Illicit drugs are not the only problem
An exclusive focus on illicit drug use by employees is causing the nation’s occupational health professionals to overlook another major threat to worker health and safety: licit drug use. That’s the stark assertion of Rick Lippin, MD, FACOEM, a medical planner based in Southampton, PA. Lippin, who is trained in futurology, forecasts megatrends in medicine. (For example, in 1985 he correctly forecast that the application of the infectious disease model to occupational medicine would, in most cases, fail.)
There are two reasons that licit drugs pose such a serious threat, says Lippin. "No. 1 is the increase in usage. No. 2 is the failure of our professionals to adequately address their impact on performance, especially in terms of the CNS [central nervous system]. This, by extrapolation, moves into the area of health and safety."
MROs (medical review officers, an occ-med subspecialty) have an excessive focus on legal drugs, but not enough of one on licit drugs, Lippin says. "While some mechanisms within MRO training do emphasize the impact of licit drugs, it is not nearly enough," he says. "The reason for that is a corruption in the licit versus illicit mentality. We are carrying out the policies of a society of leaders obsessed with illicit drugs. We’re so obsessed with marijuana and cocaine, but we have a huge number of workers walking around with prescribed drugs that are impacting on their performance. But we don’t measure performance — we look for drugs in the urine. "
A triple threat
Lippin sees the threat coming from three distinct types of licit drugs: analgesics, psychotropics, and sedating antihistamines. In the area of analgesics, he points out drugs such as Tylenol with codeine or Percocet. "You and I could very easily verify that the use of those two meds in the last 10 years among workers has significantly increased," he says. "Workers are aging, they’re in more pain for a lot of reasons, and they’re taking more pain relief medications. And, they’re trying to work through that pain because they’re afraid of losing their jobs."
However, he notes, there have been a number of studies on the impact of narcotics on performance. "If you pull out the PDR [Physician’s Desk Reference] on those two pills and look at the side effects, drowsiness is clearly one, as are impaired cognition and impaired motor abilities," says Lippin. "Does that make them the devil? Not necessarily, but if you drive a truck or work around machinery, it might."
In the area of psychotropics, over the last 10-15 years, there has been a huge prescripting shift of physicians from anti-anxiety agents to stimulants, and also to antidepressant medications, he says. "The number of active workers in this country estimated to be on drugs like Prozac, in my opinion, is way underreported," Lippin claims. "In essence, it’s like the elephant sitting in the living room that no one is talking about. Not that these drugs don’t help people, but they do have side effects." In other words, he says, we have to take a good hard look at the use of these drugs by workers in safety-sensitive jobs. "You’ve got to look at what Zoloft, for example, does to performance functions," he advises.
Sedating antihistamines can be both bought over the counter and prescribed. "The pharmaceutical industry has responded by coming up with nonsedating antihistamines, and these should be used liberally," Lippin advises. "But some physicians prescribe sedating antihistamines because they are cheaper. People gobble these up over the counter during allergy season in particular, and they walk around drowsy. But if you talk to a typical occ-med professional, they’re not looking for that."
What we should do
Lippin recommends that occupational health professionals take several steps to help offset the potential threat posed by licit drugs. "We should do a much better job, even though we’re not required to by DOT [Department of Transportation] or other agencies, to take a complete medication history," he says. "We should aggressively pursue discussions with patients [about licit drug use] and record whether or not they are experiencing CNS side effects."
Second, he says, occupational health professionals should lobby for change, both on the micro and macro level levels, for agencies like the DOT to be more inclusive of the whole licit drug issue. "The FAA [Federal Aviation Administration] has formularies which list certain drugs, and they do a better job than the average industry. After all, they don’t want pilots to make errors to the point where they crash and kill hundreds of people," says Lippin. "They have testing panels and procedures in place that are much more aggressive in terms of licit drugs. I hold them up as a potential model for DOT and others to follow."
Last but not least, he says, we need to move away from policing urine to assessing performance. "We should support the research of those companies that are trying to replace drug testing with CNS performance testing," he declares. "Even fatigue is a safety hazard. Fatigue, stress, it doesn’t matter — what matters is the person’s brain is not functioning. That’s the whole problem with drug testing; it misses this."
In 20 years, the futurist predicts, this focus on drug testing will be looked back on as a major tragedy in the history of American medicine. "We will be looked upon as having abandoned professional ethics — not looking at safety and health, but instead, becoming pseudo-cops," he warns. "We are an arm of the drug czars, instead of being practitioners worried about whether our workers are safe and healthy."