Wednesday, June 10, 2009

Alcohol & Drug Free Workplace Part 3

Alcohol & Drug Free Workplace Program must starts with a good policy statement. The policy which shows the full commitment of the top management on the program as well as allocation of a budget to run the program. The policy also clearly determines when to do the urine drug screens (UDSs)- randomly as well as when there is an incident/accident occured or other indications such as 'tell tale ' signs amongst the worker. 'Tell tale' signs such as odd behaviour like in the case mentioned in my previous posting. Possible other 'tell tale' signs such as frequent sickness absence, poor health ec cetera. After confirmation of the urine result, the policy must clear in the 'action to be taken' whether to send the worker for rehabilitation or disciplinary actions. If the worker voluntarily come forward for the test, the policy must clear enough not to punish the worker.
Beside the policy, the procedures to perform the test and how to randomly pick up the worker for the test must crystal clear , cannot just do a selective random check up only.
The lab. where the test done must have a high quality standard with recognition by an international body such as NATA. The appointed person who collects the urine and the doctor who interpretes the result must have a proper training in this field of specialisation. In Malaysia, SOEM-MMA regularly conduct a MRO course for doctors.

Monday, June 08, 2009

Alcohol & Drug Free Workplace Part 2

The worker’s blood test result (which is quiet comprehensive -Full Blood count, Kidney function,Liver function ec cetera) are all normal. The urine drug screens (UDSs) showed the following results:
Cannabinoids & Opiates Class were Negative & Coccaine/Metabolite was not detected. AMPHETAMINE was detected.
The other UDSs for Barbiturate Class and Benzodiazipine class will be performed in Australia together with confirmation test (GCMS) for the positive drugs.
Exactly one week later, the urine confirmation test (GCMS) done in Australia was ready and shows the following result:
UDSs (EMIT) for Benzodiazepine Class was detected.
Urine GCMS analysis identified both Ephedrine and Pseudoephedrine and 7-1 amino-Clonazepam.
I consulted Prof. Dr Aishah Latiff of DOPING Centre USM Penang (one of resource persons during the MRO course in 2005) for advised. She agreed with me that the Test for Amphetamine is NEGATIVE and Benzodiazipine Class is POSITIVE.
This official result will be revealed to the management of the company. I called the worker for the last time to inform him about the official results.He denied taking any drug from benzodiazepine class. He sworn for only taking cough syrup. He strongly persuaded me to help him. Based on my strong ethical and religion belief I cannot act wrongly and I have to reveal the TRUTH. BUT I advised him to quit the job before his employer dismissed him. The rest of the story are history.
There are few lessons we can learned from this incidence. The most important lesson is to have a proper well designed policy and program for handling alcohol and drug abused case at your workplace.
I will discuss on the elements of proper Alcohol & Drug-Free Workplace in my next posting.
For this posting I want to discuss few terminologies which are commonly used in handling drug abused case.
1. Chain of Custody (COC) : the procedures used to document handling of urine specimen from the time donor gives it to the COLLECTOR until it is destroyed.
2. Collector is a person specially trained to collect the urine
3. Medical Review Officer (MRO) is a doctor with special training in interpreting and handling drug testing. This position is only available in US.
4. Urine drug Screens(UDSs) : the lab. test designed to detect the drug in the urine. It is of 2 types : Screening test normally using immunoassay such as enzyme multiplied immunoassay technique(EMIT) and confirmation test using Gas chromatography-mass spectrometry (GC-MS).
5. POSITIVE RESULT : Screening and Confirmatory are Positive
6. NEGATIVE RESULT: Screening or/and Confirmatory is Negative
7. FALSE POSITIVE or EXCUSE POSITIVE : Screening and Confirmatory are positive but with legal/ authorised drug used
For the start, you can use Code of Practice on Prevention and Eradication of Drug, Alcohol and Substance abuse in the workplace, 2005 for reference (you can download a copy from DOSH website by clicking here)

