Transcript Dr_Brendan_Adams_MOST_Presentation

Drugs and Alcohol in the
Workplace: A Problem
of Impairment
Dr. Brendan Adams
Medical Occupational Services Team
October 6 , 2003
Edmonton
What impact does impairment have
on work?
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Talk overview
Common points of confusion:
 Speaker
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Bias
Lawyer/Human Rights Rep.
Union/Employer
Physician/Psychologist/Counselor
Drug testing company
Law enforcement
Effects of use in general population v.
Alcohol/Drug Addicts
Why impairment is a problem:
 Drug use, especially alcohol, is common.
 Impairment secondary to drug use often is
unrecognized by everyone, including the
employee.
 Drug use is part of our culture, and we have
many “blind spots” – (mythology)
 Impairment can, and too often does, have lethal
consequences.
 These losses, both financial and medical, are
entirely preventable.
The obligatory statistics!
 Worker absenteeism attributed to substance
abuse costs Alberta economy approx. $720
million/year (1996).
 More than 12,000 Alberta workers yearly know
of a workplace injury(ies) that they believe were
related to drug or alcohol use.
 Direct losses in the Canadian workplace in
1992 were $4.2 billion.
 In Alberta, 1995, 20.4% of all drivers in fatal
crashes had been drinking.
Behind the statistics - Why you
should care, because:
 You are the one who gets killed or mutilated.
 Accidents affect a whole lot more than just your
job.
 You have a family or loved ones who care
about you, and depend on you.
 If you are young, you may be making choices
which will affect the rest of your life.
 What do you care about? You will lose it.
Addiction/abuse is a spiritual illness. First the drinker takes a
drink…
Psychoactive substances
 Why do we use them?
 Concept of neurotransmitters
 Concept of brain anatomy
 Pleasure centers
 “Dopamine” disease
 Brain signals:
 “Gotta have it”
 “Got it”
 Drugs and Behaviours are similar at neuron
level eg. Food, sex, gambling, risk-taking
Alcohol
Alcohol
 Basic facts:
 Sedative/hypnotic
 Rapidly absorbed, slowed by food, water soluble
 Eliminated by zero order kinetics, one ounce per 3
hours (slower in women)
 Converted to acetaldehyde then to acetate
 One drink in North America = 12 grams EtOH
 Amount of pure ethanol calculated by %abv x .78
= gm EtOH/100 ml
 Advise maximum 2 standard drinks/day for men, 1
for women = low risk drinking
The basic problem of street drugs is not knowing
what you’re putting in your body….not like alcohol,
right?
 Wine
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standard drink (12 gm) = 130 ml (4.5 oz) of
12% wine = 110 Cal.
 118 ml of 13%; 109 ml of 14%;
 How many standard drinks in a bottle?
 In a litre?
 Does champagne have more or less % EtOH?
 What percentage of alcohol in fortified wines?
(eg. Sherry, Dubonnet?)
 How much does a wine glass hold? Let’s find out!
Wine
 One 750 ml bottle of wine contains 76 gm EtOH
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(13%) or 82 gm (14%), 6.3 or 6.8 standard
drinks
A litre of wine contains 8.4 or 9.1 drinks
Sparkling wines are typically 10-11% abv
Wine glasses typically range from 4-12 oz (114342 ml) i.e. 1-3 standard drinks
Sherry is 20% abv, Dubonnet = 16%; 1
standard drink is 76 ml (2 shot glasses) and
100 ml respectively
Ok…I don’t drink wine, but beer, I know.
 Beer
 What
% abv is beer? Strong beer? Lite beer?
 How many drinks is one bottle of beer?
 What if you drink supercans?
 How much beer in a pint?
 How much beer in a pitcher?
 What’s a “depth charge”?
Beer
Standard beer is 5% abv, 355 ml bottles
which is 13.8 gm/bottle; 1.2 standard drinks.
