Mitigating Substance Misuse During the COVID-19 Pandemic
In this webinar, you will learn about:
- The workplace importance and benefits of drug testing
- When to drug test and how to select the right type of test
- What to do if an employee tests positive for drugs
Cori Repp, MD, MBA, MROCC, medical review officer
Hello, and welcome to the Concentra webinar, Mitigating Substance Misuse During the COVID-19 Pandemic. Today’s webinar will be presented by Dr. Cori Repp. Dr. Repp is a clinical instructor, conference speaker, and industry spokesperson, as well as a certified medical review officer, American Board of Disability Analysts Fellow, and a certified medical examiner.
At the conclusion of the presentation, we will have a 10-to-15 minute Q and A session with Dr. Repp. You can submit your questions throughout the presentation, to be answered during the Q and A. Dr. Repp will answer as many questions as possible within the time allowed. A recording of the webinar will be e-mailed to you after the presentation so you can view it again at your convenience.
Dr. Repp, we're ready to begin.
Dr. Cori Repp
Good afternoon, I'm Dr. Cori Repp. I'm the director of medical operations for Concentra in central Florida. I've been practicing occupational medicine for almost 15 years, and I've been a medical review officer for 13 years, helping employers create and administer safe work practices, including workplace drug testing.
The COVID-19 pandemic has impacted the workforce in many ways. Employees experience multiple stressors, including job and financial insecurity, concern for their own well-being, as well as that of their families. With these added stressors, individuals with substance abuse disorders – diagnosed or undiagnosed, in treatment or recovery – are particularly at risk.
Extended quarantine and time away from work with illness of their own or of a family member can disrupt the general flow of life. These stressors and disruptions can increase opportunities for substance abuse or misuse. As we go into the presentation, Mitigating Substance Misuse During the COVID-19 Pandemic, there are many factors that can impact the ability of individuals to remain drug-free, especially when you consider that one in five American adults take medication for their mental health. Lack of access and lack of health insurance can cause difficulties for those individuals to maintain their medication, further increasing the chance for substance abuse or misuse.
Reviewing our agenda for today's presentation, I'm going to speak about why workplace drug testing is important; some of the signs and symptoms of substance abuse; the benefits of workplace drug testing; when you would want to test; what to look for when you're testing; drug testing specimen types or what types of body fluids and body products can we use to test for drugs; and how we collect those test results. We'll talk a little bit about regulated and non-regulated drug testing; what to do if an employee test positive; DOT physicals and their specifics, above and beyond drug testing. We will also talk about workplace drug testing best practices. After that, we'll have a little bit of time for Q and A.
I do want to bring up a small legal disclaimer. This presentation is intended to be a general overview of workplace drug testing. It doesn't take into account some of the very specific state and local regulations. Please make sure that you have legal advice prior to initiating a drug testing program or making any changes to your existing one.
Why Workplace Drug Testing is Important
Why is workplace drug testing important? The National Institutes of Health tell us $740 billion is lost due to drug abuse and addiction costs. This is a composite of workplace productivity and health care expenses due to accidents, treatments, and presenteeism. The Substance Abuse and Mental Health Services Administration, SAMHSA for short – you’ll see that reference throughout the presentation – they say that 76 percent of people with a drug or alcohol problem have a job and overall, drug abuse trends are not going down. Sixteen percent of emergency department patients who are injured at work have alcohol in their systems.
Failed drug tests have gone up substantially. The numbers that we present to you here are from Quest Diagnostics, one of the largest private drug testing laboratories and reporting agencies. Quest compared 2015 versus 2018. In transportation and warehousing, two very safety-sensitive sectors, there was a 34.5 percent uptick in failed drug tests. In wholesale trade and construction, there were substantial upticks, as well. Remember, these numbers were from 2015 to 2018 – times when the economy was good and things were flowing nicely. We haven't seen any of the data from 2020 yet; but based on some of the anecdotal accounts I've heard from other medical review officers, I do anticipate that we are going to see an even greater rise in failed drug tests compared to 2015, or even 2018.
