Substance abuse & work access to opioids

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rrwayne

Substance abuse & work access to opioids

Post by rrwayne » Tue Mar 12, 2013 12:40 pm

A nurse, with a known h/o opioid substance abuse involving Percocet (h/o chronic pain) who is applying for a LPN job will have duties which involve access to opioids. The nurse is currrently on Suboxone. Regarding safety, how would one address this situation? I would hesitate to place this nurse in a position of failing, as the nurse is currently being treated actively for opioid substance abuse, not to mention the degree of possible risk for the employee and patients. Advice requested.



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Re: Substance abuse & work access to opioids

Post by Robert Swotinsky MD » Tue Mar 12, 2013 1:50 pm

She is unqualified for the position because of risk to herself and others. If there was evidence of long-term (e.g., 12-month) sobriety, she may be qualified. But, given that she is currently in an opiate treatment program, that is not the case.

Tool4239

Re: Substance abuse & work access to opioids

Post by Tool4239 » Wed Apr 26, 2017 9:57 pm

But on the other hand if he or she had been maintained on the Suboxone for more that a year or even 2+ years then this would also go to help substantiate the case for ongoing recovery. Let us not forget that the medication buprenorphine along with the strict monitoring in a federal treatment program not to mention the thought of follow-up visits would only help further the person's road to full recovery. I think we choose to ignore the fact sometimes that some patients may need to be maintained on a medication like buprenorphine for years possibly decades or in rare cases indefinitely, but does that mean we should tear down the fabric that makes the person who they are. Standing in the way of this person's livelihood by way of a earned degree/career choice is not in my opinion an MRO's role. Better yet I'd do an inquiry into the person's treatment success and failures and let the decision be made by hard factual evidence can this person and does this person want to succeed in life and recovery if so don't be the road block be the bridge. The treatment of choice in the US epidemic for opioid addiction is buprenorphine by far and I predict one day we will see a great many buprenorphine patients on maintenance therapy and the road to recovery is a hard one, therefore taking away someone's ability to work and put food on the table because they have a possible genetic disease is in my opinion the road back to drug addiction and the end. How would you feel if you had cancer or diabetes and someone told you if you want to use your M.D. to earn a living you can't treat your cancer or diabetes. Just my own food for thought.

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Re: Substance abuse & work access to opioids

Post by Robert Swotinsky MD » Fri Apr 28, 2017 10:02 am

I agree that restricting someone from their chosen career is typically not going to help out that person. The question that was posed is whether restriction is medically appropriate. The determination of fitness for duty is not designed solely for the worker to appreciate as a benefit, but instead is intended to ensure safety to that worker, coworkers, resources (e.g., machinery, infrastructure), and to the public.

There is a misunderstanding in the previous post which says that MROs should not decide fitness for duty. This thread is in a forum on "fitness for duty" and is not in the forum on "MRO." I agree that MROs don't make fitness for duty determinations, although they are obliged to notify the appropriate people if they suspect there may be a fitness for duty concern.

As to whether someone with cancer or diabetes might be deemed unfit for their work - maybe yes, maybe no. There are validated tools for measuring disease activity and guidelines for functionality for these conditions. These include specific guidelines for diabetes and police work, diabetes and truck driving, diabetes and airplane pilots, etc. So it would depend on the specifics of the condition and the job responsibilities.

There are not validated tools for measuring impairment by those who are opioid dependent or are prescribed chronic opioid therapy. To leave it to the opinion based on a provider's faith in and analysis of "hard evidence"" of the patient's sobriety is perhaps defensible in the sense of an opinion, but there are not validated tools of measuring sobriety particularly when secondary gain is a potential counfounder. This is not something in which doctors can demonstrate any particular expertise. Statistically, only 20-30% of opioid dependent patients achieve long-term abstinence per DSM-V. As far as I know, medical science has not developed a reliable means of identifying those 20-30%.

Consider this analogy: If a truck driver has a seizure disorder, he or she is considered high risk to continue truck driving. But, if he or she if off seizure medicines for 10 years and remains seizure-free, the risk is then considered low enough to allow return to driving. Perhaps a similar approach would apply to determining fitness for duty of the opioid-dependent nurse whose job involves access to opioids.

Anecdote #1. On a number of occasions I've been asked to review records involving patients in medication-assisted treatment. Invariably, the prescribers advocate for their patients and indicate they are doing great in their sobriety. At the same time, the records (which offer at least some evidence) indicate multiple drug tests that have been skipped, tests of limited reliability (nonobserved collections, invalid results, limited test panels), and/or are positive for various drugs.

Anecdote #2. Opioid-dependent health care providers have been implicated in diversion of IV opioids in multiple, nationally publicized cases. These include at Exeter Hospital in New Hampshire, and a separate, multi-state case that finally ended in Colorado. In addition to patients not getting the appropriate medications (because saline had been swapped for opioids), patients were exposed to, and some caught, bloodborne infections from the health care providers who shot up with the syringes before refilling them with saline and putting them back for use on patients.

Guidelines published by ACOEM do not recommend safety-sensitive work by patients who have opioid dependence or who are prescribed chronic opioid treatment.

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