Kathryn L. Mueller

Workplace health protection and promotion: a new pathway for a healthier--and safer--workforce.

Traditionally, health protection and health promotion activities have operated independently of each other in the workplace. Health protection has usually been viewed as encompassing the activities that protect workers from occupational injury and illness ranging from basic safety training to the us

ACOEM practice guidelines: Opioids and safety-sensitive work

Objective: ACOEM has updated the treatment guidelines concerning opioids. This report highlights the safety-sensitive work recommendation that has been developed. Methods: Comprehensive literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel to develop evidence-based guidance. A total of 12 moderate-quality studies were identified to address motor vehicle crash risk, and none regarding other work among opioid-using patients. Results: Acute or chronic opioid use is not recommended for patients who perform safety-sensitive jobs. These jobs include operating motor vehicles, other modes of transportation, forklift driving, overhead crane operation, heavy equipment operation and tasks involving high levels of cognitive function and judgment. Conclusion: Quality evidence consistently demonstrates increased risk of vehicle crashes and is recommended as the surrogate for other safety-sensitive work tasks.

Marijuana in the workplace: guidance for occupational health professionals and employers: Joint Guidance Statement of the American Association of Occupational Health Nurses and the American College of Occupational and Environmental Medicine.

Marijuana (cannabis) is the most frequently used illicit drug of abuse in the United States and worldwide. Moreover, it is second only to alcohol as the most prevalent psychoactive substance seen in cases of driving under the influence of drugs. It is also by a wide margin, the drug most often detected in workplace drug-testing programs. The primary psychoactive substance in marijuana is delta-9tetrahydrocannabinol, known simply as THC. Present in steadily increasing concentrations in street-purchased, smokeable plant material, the THC content in marijuana averaged 3% in the 1980s, but by 2012 it had increased to 12%. The US government classifies marijuana as a Schedule I drug (defined as those drugs with no currently accepted medical use and a high potential for abuse, and the use/possession of which is subject to prosecution). Workers covered by federal drug-testing programs are uniformly prohibited from using marijuana at any time. In addition, federal law allows employers in every state to prohibit employees from working while under the influence of marijuana and are permitted to discipline employees who violate this prohibition. Nevertheless, with public attitudes toward marijuana use changing, prohibitions for its consumption outside of federal law now vary from state to state. Although the possession and use of marijuana continue to be prohibited by federal law, numerous states and the District of Columbia currently have enacted laws regarding marijuana use that conflict with federal law and policy, with legislation pending in other states. This changing legal environment and the evolving scientific evidence of its effectiveness for treatment of select health conditions require an assessment of the safety of marijuana use by the American workforce. Although studies have suggested that marijuana may be used with reasonable safety in some controlled environments, there are potential workplace consequences involved in its use that warrant scrutiny and concern. The potential consequences of marijuana use in the workplace include the risk and associated cost of adverse events and the loss of productivity. These safety concerns and the changing legal scene have led the American College of Occupational and Environmental Medicine (ACOEM) and the American Association of Occupational Health Nurses (AAOHN) to develop this guidance document to assist occupational health professionals and employers in identifying and addressing impairment issues related to the use of marijuana and prevention of injuries related to impairment. This guidance summarizes current evidence regarding marijuana consumption, discusses possible side effects including temporary impairment as it relates to the workplace, reviews existing federal and state laws and legal implications for health care professionals and employers, and suggests various strategies available to employers for monitoring workers for marijuana use. It is outside the scope of this article to address any potential medical benefit of marijuana. Studies conducted to evaluate the effects of marijuana drug use by workers have demonstrated variable risk. This variability relates to study design, demographics, work type, and potential confounders (eg, general risk-taking behavior among illicit drug users). This discussion on the effects of marijuana is based on a literature search of the currently available evidence (see the Appendix). Articles were graded using the following criteria: inadequate for evidence due to low-quality research; adequate for evidence (+); or high quality (++). High-quality studies, meta-analyses, or multiple adequate studies with the same conclusion qualified as good evidence for the guidance purposes of this document. Statements referring to evidence without a qualifier reflect the results of an adequate study. 581983WHSXXX10.1177/2165079915581983Phillips et alJoint Guidance Statement research-article2015

Suggested improvements in practice guidelines: market research to support clinical quality improvement.

The American College of Occupational and Environmental Medicines Practice Guideline Dissemination Project included market research to better understand the wants and needs of physicians, case managers, and insurance adjusters who used the guidelines. We used structured and open-ended survey questions and focus groups administered to a cohort of physicians, adjusters, and case managers trained as part of the project. Respondents were generally satisfied with the format and contents of the guidelines. They requested additional material on case management and facilitation of effective treatment and return to work by other health professionals. They also suggested a variety of formats to improve the accessibility of the guidelines. The suggestions may be used in new product development or for guideline revisions.

