
• Add early screening for prescription drug misuse.

31. What Employers Can Do
• Include prescription drugs and marijuana in
written drug policy
• Train supervisors on new issues concerning
prescription drugs and marijuana (by state)
• Educate employees on changes & new efforts
• Provide an employee assistance program (EAP)
• Add prescription drug testing to other drug
testing policies.

32. Written Policies
When jobs require “being fit for duty,” conventional
wisdom is that employees are responsible for asking their
healthcare provider about likely effects of prescribed
drugs, including medical marijuana. Healthcare providers
are less likely to know the effects of medical marijuana.
Employees should provide the employer information
concerning particular work-related restrictions the
healthcare provider believes they face.
Where medical and/or recreational marijuana is legal,
drug-free workplace policies need to provide clear
guidelines concerning the use of prescription drugs and
marijuana.

33. Example Policy
Manufacturer with approximately 5,000 employees
based in Charlotte, North Carolina.
The company updated its drug-free workplace policy to
instruct employees that marijuana remains banned for
employees, no matter if they travel through or live in
states with legalized marijuana.
Affirmed that if marijuana is legalized for recreational
use, employees are prohibited from using it at work.
Policy noted that those on prescribed medical
marijuana are not allowed at work while being treated,
similar to the company’s policy on narcotic prescriptions
(Harrison & Wojcik, 2014, April 27).

34. •Contact EAP associations and/or local companies
to learn about the employee assistance services
they offer their workers, how services are provided,
costs, and results
•Determine whether there is an EAP consortium in
your community that local businesses can join to
receive EAP services at prices typically available
only to larger companies.
Provide Access to an EAP

35. Workplace Programs & Odds of Prescription Drug Misuse
by Worker Age (No Effect = 1.00) (based on NSDUH 2004-08)
0.85
0.72
0.85
0.64
1.00
0.60
1.00
0.83
Ages 15-25 Ages >=26
Drugfree Workplace Program EAP Education Drug Testing
Source: Miller, Novak, Galvin et al. (2015). School and Work Status, Drugfree Workplace Protections, and Prescription
Drug Misuse among Americans Aged 15-25. Journal of Studies on Alcohol and Drugs, 76:2, 195-203.

36. SAMHSA’S PREVENTING
PRESCRIPTION ABUSE IN THE
WORKPLACE (PAW) TECHNICAL
ASSISTANCE CENTER

37. PAW Technical Assistance Center
Established in 2011 to assist employers,
employees, employees’ families, unions,
and associations reduce prescription drug
misuse by stimulating, informing, and
supporting prevention efforts through
technical support and collaborative means.

38. Multi Media Approach to Resources
Fact Sheets
•Awareness
•Dangers
•Disposal
•Theft
•Statistics
•Target
industries
•Prevention
strategies
Issue Briefs
•Workplace
costs
•PDMP cost
savings
•Pain
Management
•EAPs and
return to
work
Web and Social
Networking
•Webinars
•Weekly
literature
update
•Social media
postings
Training and
Expertise
• Intervention
program
enhancement
• Rx abuse-
related data
analysis
Prevention
Tools
• Industry
specific Rx
abuse
screeners
• Rx related
resource
guides
TA Resources

39. SAMHSA Prescription Drug Abuse
Weekly Update
• Weekly compilation of news and journal
articles to assist in forming policy, research,
and programs to reduce prescription drug
misuse or abuse
• Over 1,700 current subscribers
• Email paw@dsgonline.com to subscribe

40. Fact Sheets and Issue Briefs
TA Products cover a range of topics including
• General information about prescription drug and
related issues (medical marijuana) risks and
policy issues
• Pain management education
• Messages targeting workplaces, unions,
employees, and their families
• Messages targeting specific occupational and
community groups
• http://tinyurl.com/PAW-Fact-Sheets

41. DEVELOPING OCCUPATION-SPECIFIC
SCREENING TOOLS FOR
PRESCRIPTION DRUG MISUSE

42. SCREENER DEVELOPMENT STEPS
Step 1: Define the industry risk factors to assess in the screening tool
Step 2: Identify problematic workplace behaviors associated with
substance use
Step 3: Categorize behaviors related to risk factors or other sorting scheme
Step 4: Develop survey items from the reduced set
Step 5: Combine industry specific items with a validated drug use screen
Step 6: Launch survey to industry target group
Step 7: Conduct statistical analysis to identify latent factors, or clusters of
related items
Step 8: Identify items within factor that are the strongest candidates
Step 9: Develop short screen from the final item set

43. Risk Factors: Flight Attendants
• First responder – high stress
• High rate of job-related injuries
• Irregular work and sleep schedules
• Readily available access to prescription drugs
internationally
• Workplace culture of sharing prescription
drugs with coworkers

44. Instrumentation
• The AFA-CWA peer-based EAP collaborated with SAMHSA’s
PAW to develop a short screening instrument to identify
problematic prescription, illicit, or over-the-counter drug use.
• Representatives from 20+ airlines submitted potential items
they deemed indicative of problematic drug use for flight
attendants
• Project working group (AFA, CSAP & RTI) selected 12 items
from among the ~30 potential items submitted
• PAW also administered the 10-item short version of the Drug
Abuse Screening Test (DAST; McCabe et al., 2006) for
validation.

