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“And while the future’s there for anyone to change,

Still you know it seems
It would be easier sometimes to change the past”

– Jackson Browne, Fountain of Sorrow

 

Posted by Jeffrey Jacobs, M.D., M.P.H.

If you read my previous blog post, you’ll know that I recently attended an ORCHSE conference that has provided me with plenty of food for thought.

One session I attended reminded me of these lines from a song by Jackson Browne. What does his 1970’s-era, plaintive ballad about an imminent romantic break-up have to do with positive behavioral change?

We all know that when we are trying to make health-oriented behavior changes for ourselves or encouraging them in work colleagues, friends and family members, it’s extremely hard to overcome the past. Health beliefs, behaviors and coping skills are hardwired in our brains. Even when we receive sound guidance for positive change that we should intuitively appreciate, we often don’t make constructive progress.

At the ORCHSE meeting, Greg McGloughlin, CEO of HBD International, offered the “Secret Sauce” for successfully becoming more engaged in the process of making healthy behavior the norm.

McLaughlin cited three important factors involved in driving behavior change:

1. We should be aware that behavior change is a process that involves multiple stages before success can be achieved. According to the transtheoretical model of behavior change developed by Prochaska and DiClemente in the early ’80s, individuals must first be at a stage where they are ready to change.

2. The message has to be delivered and received at the correct time in order to begin and successfully achieve behavioral change. A person in the precontemplative or contemplative phase simply isn’t ready to overcome the barriers necessary to succeed, no matter how well-crafted the health promotion message. However, once the individual is ready, McGloughlin recommends that the message be short and compelling. Experience and studies show that too much information can often overwhelm individuals and discourage them from trying.

McGloughlin shared the following message as an example. The tag line, “Do you service your car more regularly than you service your health?” really resonated with me.

For health educators and employers, he recommends introducing one or two core messages/educational strategies around a single health goal, such as quitting smoking, walking for exercise or improving nutrition. He advises against introducing five or six content areas with multiple related recommendations

3. The message should be frequently repeated (at least monthly) in order for it to gain traction. Scientific literature shows that the percentage of the message that is remembered is highest immediately after it is received and drops precipitously (almost 90 percent forgotten) within seven weeks. With monthly sessions, the percentage of message remembered remains at 20 to 25 percent. Reinforcing the message/behavior incrementally increases and remains higher than messaging given every two months (50 percent remembered with monthly sessions vs. 25 percent with bi-monthly sessions).

Even armed with this knowledge, changing health behavior still remains a tough row to hoe.

However, health educators and employers may be more successful at encouraging positive change by timing the dissemination of simple-yet-memorable messages with a call to action at appropriate intervals and aiming them at employees who are in a stage where they likely to be receptive.

From Jackson Browne’s perspective, putting these theories into practice may make it more feasible to change the future, but that’s in another one of his songs (Doctor My Eyes)!

Jeffrey Jacobs, M.D., M.P.H., is Vice President (clinical lead), Medical Exams & Travel, and an Associate Medical Director at WorkCare.

Acknowledgement: HBD International provided the graphs/illustrations for this blog.

However you choose to pronounce the acronym, it’s helpful to understand the origins of ORCHSE Strategies.

The company was established as Organization Resources Counselors, Inc., in 1972 to facilitate industry understanding of governmental occupational health, safety and environmental policy and regulatory decision-making. Health, Safety and Environment was later added to the name to represent the interests of member organizations in diverse industry sectors.

I recently attended an ORCHSE meeting in northern Virginia to meet with other EH&S professionals. I was impressed with the quality of the presentations. One in particular stood out.

James Wesdock, M.D., M.P.H., Global Health Director at Alcoa, presented a straight-forward proposal to offer all welders a vaccine to protect against pneumonia. He explained the reasoning behind this initiative:

1. International research consistently demonstrates an increased risk of pneumonia in welders compared to the general public. Additionally, welders who develop pneumonia (invasive pulmonary disease or IPD) have an increased risk of dying from pneumonia at a rate two-to-three times greater than their counterparts in the general public. The risk window for developing pneumonia is related to recent welding exposures (within the last 12 months). The risk level reverts to the general population rate after retirement. Exposure to iron metal fumes during welding is believed to be a contributing fact in the development of IPD.
2. A safe and inexpensive pneumococcal vaccine is available to prevent IPD. This is important because the vaccine protects against Streptococcus Pneumoniae (pneumococcus), the bacterium that poses the greatest risk to welders who contract the disease. Most healthy adults develop immunity to pneumococcus within a month after vaccination; about 75 percent remain protected for up to 10 years. Side effects typically include vaccination site soreness, swelling and redness, headache, fatigue and muscle aches. Adverse reactions are similar to other types of vaccine reactions, such as influenza vaccines.