 5 bottles = 6 drinks
 Strong beer = (6-11%) 8.5% abv; 23.5 gm/bottle; 2
standard drinks
 Lite beer = 4% = 11 gm/bottle = .9 standard drinks
 Supercans = 473 ml; 1 supercan of Wildcat = 22.3
gm, approx 2 standard drinks
 Also available in 650 and 950 ml cans
 1 pint = 2 cups = 455ml = 17 gm EtOH = 1.5
drinks; 2 pints = 3 standard drinks
 Pitcher = approx 1.5 litre = 58 gm = 5 drinks
 Depth Charge is 1.5 oz Vodka added to beer; 17
gm + 13.4 gm = 30 gm = 2.5 drinks
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Confused? Don’t worry, spirits are
much more complicated!
 What does ‘proof’ mean?
 What % abv is typical for spirits? How about
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single malt scotch?
How many drinks in 750 ml (26 oz) bottle, how
about 1.14l (40 oz)?
How about liqueurs? Bailey’s vs Grand
Marnier?
How about Alcopops? Where do they fit in?
Mike’s Hard Lemonade, Cider?
How much is in that glass? How many standard
drinks is that? Does the amount of mix matter?
How about ice? Let’s find out!
Spirits
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Proof is 2x abv. Most spirits are 40% abv
One standard drink is 38 ml, 1.4 oz
Shot glass holds approx 50 ml, 1.3 drinks
750 ml bottle holds 234 gm, 19.5 drinks; 1.14 l
bottle holds 355 gm, 30 drinks
 Liqueurs range from 16% (Bailey’s) to 40%
(most)
 Studies show most people err by 2.5 to 3 times
in optical volume measurements
 Alcopops – 7% abv. Eg Mike’s = 18 gm/bottle =
1.5 standard drinks. Not the same as beer!
Alcohol
– Blood Alcohol Concentrations.
Measured in grams/100 ml blood.
 .01 – marked increase in sleepiness. Impairs sleep.
 BAC
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.02 – decreased ability to understand commands, esp.
radio.
.05 – too impaired to operate a vehicle. 24 hour
suspension. Poor speed/distance perception. Poor
problem solving skills.
.08 – “legally” impaired.
.1-.19 – neurologic impairment, reaction time, ataxia..
.2-.3 – severe impairment
.4 – hypothermia, stage 1 anaesthesia, aspiration
.5-.8 – onset of coma, death
Alcohol
 Metabolism decreases BAC by .015 per
hour
 A typical “night out” sees a BAC of .1 to
.2 (10 -20 standard drinks)
 Return to BAC of 0 will take more than
10 hours after last drink.
 Impairment will last 20 – 30 hours
 See next slide for a “typical day”
Alcohol Facts
 1 a.m. Drives home drunk
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BAC.165
2 a.m. Worker goes to bed
.15
3 a.m. Sleeping
.135
4 a.m. Bathroom
.120
5 a.m. Restless
.105
7 a.m. Alarm goes off
.075
8 a.m. Drives to work impaired
.060
8:30 a.m. Begins work impaired
.055
Noon
0.0
Afternoon – hung over impairment continues
Impairment
 Hung over state:
 Dehydration
 Metabolic
Acidosis
 Hypoglycemia
 Disequilibrium
 Sleep debt
 Cognitive Impairment
So, if I carefully measure my drinks, I
should know what my BAC is right?
Um… not exactly.
 The Globe and Mail’s “Gord Campbell
experiment”
Failing to plan is planning to
fail! The Teen Party Plan
 55% of people under age 19 drink alcohol
 What is your party plan?
 Decide whether you are going to drink. (It’s okay
not to).
 Decide what, when, where and how much.
 Plan how to stop, what to say etc. Pour your own!
 Plan on what to do if you/your friend makes a
mistake.
 Surrender car keys
 “Safe Ride” contract – “Code Red”
 Have you ever called a cab?
 What do you do with someone who is “passed
out”?