45. Data Collection
• AFA EAP created an anonymous survey
using Survey Monkey
• 2,163 participants responded
• Most items had a response rate of 98.5%
or higher

46. Analysis
• Factor analysis uncovered three factors among
flight attendant specific items
– Planning factor: Behaviors indicating planning
work around their drug or medication use
– Occupation factor: Behaviors associated with
coworkers and special occupational opportunities
to obtain medication
– Pain/pain management factor: Behaviors
associated with pain management and the
experience of injury

47. DAST Screener Items

48. Final Screening Instrument
• Six items with the best measurement properties
• Validated by the DAST screener
• Flagged cases that the DAST was unable detect

49. Conclusions on Flight Attendant Drug
Screening Tool
• The 6-item flight attendant specific drug screening
items detect problematic behavior unique to this
occupation.
• Having a specialized Confidential Drug Screening tool
for Flight Attendants appears to be a step forward in
better screening, especially for high risk users.
• Risk indicators for flight attendants, which were not
previously available, provide early identification and
screen for brief interventions or treatment when
required.

50. Flight Attendant mobile app developed to
integrate screening tools with other
wellness information

51. PROGRAMS ADDRESSING
PREVENTION OF PRESCRIPTION
DRUG MISUSE

52. Workplace Evidence-Based Programs
Overall Reduced Costs
Decrease
Prescription
Drug Misuse
Increase
Health &
Wellness

53. Web-Based Health Information
• SAMHSA’s GetFit web-based program provides a range of
prescription drug prevention applications and related
health promotion
• Evaluation of Amtrak’s version of SAMHSA’s GetFit
interactive substance abuse and prescription drug
prevention/health promotion website. Supports peer-to-
peer substance abuse and prescription drug prevention
program.
– Dramatically improved peer helper capabilities
– Enhanced ability to provide 24-hour confidential, integrated
health-related information to employees & easier access to up-
to-date prevention of prescription drug and related materials.
– Ready access to information on NA, AA, and Alanon meetings;
assisting mobile employees at high risk.

54. SAMHSA’s Young Adults in the Workplace (YIW)
• Six grantees implemented and evaluated
prevention programs in over 100 worksites
for 16-24 year-old employees in healthcare,
retail, restaurant, transportation, and
unionized trade industries
• Reached over 1,400 young employees and
their families
• Programs can be modified and enhanced
with prescription drug prevention

55. YIW Lessons Learned
Essential for Participant Buy-in:
 Framing prescription, illicit drug and alcohol
prevention messages in the larger holistic context of
physical and emotional health
 Making connections between health behaviors and
outcomes relevant to young adults (e.g., getting
ahead at work or “being on the top of your game,”
perceived peer influence)
Employee Engagement Strategies:
 Incorporate multimedia technology, such as message
boards and podcasts, to deliver the intervention
message
 Incorporate prevention efforts into mandatory
trainings/orientations
 Provide incentives for employees

56. SmartRx: Your Prescription for Good Health!
• A self –guided online tool designed to prevent misuse of
prescription medications among adults
• Training can be completed in 1-2 hours
• Covers use of analgesics, anxiolytics, sedatives ,
and stimulants

57. Studies of SmartRx Show:
• The SmartRx program increases knowledge of
proper medication administration
• Increases the ability to manage own
medications
• Lowers concerns about medication
administration
• Users describe the program as comprehensive,
clear, informative, and useful
www.smartrxonline.com

60. Contacts
• Deborah Galvin, Ph.D., SAMHSA
Deborah.Galvin@samhsa.hhs.gov
• Jennifer Fan, Pharm.D., Ph.D., SAMHSA
Jennifer.Fan@samhsa.hhs.gov
• Laurie Cluff, Ph.D., lcluff@rti.org
• Scott Novak, Ph.D., snovak@rti.org

61. Workplace Issues
and Strategies
Presenters:
• Jennifer Fan, PharmD, JD, Pharmacy Advisor, Center for Substance Abuse
Prevention, Substance Abuse and Mental Health Services Administration
• Laurie Cluff, PhD, Workplace Health and Safety Research Psychologist,
RTI International
• Scott Novak, PhD, Senior Developmental Epidemiologist, RTI
International
Prevention Track
Moderator: J. Kevin Massey, MS, Business and Program Development
Specialist, Weitzman Institute, Community Health Center, Inc., and
Member, Rx and Heroin Summit National Advisory Board