The American Board of Independent Medical Examiners.

The training program of the American Board of Independent Medical Examiners provides pre-eminent continuing medical education in impairment and disability evaluation. This education enhances physician knowledge, skills and ability, ensuring better impairment rating and disability evaluation. The ABIME certification examination assesses the skills and knowledge of candidates for certification. Physicians who pass the examination are certified and re-certified based on a standardized process. Initial certification can be achieved through examination only.

Marijuana in the Workplace: Guidance for Occupational Health Professionals and Employers Joint Guidance Statement of the American Association of Occupational Health Nurses and the American College of Occupational and Environmental Medicine

Employers are often put in a difficult position trying to accommodate state laws that allow the use of marijuana for medical purposes while enforcing federal rules or company drug-use policies based on federal law. To ensure workplace safety as well as compliance with state and federal legislation, employers should review state laws on discrimination against marijuana users and ensure that policies enacted are consistent with the state’s antidiscrimination statutes. Although it appears that in most states that allow medical marijuana use, employers can continue enforcing policies banning or restricting the use of marijuana, this approach may change on the basis of future court decisions. The Joint Task Force recommends that marijuana use be closely monitored for all employees in safety-sensitive positions, whether or not covered by federal drug-testing regulations. Best practice would support employers prohibiting marijuana use at work. Employers, in compliance with applicable state laws, may choose to simply prohibit their employees from working while using or impaired by marijuana. In some states, employers may choose to prohibit marijuana use by all members of their workforce whether on or off duty. Nevertheless, in all cases, a clear policy to guide decisions on when marijuana use is allowed and how to evaluate for impairment must be widely distributed and carefully explained to all workers. Legal consultation during policy development and continual review is imperative to ensure compliance with federal, state, and case law. Drug-use and drug-testing policies should clearly delineate expectations regarding on-the-job impairment and marijuana use outside of work hours. Specific criteria for use by supervisors and HR personnel when referring employees suspected of impairment for an evaluation by a qualified occupational health professional are critical. Detailed actions based on the medical evaluation results must also be clearly delineated for HRs, supervisors, and workers. The Joint Task Force recommends that employers review the following points when developing workplace policies that address marijuana use in the workplace: 1. For employees covered by federal drug testing regulations (eg, DOT and other workers under federal contract), marijuana use, both on or off the job, is prohibited. Thus, employers may use urine drug screening in this population. 2. Employees in safety-sensitive positions must not be impaired at work by any substance, whether it be illicit, legally prescribed, or available over-the-counter. Employers may consider prohibiting on the job marijuana use for all employees in safety-sensitive positions, even when not covered by federal drug testing regulations. Nevertheless, legal review of the employer’s policy in the context of state statutes is strongly encouraged. When employers allow medical marijuana use by employees, consultation with a qualified occupational health professional is recommended. 3. Employers residing in or near states that allow the use of recreational marijuana must establish a policy regarding off-work use of marijuana. In many states, the employer may choose to prohibit employees from simply working while using or under the influence of marijuana or may choose to prohibit marijuana use both on and off the job. Urine drug testing above traditional cutoff levels, or serum testing at any level, would be reasonable criteria for the employer wishing to ban both on- and off-the-job use. To detect impairment, a limit of 5 ng/mL of THC measured in serum or plasma as THC (or possibly the sum of THC plus THC-OH for employers who choose to evaluate both psychoactive components) would meet the goal of identifying individuals most likely to be impaired. Nevertheless, employers using the 5 ng/ml level need to understand the limitations of using a single number to fit all cases; therefore, a medical examination focused on identifying impairment is always recommended. Legal consultation is strongly recommended. 4. Although it appears that in most states that allow the use of medical marijuana, employers may be able to continue policies banning or restricting the use of marijuana as previously discussed, this practice may change on the basis of future case law. Currently the ADA does not apply in these situations because marijuana is illegal under federal law. Legal consultation is again strongly recommended. 5. Most workers’ compensation statutes allow reduced benefits when a worker is under the influence of alcohol or illegal drugs. Two samples should usually be obtained as a second confirmatory test may be needed. Proof of use and/or impairment is usually required for these cases, and a positive urine drug test (for the inactive metabolite) does not prove acute impairment. The serum level of less than 5 ng/mL could be used for presumptive evidence of impairment in these situations. An MRO is most helpful in helping determine these types of cases because legal testimony may be required. 6. All employers should have clear policies and procedures for supervisors to follow regarding the criteria for identifying potential impairment and the process for referring an employee suspected of impairment for an occupational medical evaluation. Policies should include action required by HR personnel based on the results of the examination. 7. Employee education is vital to ensure compliance with company expectations. Education is needed at hire and again at regular intervals. Workers must know the company’s chemical substance policy and management’s expectations for adherence. The employer’s commitment to a drug-free workplace and existing company policy will influence the education program’s content. At a minimum, employees should learn how chemical substances affect their health, safety, personal behavior, and job performance. Supervisors and employees should also be educated about how to recognize behaviors indicative of impairment, whether the source is medical marijuana, prescription medications, illegal drugs, alcohol, over-the-counter medications, fatigue, or any combination thereof. 8. In states where marijuana use is permitted, employers should provide educational resources regarding the detrimental effects of marijuana use, including caution regarding dose and delayed effects of edible products. This information may be obtained from SAMHSA and state governmental agencies. The safety of workers and the public must be central to all workplace policies and employers must clearly articulate that legalization of marijuana for recreational or medical use does not negate workplace policies for safe job performance. The evolving legal situation on medical and recreational marijuana requires employers to consult with legal experts to craft company policy and clarify implications of impaired on-duty workers. This changing environment surrounding marijuana use requires close collaboration between employers, occupational health professionals, and legal experts to ensure that workplace safety is not compromised.