 Think about other alcohol influenced risky
behaviours (sex, drugs, water, machines)
Marijuana
Marijuana
Marijuana - devices
Marijuana
 THC – delta 9 tetrahydrocannabinol
 MJ in 60’s typically 3-5%, now typically 10%,
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can be 40% (hash oil, BC bud)
Fat soluble (vs. EtOH)
Long ½ life
Binds to brain receptors, esp cerebellum
(driving) and hippocampus (learning);
cumulative drug load
Extreme tolerance develops quickly
Effects: next slide
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Physical
Psychological
Effects of Marijuana Use
 Physical:
 Some estimates 20x carcinogenicity of
cigarettes; (and additive to) – 60-70% more
carcinogenic hydrocarbons
 CAD, cardioacceleration, MI risk 4x in first
hour
 Anti-androgen, anti estrogen
 THC crosses placental barrier, milk
Effects of Marijuana Use
 Psychological
 Perceptual distortion, esp time/distance, peripheral
vision, colour, attention.
 Learning impaired – lasts 4 weeks.
 Addiction liability – similar to opiate w/d, less than coc.
 Classic W/D syndrome, esp. aggression, peaks @ 1
wk. U of Vermont study 6.3/9 criteria DSM IV
“Reefer Madness” – the
ultimate irony
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The marijuana – schizophrenia link
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Swedish study – 50,000 men followed for 27 years
50 x by age 18 increased schizophrenia by 30%
13% of all cases could be prevented by eliminating
marijuana
British study – 1/10 smokers dx schiz by age 26
The depression link
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6 year study of 2000 adolescent girls in NZ
Daily users 5x likely to become depressed
 Gateway drug – myth or fact?
Marijuana Myths
 It’s my own !*&# business what I do in my own
time…
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Impairment can be chronic
 It’s a blue collar/cultural problem
 It’s less impairing than booze…
 Wrong
 It’s safer than booze…
 Wrong
 Doctors have found many medical uses for
marijuana…
 It’s a “soft” drug….
 It’s not addictive…
Cocaine
Cocaine
(crack, snow, blow, C, flake)
 “God” drug
 One
of the oldest known drugs
 Extracted from leaf of coca bush
 HCl salt or “freebase” (smokable – crackles)
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Produces rush lasting 5-15 minutes,
euphoria for 2-4 hours
 Talkative/overconfident/irritable/energized
 Often
use another drug to counter side
effects of jitteriness, irritability, depression
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One dose alters brain response (acute
tolerance) (next slide)
Cocaine
Cocaine
 Faster route – more intense effects
 Initial
impairment through euphoria/ poor
judgment – to paranoia – to acute psychosis
 Secondary impairment through “crash” and
craving
 Tertiary impairment through brain chemistry
alteration and rapid development of addiction
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Massive cardiac and respiratory side
effects esp malignant arrythmia (risk 24x
normal in first hour after use)
Seizures, (sensitization), sudden death
Cocaine and Alcohol
 “One plus one equals three!”
 New compound – cocaethylene
 Manufactured in the liver
 Increases impulsivity
 Profoundly impairs judgment and memory
 Increased risk of sudden death
 The most common two drug combination that
results in death
 Memory impairment vastly potentiates relapse
“Crystal Meth”(Methamphetamine)
(meth, crystal, ice, jib, crank, speed)
“Crystal Meth”(Methamphetamine)
(meth, crystal, ice, jib, crank, speed)
 Man made analog of amphetamine.
Smokable. Made in basement labs.
 Triggers massive release of dopamine –
intense “rush”
 Neurotoxic in animal models – destroys
dopamine and serotonin neurons (next
slides). Long term damage
 Predisposition to neurodegenerative
diseases later in life?
“Crystal Meth”
“Crystal Meth”
Crystal Meth
Impairment
 Impairs tests of perceptual speed,
manipulation of information
 Impairment of coordination
 Violent behaviour more common with
this drug than others “tweaking”
Ecstacy
Ecstasy
MDMA – “E”
 Methylenedioxyamphetamine
 Hallucinogen,
(euphoria, depression)
 Effects last 4-6 hours, after effects last weeks
to months
 Works on serotonin system (mood)
 May damage neurons permanently after 1
use
 Addictive potential like very weak cocaine
 Malignant hyperthermia, chronic paranoid
psychosis, cardiac arrest, coagulopathy
A Drug is a Drug is a Drug!
 Prescription Drug Abuse
 3 Major Categories
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Opioids (Tylenol #3)
Depressants (Valium, Imovane)
Stimulants (Dexedrine, Ritalin)
Drug Myths
 I am stronger than the drug – I can control what
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others cannot. I’ve quit before, I can again.