Signs and Symptoms of Substance Abuse
Substance abuse takes a toll on employees. There are signs and symptoms that can really stand out and they can help to identify individuals who may have a problem. I say “may” because these signs and symptoms are relatively general, not specific. For example, things like lack of focus, poor coordination, declining performance at work, mood swings – when you've got someone who's usually an easygoing person and now is tending to be angry over minor issues. Individuals with chronic illnesses that appear to flare often, poor attendance, poor physical appearance, or lethargy – just being tired all the time – all these are signs that are not specific to drug abuse. These can be signs of many other medical issues; however, they are some of the signs we see exhibited when individuals have concerns with substance abuse.
Benefits of Workplace Drug Testing
You are never going to catch everyone who uses substances but when you do drug testing in the workplace and communicate that you are testing or that you are a drug free workplace, it can deter substance misuse or abuse at work. If there's someone who is a heavy user or a chronic user, could they potentially not use a substance long enough to pass a drug screen? They could, but for a lot of these individuals, this is their lifestyle. If they see that a company does drug testing, more than likely, they are going to look for a job somewhere else. They will look for a company that does not do drug testing.
The other use of workplace drug testing is to identify job candidates and current employees who potentially have drug and alcohol problems. With this use, drug testing may help reduce work-related injuries and associated health care costs, while also reducing absenteeism and lost productivity, all due to issues with substance abuse disorders.
A big reason we do workplace drug testing is because individuals who are intoxicated are not at their best, and they are not able to tune into everything that's going on. This can cause bad accidents to happen. If you want to protect the general public and your workforce, workplace drug testing is one way you can do that and avoid some of those accidents – just by ensuring that your workforce is present, capable, aware, and not intoxicated.
When to Test
(pre-employment, reasonable suspicion, post-accident, return to duty, follow-up, random)
When should we test? What do we test for? And why would we test? There are six different reasons to test, with some different procedures behind each of them. These include pre-employment testing, reasonable suspicion, post-accident testing, return to duty, follow-up testing, and random testing.
Pre-employment testing, as it says, is done to determine if a potential hire is abusing drugs or alcohol. One of the great things with pre-employment testing is that it is generally accepted that, if a job offer is given and the individual does not pass the drug test, the job offer can be contingent upon having a negative drug test.
Reasonable suspicion testing is conducted when there is evidence that would give us a cause. Basically, reasonable suspicion testing can be done if a supervisor or another employee directly observes something that shouldn’t be going on at work – something like an odor of alcohol on the body or breath. Or perhaps the employee is observed to be unsteady when standing or walking or appears disoriented or confused. Or maybe their behavior just seems out of keeping with how they normally act, or a little erratic. Things like an inability to complete, routine tasks, things that they would normally be able to do. However, you cannot do “reasonable cause testing” based on word of mouth. You have to be very careful is someone says an employee was walking with a creative gait a little bit, and as they going down a completely flat, straight, well-lit hallway, they were tripping over their own feet. This is kind of unusual. You can't use it, if it's hearsay, or a third person – a “he said/she said” word of mouth information.
For regulated employees, 49 CFR 382.603 requires supervisors to be trained in order to make and document these observations, for them to be admissible for reasonable suspicion testing. One thing that may come as a surprise to you is that voluntary admission of controlled substance or alcohol issues for DOT does not constitute a violation. If someone says, I was on vacation two weeks ago and I smoked a joint, you can't automatically conclude this individual violated the drug and alcohol policy. This was self-admission. The only difference associated with that is if they tell the wrong person; while they are getting a drug test done, they decide to tell the collector. That would constitute a violation. But if it's just something where someone heard someone else talking about substance use, in and of itself, that does not constitute a violation.
Post-accident testing is familiar to most of us. It occurs after an employee has been involved in a workplace accident and when we believe drugs or alcohol may be a factor in the accident. One of the most important items that you need to address is that the timeframe following the accident should be as short as possible for this type of test. DOT has specific requirements for the post-accident regulated testing. If you're outside of those, only non-regulated testing would be allowed or apply. But the employer must determine when the testing will occur, if the testing should occur, based on their policies, and based on the timeframe. We definitely want to make sure that post-accident tests are performed as soon as possible to ensure that substances in the body at the time of the accident are reflected on the drug screen.