Obesity in the Workplace: Impact, Outcomes, and Recommendations

Objective: To conduct a comprehensive literature review to develop recommendations for managing obesity among workers to improve health outcomes and to explore the impact of obesity on health costs to determine whether a case can be made for surgical interventions and insurance coverage. Methods: We searched PubMed from 2011 to 2016, and CINAHL, Scopus, and Cochrane Registry of Clinical Trials for interventions addressing obesity in the workplace. Results: A total of 1419 articles were screened, resulting in 275 articles being included. Several areas were identified that require more research and investigation. Conclusions: Our findings support the use of both lifestyle modification and bariatric surgery to assist appropriate patients in losing weight.

Advancing Value-based Medicine: Why Integrating Functional Outcomes With Clinical Measures Is Critical to Our Health Care Future

E ach year, millions of American workers develop health problems that may temporarily or permanently remove them from the workforce. Although most are able to work again after a brief recovery period, in approximately 10% of cases, workers incur injuries or illnesses severe enough to lead to prolonged or permanent withdrawal from the workforce. These conditions are both workand nonwork related—and range from injuries in the workplace to illnesses such as cancer, heart disease, and diabetes. Although these illnesses may not be related to a person’s job, they nonetheless impact workers’ ability to function effectively in everyday life. Functional impairment related to injury or illness is a condition in which individuals may have a loss of physical ability, limitations on their day-to-day living activities, or restrictions on their societal interactions. People who are functionally impaired often have a multidimensional condition, the collective impact of which is much greater than physical impairment alone. Those who are functionally impaired may not be able to drive, cook for themselves, or keep up with finances, household care, and other personal daily activities. In addition, there is the

Opioids and safety-sensitive work.

E xtrapolation of data has been used for decades to perform quantitative occupational and environmental risk assessments. Extrapolation has been used to develop nearly every one of the hundreds of occupational chemical, physical, and biological exposure standards in the United States and the rest of the world. Such standards have reduced burdens of occupational injuries, illnesses, and diseases. Industrial hygienists, epidemiologists, and toxicologists have developed criteria for these processes including extrapolation such as “(1) a stable positive association with an adverse health outcome; (2) high overall study quality; (3) no substantial confounding; (4) quantitative exposure assessment for individuals; and (5) evidence of a dose– response relationship” to serve as a basis for extrapolation.1 The US Environmental Protection Agency also regularly extrapolates data.2 It is worth noting that, in contrast with the recent American College of Occupational and Environmental Medicine opioid practice guideline,3 most occupational and environmental risk analyses have relied primarily on animal models. Thus, the extrapolation used in the American College of Occupational and Environmental Medicine guideline on safety sensitive work should be substantially less controversial because it uses human population studies rather than animal studies on the effects of opioids. Dr Swotinsky has suggested that one should only use direct studies of each occupation or task to provide guidance for safe work. His position is that guidance developed from extrapolating 12 large, consistent epidemiological studies of driving activities to nondriving activities that also are safetysensitive jobs is insufficient; the recommendation not to drive under the influence of opioids should only apply to driving. What he did not state is that the available studies are largely of private drivers. One could therefore take the additional position that