Drugs make me more creative/social etc.
Life is better stoned.
Drugs do no permanent harm.
What I do in my own time is my own business –
the company doesn’t own my soul!
Don’t tell me what to do!
Doctors/counselors/authorities are liars.
*** is way safer than alcohol.
I know a guy who’s been doing this for years
and he’s fine…
Summary of First Section
 Alcohol is alcohol. Alcohol is a drug
 A drug is a drug is a drug
 There are no “safe” or “soft” drugs. Just
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different.
Impairment is quite different than intoxication
All psychoactive drugs impair an person’s ability
to work/learn safely – sometimes for several
weeks after ingestion. Sometimes permanently.
Almost everyone is unaware of the extent of
their impairment
There are no easy answers to drug use in
society
Summary – some suggestions
from what we’ve learned so far:
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Know more. Talk more. Use/buy smart.
Decrease your use. Shandys, spritzers
It’s okay not to use. Support those who don’t.
Some people should never use psychoactive
drugs of any kind.
Avoid early introduction of alcohol in a child’s
life
“Just say no” is not an effective strategy for kids
Consequences for use are essential. Avoid
normalizing abnormal.
Do you, or a love one, have a problem? Next
section…
Section 2 – Alcohol and drug
addiction
 Addiction is a very distinct entity from use or
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abuse
It is a disease with well recognized symptoms
Hallmark symptoms are loss of control and
tolerance
Addiction involves changes in brain
chemistry/structure, and is irreversible
2/3 of alcohol addiction is genetic
Addiction is a family disease
There are only 4 outcomes to drug/alcohol
addiction
There is only one treatment - abstinence
Addiction in the Workplace
 This is a whole separate topic
 Consider:
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Not all users are abusers/addicts!
Detection/ Performance Management
Intervention, progressive model
Bipartite approach essential
Policy/procedure addressing each step
Re-integration and aftercare the most
critical stage
Relapse prevention and safety
Alcohol addiction
 Affects 6% general population, (10-12% of oil
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patch as industry)
Reasons for increase is industry codependency*, lack of direct supervision,
irregular hours, ability to shift employers
Typically takes 5-10 years to develop (see
following slides). Follows typical course
The Alcoholic is impaired from chronic alcohol
effects in addition to acute effects already
discussed
Chronic effects: hepatitis, hypertension, “wet
brain”, blackout, DT/w/d seizures, chaotic life
syndrome
Enabling/co-dependency
 “We enable another person when we
protect them from experiencing the
consequences of their behaviour”
 Accepting
excuses
 Making excuses for another’s behaviour
 Covering up for those experiencing problems
 Giving people “breaks”
 Ignoring or avoiding the problem
 Treating the problem as a joke
 Enabling is usually well intentioned
 Reasons:
 To
avoid conflict
 Because we feel helpless
 To avoid embarrassment or stigma
 Because we feel the problem is somehow a
reflection of our own competence
 Because we might have to face our own
problem
 Enabling results in the person’s death
 After spouses and co-workers, Doctors
are often prime enablers!
Drug Testing
`No, no!' said the Queen. `Sentence first-verdict afterwards.'
Alice in Wonderland by Lewis Carroll
Drug Testing
 Really, a whole separate lecture. Briefly:
 What are you trying to accomplish?
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Model of change
 Consider examples of
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Traffic radar
Prohibition
 Must be part of an effective, enlightened
policy/process
 Must be used in concert with performance
management/ other HR tools
Information Sources
 National Institute on Drug Abuse www.drugabuse.gov
 Substance abuse network of Ontario
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http://sano.camh.net/
National Institute on Alcohol Abuse and Alcoholism
www.niaaa.nih.gov
The National Council on Alcoholism and Drug
Dependence www.ncadd.org
AADAC www.aadac.com/
AA/NA/CA www.aa.org/ etc.
Recovery www.recovery.org/
Literature www.hazelden.org/
Local expert: Dr. Dan Ryan, 2835 Millwoods Road NW,
450-4550