Return-to-duty testing may not be exactly what you think it is. Return-to-duty testing is specifically for employees who violate their employers’ drug and alcohol policy. Return-to-duty testing is not for an employee who has been off work for some other reasons, such as being quarantined for two weeks for COVID-19. That that would be more of a pre-employment testing and fall more under those guidelines. Return-to-duty testing guidelines vary for DOT and non-DOT workforces, so it’s very important to know the return-to-duty process with DOT. This is conducted periodically when an employee returns to the workplace after completing the return-to-duty process and can include intervention with a substance abuse professional staff or some other processes that are administered, in addition to random testing. There will be at least six unannounced tests in the first 12 months following the return-to-duty test for the follow-up period.
Random testing, by definition, must be a truly random selection process so that each employee has an equal chance to be tested every quarter. Now, that can get a little bit tough when you've got a smaller company. Gosh, if you've got only two employees, one of them is going to be tested every quarter, and that can get a little bit expensive. One of the great things about using a partnership with a drug testing consortium is that you can spread out the cost a little bit more for your DOT random drug testing. You can join a pool consisting of multiple companies. Doing that saves you testing costs and time, and it really helps you ensure that you're compliant because you have the partner company ensuring your compliance. This is ideal for owner operators, small companies with a few employees.
What to Look for When Testing
SAMHSA guidelines require drug tests to check for specific illegal drugs – that’s for regulated drug tests. Non-regulated policies and tests can be a little bit different. Specific drugs that are tested for include illegal drugs, prescription drugs, and alcohol, in some cases. There are two different drug test panels that you hear a lot about. The most commonly requested are the SAMHSA five-panel or the SAMHSA 10-panel. They include a variety of drugs that are illegal and some that are legal – everything from amphetamines to THC, which is the active ingredient found in marijuana, to cocaine.
Opiates now includes semisynthetic opioids, which can include legal medications like hydrocodone and oxycodone, taken with a physician's prescription. Phencyclidine, which is PCP can be found in other illicit drugs. There are a lot of combinations, but we see that it's popping back up. Barbiturates, or downers. Benzodiazepines, which again, can be legal drugs. Methadone is often used to treat other forms of opioid addiction. And then Propoxyphene, which is Darvon compounds, is not legal in the United States but is still used in some other countries.
Drug Specimen Types
(urine, hair, blood, saliva)
What do we use to test for drugs? What body substances do we most commonly use?
Urine testing. I think the one that is most familiar to everyone is urine because it is the most popular way to screen for drug use. Ninety-five percent of U.S. workplace drug testing is done with urine tests. It’s non-invasive, very inexpensive, and specimens are easy to get from the donors. It has a good detection period, generally 5 to 10 days, depending on the type of drug you're looking for. It detects the same substances as on the five- and 10-panel screens – those that we went over already, such as amphetamines, methamphetamine, barbiturates, cocaine, marijuana, MDA opioids, one of the things, like, they are not fixed, and I am here the indicative of heroin use that one is actually out of the urine within an hour or so. That could be a really tough one to capture on the urine drug testing. Hydromorphone, hydrocodone, oxymorphone, oxycodone. When you're when you're looking for someone who is maybe taking pain medicine that they're not prescribed. Nicotine and alcohol can be tested on that, as well, even though those are not part of the SAMHSA five- or 10-drug panels.
So, urine overall is a good specimen in terms of the lack of invasiveness, in terms of the cost, and the ease of testing, and the variety of things that you can detect. A big problem with urine drug testing is substitution, adulteration, and ensuring that the specimen you're receiving is the specimen from the person giving the sample. Those can all be downsides of urine, and that's why it's really important, when you're looking at any type of drug testing, to make sure that your collection site partner has very well-trained collectors. That applies to all of the different specimen types; you need to ensure that your collection site has well-trained, certified collectors. At Concentra, we’re on top of that. We ensure that our collectors are all well-trained. Anytime there's a positive drug test and someone loses a job or a benefit due to that, it’s very common to have litigation. The first things the attorney always asks for are the chain of custody form and the testing from the lab. It's very nice to have a partner that is committed to ensuring all the i's are dotted and all the t's are crossed.