According to data presented by Dr. Wesdock:

• Vaccinating 588 welders would prevent one case of IPD in 10 years
• Vaccinating 4,900 welders would prevent 1 death from IPD in 10 years

By comparison, about 1 million people get pneumonia and approximately 50,000 die of it annually in the U.S., the Centers for Disease Control and Prevention reports. Vaccination could help prevent many of these illnesses and deaths.

Alcoa has offered voluntary vaccination to its employees since June 2017. Nearly 800 welders have been vaccinated (about 30 percent of eligible employees). In Brazil, a group of 76 Aloca workers uniformly accepted the vaccine. In the United States, only about 13 percent of eligible individuals have agreed to receive the vaccine.

It appears that cultural norms influence vaccination rates. For example, Dr. Wesdock said Brazilian workers may be more willing to trust medical authorities and accept their recommendations than employees in the U.S.

He encourages corporate medical directors in companies with welders to consider this preventive approach. For more information, contact Dr. Jacobs: Jeffrey.jacobs@workcare.com

Dr. Jeffrey Jacobs is Vice President/Clinical Lead, Medical Exams & Travel, and an Associate Medical Director at WorkCare.

I recently reviewed the results of a urine drug screen (UDS) involving an employee in Maine. The lab report showed positive for marijuana (THC).

I called the donor to conduct the Medical Review Officer (MRO) interview. Had this been a federal test, the interview would have been straight-forward. Since he did not have a prescription for Dronabinol (Marinol), a cannabinoid used to relieve certain symptoms for people with AIDS or cancer, I would have simply reported it as positive for THC.

However, because the test was non-federal, I needed to be familiar with the employer’s policy regarding THC (zero tolerance or other) and applicable state regulations. In this case, Maine legalized recreational marijuana in 2016. The state began allowing sale and use last year following legislative wrangling and a series of court rulings.

One of the myths about work-related urine drug screening in Maine is that state law prohibits testing for THC. In fact, the donor tried to educate me about this and promised that his lawyer would call me to provide further instruction. This prohibition actually requires further explanation.

According to the Maine Department of Labor’s Bureau of Labor Standards’ Guide for Employers: Marijuana in the Workplace, under the Marijuana Legalization Act, Section 112, Employment Policies, except as otherwise provided in the Maine Medical Use of Marijuana Act, an employer:

• Is not required to permit or accommodate the use, consumption, possession, trade, display, transportation, sale or cultivation of marijuana or marijuana products in the workplace.
• May enact and enforce workplace policies restricting the use of marijuana and marijuana products by employees in the workplace or while otherwise engaged in activities within the course and scope of employment.
• May discipline employees who are under the influence of marijuana in the workplace or while otherwise engaged in activities within the course and scope of employment in accordance with the employer’s workplace policies regarding the use of marijuana and marijuana products by employees.

In order for an employer to enforce these policies, they must first get state approval. The guide states:

“In Maine, marijuana is still on the list of substances for which an employer may test. Testing is only allowed if a company has a drug testing policy that has been approved by the Maine Department of Labor (MDOL). Employers that do continue to test for marijuana, or take disciplinary action for marijuana use, must comply with the Substance Abuse Testing Law, the Marijuana Legalization Act, the Maine Medical Use of Marijuana Act and the Maine Human Rights Act.”

In this case, the employer was aware of state regulations and had applied to MDOL for policy approval, but at the time of the test the state had not completed its review. As the MRO, I reported the test positive for THC. Now the case is in the hands of the Designated Employer Representative (DER) and legal counsel to make a decision on how to handle the situation.

This is just one example of the challenging nature of non-federal drug testing, with the federal government listing THC as a schedule 1 drug without medical benefits and certain states legalizing the use of marijuana for its beneficial medicinal properties as well as recreational use.

It is important for employers and those who support them, including MROs, to stay abreast of developments in this area. It is essential to have clearly defined drug testing policies that are understood by job applicants and all employees.

When there are questions, it is advisable for employers to rely on legal counsel as part of their ongoing efforts to provide safe and healthy workplaces without violating applicable laws, including employee rights.

Dr. Jacobs is Vice President/Clinical Lead for Medical Exams & Travel and an Associate Medical Director at WorkCare.

This week’s deep freeze across the Midwest serves as a reminder that extremely cold conditions call for extreme safety measures. But even exposure to moderately low temperatures, wind and water can have serious health consequences.

Hypothermia, or abnormally low body temperature, develops when the body is unable to replace heat lost to the environment. In addition, when surfaces are icy, or obstacles are obscured by mud or snow, slip and fall risk increases. When it’s cold out, sprains and strains are more likely to occur in the morning before tight muscles are warmed up and at the end of the work day when employees are tired.

