Drugs and Alcohol in the Workplace: A Problem of Impairment

1. Drugs and Alcohol in the Workplace: A Problem of Impairment Dr. Brendan Adams Medical Occupational Services Team October 6 , 2003 Edmonton

2. What impact does impairment have on work? • Talk overview • Common points of confusion: • Speaker 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

3. 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.

4. 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.

5. 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…

6. 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

7. Alcohol

8. 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

9. The basic problem of street drugs is not knowing what you’re putting in your body….not like alcohol, right? • Wine • 1 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!

10. Wine • One 750 ml bottle of wine contains 76 gm EtOH (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 (114-342 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

11. 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”?

12. 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

13. Confused? Don’t worry, spirits are much more complicated! • What does ‘proof’ mean? • What % abv is typical for spirits? How about 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!

14. Spirits • 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!

15. Alcohol • BAC – Blood Alcohol Concentrations. Measured in grams/100 ml blood. • .01 – marked increase in sleepiness. Impairs sleep. • .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

16. 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”

17. Alcohol Facts • 1 a.m. Drives home drunk 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

18. Impairment • Hung over state: • Dehydration • Metabolic Acidosis • Hypoglycemia • Disequilibrium • Sleep debt • Cognitive Impairment

19. 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”

20. 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)

21. Marijuana

22. Marijuana

23. Marijuana - devices

24. Marijuana • THC – delta 9 tetrahydrocannabinol • MJ in 60’s typically 3-5%, now typically 10%, 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 • Physical • Psychological

25. 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

26. 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

28. “Reefer Madness” – the ultimate irony • The marijuana – schizophrenia link • 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 • 6 year study of 2000 adolescent girls in NZ • Daily users 5x likely to become depressed • Gateway drug – myth or fact?

29. Marijuana Myths • It’s my own !*&# business what I do in my own time… • 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…

30. Cocaine

31. 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) • 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 • One dose alters brain response (acute tolerance) (next slide)

32. Cocaine

34. 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 • Massive cardiac and respiratory side effects esp malignant arrythmia (risk 24x normal in first hour after use) • Seizures, (sensitization), sudden death

35. 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

36. “Crystal Meth”(Methamphetamine) (meth, crystal, ice, jib, crank, speed)

37. “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?

38. “Crystal Meth”

39. “Crystal Meth”

40. Crystal Meth Impairment • Impairs tests of perceptual speed, manipulation of information • Impairment of coordination • Violent behaviour more common with this drug than others “tweaking”

41. Ecstacy

42. 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

43. A Drug is a Drug is a Drug! • Prescription Drug Abuse • 3 Major Categories • Opioids (Tylenol #3) • Depressants (Valium, Imovane) • Stimulants (Dexedrine, Ritalin)

44. Drug Myths • I am stronger than the drug – I can control what 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…

45. 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 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

46. Summary – some suggestions from what we’ve learned so far: • 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…

47. Section 2 – Alcohol and drug addiction • Addiction is a very distinct entity from use or 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

48. Addiction in the Workplace • This is a whole separate topic • Consider: • 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

49. Alcohol addiction • Affects 6% general population, (10-12% of oil patch as industry) • Reasons for increase is industry co-dependency*, 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

50. 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