Hair testing is another drug testing specimen type that we can do. It is highly effective when you’ve got a safety-sensitive position where you can't tolerate any risk of an individual using drugs at all. Hair is a great specimen because the drug will be in the hair for about 90 days post-use. However, hair testing is costly. You always want to use the urine test as a backup. Hair can be used to detect drugs like cocaine, marijuana, opioids, amphetamines, Ecstasy, PCP. It can even be used to determine alcohol use.
Hair testing is not used in a regulated DOT setting currently but it is in discussion and possibly could be something coming in the next year or two. But if you've got those safety-sensitive positions, where you absolutely can't take the chance that this individual ever uses illicit substances, hair testing can be a really good option for that longer detection periods.
Blood testing is the next specimen type we can use for testing. Blood draws are relatively invasive. They're not the most popular way of testing because they are invasive and costly. Also, there's a very short detection period for blood. Blood tests are best used in a situation where you need to know the intoxicant’s potential level or be intoxicant-specific to the time of an event (or accident). Blood can be used to detect things like alcohol; it’s very commonly used for alcohol, amphetamines, cocaine, fentanyl, marijuana, methamphetamines, opiates, phencyclidine, nicotine, and tramadol. There are many drugs that can be tested for in blood. But it's not approved for routine regulated testing. You definitely want to ensure that, if you're using it, you have a drug testing protocol so the proper chain of custody form is sent with that specimen. Again, this is a reason you definitely want to ensure that you have a partner who knows the needs of your company and the regulations and has the certification to produce those type of assessments.
Saliva testing is one of the more up-and-coming drug testing specimen types and one that I particularly like. I really like it because it's not invasive. This is a very simple swab. It looks like a toothbrush and, depending on the manufacturer, the saliva test can take from just a few seconds up to a minute. You give the toothbrush to the person being tested. He or she can do the swab, as long as your collector is checking to make sure it’s the right person, that the specimen is coming from the person you are testing. Saliva testing also avoids that darn shy bladder with urine testing, where somebody sitting around for three hours, trying to produce a specimen. Sometimes they can't, and then you've got additional work-up with shy bladder. With saliva testing, you don't have that. There have been discussions about dry mouth concerns but, in general, it takes very little saliva to produce enough specimen on the swab to be tested. Saliva also has a shorter detection period than urine. It's not quite as long in the detection period. Right around three days is what they consider the maximum for most of the substances we’re testing for.
Very similar panels of drug abuse and drug misuse. We can test for alcohol, barbiturates, the benzodiazepines, things like cocaine, Ecstasy, marijuana, opioids, amphetamines, PCP, methamphetamines. One of the drawbacks with saliva is that saliva testing is not approved for regulated testing. We don't really have an idea when it will be or if it will be. But, again, it can be a test alternative for concerns that are not regulated, not DOT-driven.
The concern is still was the specimen released from this donor or was this really the donor of the specimen we’re testing? It can really help with stopping that from ever being the question.
Collecting Test Results
There are rapid tests that can be performed. These tests can be done on urine or saliva. One of the great parts of rapid testing is that allows the detection of drugs that metabolize quickly, like we were talking about with heroin. That's broken down and metabolized and pretty much out of the specimen within a few hours. You may not be able to catch it in a later screening. Rapid tests can pick up a lot of those types of substances. Another great thing about rapid tests is that they can be performed at the workplace or at a clinic, and they generally take about five to 10 minutes for the procedure to be performed.