Other factors that increase exposure risk in the cold include:

• Complacency or lack of awareness about potential dangers
• Wearing clothing and footwear that are wet or inadequate for conditions
• Poor physical fitness, cardiovascular disease, or being ill with a cold or the flu
• Age/gender: Heat regulation declines with age and statistics show men are more susceptible to cold-related injuries than women
• Becoming exhausted, immobilized, injured, submerged, lost or entrapped
• Drinking alcohol or using substances that impair judgment or physical function

Did You Know?

When it’s cold, employees have to work harder to maintain their body’s core temperature. Cold-weather workers who wear heavy, protective clothing require 10-15 percent more calories a day compared to those working in temperate climates.

What Can You Do?

To work safely in cold weather, it’s always advisable for employees to:

1. Check the weather forecast, follow advisories and be prepared for changing conditions.
2. Take extra precautions on wet surfaces, snow or ice and during physical exertion.
3. Seek shelter to rewarm the body with a warm beverage and radiant heat source.
4. Wear clothing in layers to retain body heat and repel water; pack extra clothing.
5. Select footwear designed for the conditions and replace wet socks.
6. Use goggles or sunglasses to protect eyes; apply sunscreen or balm to skin and lips.
7. Exercise regularly to build strength, stamina and flexibility; stretch before/after activity.
8. Drink plenty of water, eat nutritious foods and carry snacks to boost energy.
9. Avoid excessive alcohol and smoking (nicotine constricts blood vessels).
10. Use a handhold when stepping out of a vehicle and move slowly at entryways.

Watch for Cold-Related Symptoms

It’s also important to be prepared to respond to cold-related symptoms. Shivering, an early indicator of cold stress, causes blood to flow from the extremities and skin surface to the body’s core (chest and abdomen). A person suffering from cold stress may be re-warmed by going indoors, wrapping up in blankets, moving around to generate body heat and given a sweetened, warm, non-alcoholic beverage.

Shivering, fatigue, loss of coordination, confusion (slurred speech) and disorientation are symptoms of hypothermia. In advanced stages, signs include the absence of shivering, blue skin, dilated pupils, shallow breathing and irregular heartbeat. In late stages, the victim may feel too warm and want to remove clothing. It’s important to get immediate medical assistance for these symptoms and ask emergency medical technicians for rewarming instructions. Until help arrives, you may be advised to:

• Move the person to a warm, dry room or shelter
• Remove wet clothing, shoes and socks
• Keep the person in a horizontal position
• Cover the person’s body with blankets or towels and a vapor barrier
• Place warm bottles or hot packs in armpits, the groin area and along sides of the chest

Rewarming should not be attempted if someone is unconscious. If a person is not breathing or has no pulse for a period of one minute, rescue breathing may be started. Chest compression should only be applied under the direction of emergency response personnel.

To learn more, refer to WorkCare’s Fact Sheet on Preventing Cold-Related Injuries and Illnesses.

In my role as a Medical Review Officer (MRO), I recently reviewed a case involving a job applicant who walked out in the middle of the drug screening process.

He provided an insufficient amount of urine for testing (45 mL) and left the clinic after 30 minutes.

Drug screening protocol calls for offering a donor who does not produce a testable specimen up to 40 oz. of water and directing him or her to urinate within three hours of providing the initial specimen. Once a second specimen is produced, the original specimen is usually discarded.

In this case, the specimen collector documented the donor’s departure from the clinic on the chain of custody and control form. Upon reviewing the form, I designated this case as a “Refusal to Test” and informed the client.

What Constitutes Refusal to Test?

In general, refusal to test is a conscious attempt on the part of the donor to fraudulently pass the test. The collector, the laboratory or the MRO can declare it in all three steps of the drug testing process.

Per 49 CFR, Part 40, Section 40.191, Subpart I, Problems in Drug Tests, that may mean the donor has not provided a sufficient quantity of urine to test. Alternatively, it may mean the donor:

• Does not appear within a reasonable time for the test after being directed to do so
• Fails to remain at the site until the testing process is complete
• Fails to cooperate with any part of the testing process (e.g., confrontational behavior which impedes the collector’s ability to perform the test, such as not following instructions)
• Wears a synthetic device to produce a fake sample
• Admits to the collector that the urine was adulterated in some manner

Most individuals pass their drug tests without incident. Individuals who appear to be overly anxious, act suspiciously, are argumentative or seek to delay or extend the process should be treated in a firm but respectful manner and held to the same standard as others. The test must be completed in a timely manner for all donors.

A weak link in the screening process is often found at collection sites where collectors allow questionable donor behavior to go unacknowledged or undocumented. In this case the collectors followed correct procedures. Presumably the applicant who left before providing a second specimen will not be hired.

We recommend working with a reliable provider to ensure the drug testing process runs smoothly and discourages anyone who may consider trying to cheat on a test.

Did You Know?

Showing up late or not showing up at all is not considered a refusal to test in post-offer drug screening situations. 

Dr. Jacobs is an Associate Medical Director and Vice President, Clinical Services, Medical Exams & Travel, WorkCare, Inc.