Category: General

Some recently published articles have raised red flags for me – as they should for employers and fellow physicians who are Medical Review Officers (MROs) – with respect to state legalization of medical and recreational marijuana use.

Colorado Emergency Cases

One flag popped up when the Annals of Internal Medicine published a study based on a review of emergency visits at a Denver, Colo., hospital in which cannabis use was denoted on the medical record. As you likely know, Colorado voters approved use of medical marijuana in 2000, followed by recreational use in 2012 (effective in 2014).

The study examined acute illness in connection with cannabis use between Jan. 1, 2012, and Dec. 21, 2016. Among 9,973 visits, 26 percent were at least partially attributed to cannabis use, with 9 percent of those cases involving edible varieties. Inhaled cannabis was associated with intractable vomiting in nearly 20 percent of the emergency visits studied. Conditions associated with edibles included acute psychiatric symptoms, intoxication and cardiovascular complaints.

One patient presented in the emergency department with a cannabis-caused problem about every other day in 2012. By the end of the study period, there were two to three encounters a day. Lest you think that pot-seeking tourists caused the increase, nine out of 10 patients were Colorado residents.

Canadian Findings

The next flag up on the pole is a study from the Canadian Medical Association, which found that cannabis use by drivers increased the odds of having a traffic accident by almost 2.5 times when compared to non-users. The presence of cannabis was determined by measuring metabolite in blood, urine or saliva samples.

Eleven case-control studies were reviewed. No studies that looked at workplace injuries with cannabis use were found by the reviewers, but they found that the increased odds of having a traffic accident while using cannabis can be indirectly applied to safety-sensitive work (as they have been in previous studies).

…And in New York City

A third flag was raised when the New York City Council adopted a precedent-setting municipal law banning pre-employment drug screening for marijuana.

The legislation, Prohibition of drug testing for pre-employment hiring procedures, has been sent to Mayor Bill de Blasio for his expected signature. Once the law is enacted, employers who are hiring prospective employees to work in New York City will have one year to modify their testing policies before it goes into effect.

Under the Compassionate Care Act, medical marijuana is legal in New York state for patients who are certified by medical practitioners as having serious conditions. The state has not legalized recreational use of marijuana.

The NYC bill prohibits private and public employers, labor organizations, employment agencies and their agents from requiring a prospective employee to submit to testing for the presence of tetrahydrocannabinols (THC), the active ingredient in marijuana, as a condition of employment in the city. Exceptions are provided for safety- and security-sensitive jobs, and those tied to a federal or state contract or grant. For example, the law permits testing of law enforcement officers, commercial drivers, childcare providers, and anyone in a “position with the potential to significantly impact the health or safety of employees or members of the public,”

As employers try to get their heads around this development in New York City, it may be helpful to understand that some policy-makers perceive pre-employment testing as discrimination against marijuana users.

Test Doesn’t Show Impairment

As I have noted in previous posts, a pre-employment test only tells the employer that the applicant used cannabis within the past month, not whether they are impaired. It is important to recognize that the purpose of workplace drug testing is to create a safe work environment, not to determine which employees use cannabis. While cannabis produces impairment, a drug test is not currently capable of identifying who is actually impaired at the time of the test, only that the individual has used cannabis previously.

Determining impairment from cannabis requires observation of characteristic signs and behaviors by a medical provider, in addition to confirmation by drug testing. Saliva will indicate more recent use of cannabis (in terms of hours), whereas urine can indicate use from weeks to a month or more – not answering whether the individual is impaired. As voters, states and local governments become more tolerant of cannabis use, employers will continue to be faced with challenges when using drug testing in hiring decisions.

Federal interpretations of marijuana as an illegal substance are not expected to be relaxed. Only the prescribed use of Marinol (dronabinol), an FDA-approved cannabinoid for the treatment of AIDS and cancer patients, is allowed. Meanwhile, employers are advised to continue to keep abreast of changes in the status of state and local laws permitting marijuana use, and obtain legal and medical recommendations on appropriate workplace drug testing policies.

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

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

Superstition holds that walking under a ladder is bad luck.

Falling from a ladder is far more than bad luck: It can result in real-life pain, suffering, disability and even death.

Annual national estimates of ladder-related fatalities range from 100 to 300, while more than 500,000 Americans are treated for ladder-related injuries. The cost of injuries is at least $24 billion in work loss, medical care, legal liability, and pain and suffering, according to the U.S. Consumer Product Safety Commission.

In 2017, March was declared National Ladder Safety Month to heighten awareness, reinforce training, and educate homeowners and workers about safe ladder use. The American Ladder Institute (ALI), a major supporter of Ladder Safety Month, provides related recommendations.

Safe Ladder Use

Before an employee uses a ladder, a fitness evaluation is recommended. This typically occurs during a post-offer or annual physical examination. An assessment may include weight, body mass index,  cardiac index or Framingham Cardiac Risk calculations, and/or human performance evaluations (e.g., ladder climbing ability, grip strength, step tests). Findings may be used to exclude individuals whose safety could be compromised while climbing due to health conditions such as cardiac disease, uncontrolled seizure disorders, neurological conditions that impact balance and coordination, and use of medication or illegal substances that impair function.

In the workplace, ALI advises employers to identify potential worksite hazards. For example, overhead power sources present an electrocution risk. (Aluminum ladders have an electrical conduction property.) In addition, when choosing the type of ladder to use (e.g., step, extension, platform, step stool, extension or folding), the surface it will be placed on must be considered. Is it soft, hard, uneven or level terrain? Proper ladder length must also be addressed.

Safety Tips

How far up?

An employee should never stand on the cap or next-highest rung of a stepladder because of balance issues. For extension ladders, the top three rungs should not be used.

What about weight?

Ladder duty ratings measure the upper limit weight capacity that a ladder can safely support. Capacity calculations include the user’s body weight and the weight of clothing and footwear, personal protective equipment, tools, and supplies being carried and/or stored on the ladder. It’s important  to remember that weight measurements taken during a post-offer physical may not include added items. The ladder duty rating is found on the side of the ladder and ranges from light duty (up to 200 pounds) to extremely heavy duty (up to 375 pounds).

What does OSHA recommend?

The Occupational Safety and Health Administration’s basic ladder safety training recommendations include:

• Avoiding electrical hazards
• Maintaining three points of contact while climbing  (two hands and a foot or two feet and a hand)
• Never shaking, shifting or moving a ladder while someone is on it
• Always securing the top or bottom of the ladder to prevent displacement on unstable or uneven surfaces
• Setting up the ladder at the correct angle

For more suggestions, refer to OSHA’s Quick Card on Portable Ladder Safety and the OSHA/National Institute for Occupational Safety and Health’s fall prevention and ladder safety smartphone app.

Ladder climbing is often an essential job function. A thorough physical assessment, training and monitoring on safe use is essential to help prevent injuries and fatalities…and they may even ward off bad luck.

Dr. Jacobs is Vice President/Clinical Lead of WorkCare’s Medical Exams & Travel division and an Associate Medical Director.

“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.