The only thing that you have to remember with rapid testing is that rapid testing is a screening test. If you get a result that's negative, that's wonderful. With a negative result, the individual can return to performing their duties. The problem comes if you get a rapid test that isn't negative. If it's a non-negative test, it will still need to go to the lab. Just because something is non-negative doesn't mean the individual doesn't have a prescription for the substance that's showing on the cup or the slides. Sometimes – it’s very rare, but it can occur – rapid tests will show substances that aren't even drugs of abuse but show up as a false report or false reaction on the strip. Sometimes, very rarely, there can be failures of the strips themselves. So, it's important to not just take those non-negative results and say, hey, this is a positive, because it's not. It’s not a positive until the lab has run that test and the medical review officer has reviewed the results to ensure there isn't another explanation. Again, it is very nice to have a partnership with a lab or with a facility like Concentra that can support those types of tests.
Regulatory and Non-regulatory Drug Testing
Let’s talk a little bit about the differences between regulatory and non-regulatory drug testing. A lot of times, you will hear regulatory drug testing referred to as DOT drug testing. Basically, it’s done for safety-sensitive workplaces that fall under the Health and Human Services Department, the Nuclear Regulatory Commission Testing Authority, Department of Defense, or they're part of the Department of Transportation. But these are all grouped into the safety-sensitive workplaces. These are folks that you really want to make sure they're not doing any type of drugs. These agencies didn't leave it up to the individual employers. They made their own set of rules to ensure that drug testing is being performed. These are your FAA folks, like your pilots. Federal Motor Carrier Service Administration – those are the folks driving the big trucks. Federal Railroad Administration, Federal Transit Administration, Pipeline, and Coast Guard. These are individuals who have the responsibility of public safety. You want to make sure that these individuals are in the drug testing program. So, the government does regulate or basically give the formula for how these drug tests are done, how often they're done, and items like that. Typically, these are urine or breath alcohol tests, performed in accordance with the regulations of the different agencies.
So, what is non-regulatory drug testing? Non-regulatory drug testing is really just that. It’s any non-DOT, non-regulated drug tests that the employer is choosing to use. Non-regulated does give employers freedom to design the drug testing program without the requirements of the federal government like those that apply to those industries we just discussed. You can choose the type of specimen that you want to test. You can choose the panel, whether you want a five-panel or a 10-panel or a custom panel to fit your needs, and it can be done electronically. The chain of custody can be done by paper, you know, whatever you choose.
But “whatever you choose” doesn't mean that you are completely free. You still have to be aware of the different jurisdictions. So the state, the municipalities, federal laws still apply. All these regulations and laws that are very specific, not only potentially to a bargaining agreement or a local municipality or a state's laws. I think about this a lot when we talk about things like marijuana testing, THC testing, the non-regulated drug testing. We do have to be a little bit more sensitive to that, and there's a lot that is specific to geographies that you want to take into account before you develop those programs. And, of course, very important to make sure that those programs are written and that they are applied equally and fairly to all employees.
What to Do If an Employee Tests Positive
What do you do if an employee test positive? It's different for DOT-regulated and non-DOT-regulated drug tests, as I'm sure you realize. With regulated drug tests, there are federal guidelines that have to be followed for the positive test. The first and most important thing is to make sure that the employee is removed from the safety-sensitive function. That may seem like a pretty logical thing, but unfortunately, I have seen cases throughout the years where that was not done – where someone was tested, had a non-negative test, and then was sent back to work. One of the big parameters with safety-sensitive functions. You need to make sure that you're removing that individual from the function they perform and that you inform the employee not only of the results of the test but to seek help from a substance abuse professional. If they need to enter substance abuse treatment, give them their options. The regulations don't prohibit termination of the employee if that’s permitted under the employer policies. That would be part of your policies, part of your bargaining agreements, etc. The worker who tested positive is still obligated to complete the return-to-duty process, as we discussed before, with those multiple drug screens. And who pays for those? That also is determined by the employer’s policy, collective bargaining agreements, state and local laws but there is definitely a process in place for those individuals if there's a positive test.
Now, for non-DOT-regulated employees, this is where the employer's written policy is so critical. It’s very important to have a written policy. It's also important to document any positive test result and then refer back to the relevant state and local laws. Of course, defer to your corporate counsel or your human resources advisor to make sure that the way you're operating, based on those results, corresponds to your state and local laws. I can't say enough about how important it is to have that written policy.
Safety-sensitive employees are required to have a regular physical. For DOT drivers, that can be anything from three months to one year or up to two years that they're cleared for. The DOT physicals are regulated by 49 CFR 391.41. The clinicians who evaluate the drivers are certified medical examiners. So, what does that mean? For these individuals, we’re looking at whether there are potential signs or symptoms of drug abuse and what medications they may be on that could impair their ability to function properly in the high-demand job they have. All of these items are taken into consideration, along with any medical concerns that could become safety-sensitive issues. So, if you've got an individual who is falling asleep at the wheel, the medical examiner is going to absolutely dig into that to make sure that that is addressed prior to that individual ever getting a card or certification to continue driving. If someone's on a medication, that can cause sedation, a certified medical examiner is going to look into that. If something is a safety-sensitive concern with a medication, even if it’s not a regulated drug, the medical examiner will ask some questions about how well that individual is coping with the initial side effects of the medication.
There are a lot more items that the certified medical examiners dig into to ensure that those drivers are safe. There may be reasons beyond substance use or misuse that would be a concern for a DOT physical and for the medical examiner. At Concentra, all of our clinicians who perform DOT physicals are certified medical examiners, so they are very aware of these parameters, the needs of drivers, the demands of those positions, and all of the guidelines that indicate what we might want to watch out for with regard to impairment, to make sure that the roads are safe and to ensure public safety.
Workplace Drug Testing Best Practices
I know that all of you on the phone are here because you care about your industry, and you know your industry. That is the most important factor. Make sure that you know your industry and what your requirements are – that you know what you're required to produce for the regulations you may fall under, as well as your local, state and federal testing guidelines. If you don’t know, that’s okay. But make sure you have a resource available, someone you can go to. Drug testing laws vary greatly by state, especially in regard to THC. That’s just one. Even if you're not a regulated entity, be sure you have a resource that you can go to with important questions and for help in developing drug testing protocols. Make sure that your workplace substance abuse policy is in writing. Make sure that it's very specific, and, again, work with your partners to ensure that it's been reviewed, and that you have a second set of eyes on that. You want to make sure that your written workplace substance abuse policy is absolutely ironclad and that it is applied fairly and unevenly. Make sure that everything is in writing because that's one of the first things that would be requested if there were a challenge to the policy. Also, make sure that your policy is explained to your leadership and that they're trained on what your policy is specifically. Be sure that training is documented. That’s very important.
Then, if you're going to have these policies, and you're going to write them very specifically and do all this really great work on a substance abuse policy, the most important thing is that your workforce understands that there is a substance abuse policy, and that they understand the guidelines. If there's a random testing program, they need to be aware of that, so that it doesn't come as a surprise. Again, it's more of a deterrent with random testing. With many other types of drug testing, it's a deterrent to keep individuals from using illicit substances or misusing substances. Maybe someone is at a party, and their friends have some marijuana cigarettes. They're thinking, well, you know, gosh, I could do this. But if I go to work on Monday, I might have positive drug test, and I might lose my job. Drug testing encourages that thought process to help dissuade drug use more than anything.
Be consistent in your efforts to enforce policy. If you're going to start a random program, or if you're going to do drug testing for reasons XYZ, be sure that those efforts are implemented consistently. In particular, if you have a policy that says if someone's on PTO or if someone's not available to get the test, be sure that you're addressing how they follow up.
Last, but certainly not least, partnerships are critical when it comes to workplace drug testing. Be sure to partner with an occupational health provider, not only to structure your policy to ensure testing compliance, but to ensure that there is that extra layer. Make sure that when you're getting these tests done that. if there's ever a challenge to your test, you can sleep well at night, knowing that the chain of custody is properly filled out, that it's legible, that all of your drug screeners that you've used through the partner have all been trained appropriately and that that that's an ironclad defense for you. I can't say enough how partnership is really critical in workplace drug testing because, at the end of the day, positive results are going to be challenged. They very commonly are because there are generally benefits to the individual donor that they’re going to lose if they have a positive test. Be sure that your partner is able to support you and provide for what you need with workplace drug testing.