Sunday, June 07, 2009

Alcohol & Drug Free Workplace Part I

Last Friday, my friend who is a HR personnel from one company called my handphone to consult about urine testing for drug abused. Instead of just telling the name of the lab. I decided to give brief explanation on how important to have a proper Alcohol & Drug Free Workplace policy or/and program. I recalled handling one drug abused case in early 2008. Here is the story:
“Doc, can you please check the urine of one of my worker to rule out drug abused?”, asked a supervisor who walked into the clinic , during my relief duty at one of an in-house clinic in January 2008. I quickly asked back ,“Why?, why drug test?”.
Then the HR personnel of the company came in and interrupted, “ He is suspected of drug abused because he has odd behaviour lately. Just now, he switched off the machine unncessarily, causing interuption in our production.” “OK,OK! I said....Let me handle the case properly”. Then the mentioned worker came in with another personnel. I told the personnel that I will perform full medical checkup with general blood screening test including the urine test for drugs. They agreed and left the clinic.
I asked the nurse in-charge about the Alcohol & Drug-Free Workplace Policy. The nurse looked puzzle about the policy. I explained to her what I learned from The First Medical Review Officer (MRO) Course organised by SOEM-MMA in November, 2005. She understood.
I instructed the nurse to collect the urine and also to maintain a chain of custody (COC) when sending the urine to the private lab. The nurse called the security department and one of the guard came and went to the toilet with the worker to get his urine specimen. I sent his urine for a battery of tests for drug-abused and his blood for screening test to assess his baseline health. I did a full physical examinations to find out any signs of drug-abused.
The next morning, the nurse informed me that the urine test was positive for Amphetamines. I asked the nurse to instruct the lab. to do the confirmation test . The private lab. sent the urine specimen to their HQ in Australia to do the confirmation test. "The result will be only available in one week", informed the lab. personnel.
Meanwhile, I take detail history from the worker including questions about the latest medication he took which can cause False Positive screening test result for amphetamine. There are some agents contributing to positive (False Positive) result by immunoassay screening test such as ephedrine,pseudoephedrine which is the common ingredients of flu and cough medicine. He told me he took syrup sedilix prescibed by one of a panel clinic a night before. I asked him to bring the cough syrup bottle for my reference(See photo above- the bottle box he handed to me). I called the clinic and the doctor confirmed his prescription on the cough syrup.
Sedilix-DM Linctus contained Dextromethorphan,Promethazine,Psudoephedrine and parabens. As mentioned earlier, this cough syrup contained Pseudoephedrine which can cause False Positive for amphetamine.
So, I reserved my judgment as False Positive or Excused Positive urine test at this junction.

Monday, June 01, 2009

AUDIOMETRIC TESTING - what you should know

Today is 'Gawai Dayak' Day in Sarawak, so we have Public Holiday for two days(1st & 2nd June). I would like to wish all my friends who celebrate Gawai - Selamat Ari Gawai - Gayu Guru Gerai Nyamai
I am now in the midst of reporting audiograms of workers from few industries.
What is audiometric testing? Have you done one ?
AUDIOMETRY is the testing of hearing ability. It is done using audiometer(see second photo above) and the person tested must be in silent booth. FMA (Noise Exposure) Regulation 1989, recommends to use a pure tone audiometry (PTA) (air conduction) at 500, 1000, 2000, 3000, 4000 & 6000 Hz each ear separately. The worker must have a minimum prior quiet period for 14 hours.
A lot of workers exposing to noise has high frequency hearing loss ( A dip in the above audiogram at 4000 Hz). From the audiogram we can determine hearing loss, hearing impairment and standard threshold shift (STS). A terminology used in the regulations.
Hearing loss is defined as hearing threshold of equal or more than 25 dB(A) at any frequency. *The above audiogram shows that the worker has hearing loss (45 - 55 dB for both ears (O label for right, X label for left) at 4000 & 6000 Hz.
 Hearing Impairment is an average permanent hearing threshold at 500, 1000, 2000 and 3000 Hz shifted 25 dB(A) and above.
STS on the otherhand is an average shift of more than 10 dB at frequency 2000,3000 and 4000 Hz relative to baseline audiogram in either ear. STS can only be identified by comparing the current audiogram with the previous baseline audiogram.
STS can be of two types : temporary (due to hair cell fatigue) or permanent ( due to hair cell atrophy). In order to declared the STS is permanent (PSTS), an audiometric testing must be repeated in 3 months (a requirement in FMA (Noise Exposure) Regulation 1989).
Tips: As a simple rule of thumb, you can find out whether you have STS or not by the doing this simple test. When you drive to your workplace in the morning, switch on your car radio to the volume level that you can hear. When you park your car, switch off the radio BUT dont change the volume level. When you go back home in the evening  switch on your radio with the previous volume level in the morning, if you cannot hear the radio at this previous volume level, that means you experience STS.
Three problems I always encounter in audiometric testing are (take note SHO) :
1. The worker does not bring  the previous audiogram (?employer fault) ; therefore cannot determine STS
2. The worker does not in prior quiet period for 14 hours, some of them come to do the audiometric testing immediately after their night shift, therefore the audiogram if done is not reliable
3. The worker does not know the noise level at their workplace. Therefore difficult to recommend the frequency of next audiometric testing ( 2 yearly for those who expose to noise at action level but less than PEL( 85 dB - 89 dB(A)). Annually for those who expose to noise at or above PEL(90 dB(A)) or with problem in their hearing ability). 
**Action level = 85 dB(A), PEL (Permissible Exposure Limit) at 8 hours TWA= 90 dB(A)

FMA (Noise Exposure) Regulation 1989 - how to comply?

In order to comply with FMA (Noise Exposure)Regulation 1989, all workplaces with noise hazards (PEL equal or more than 90 dB(A)) must have Hearing Conservation Program (HCP). 
HCP is very important because Noise Induced Hearing Loss (NIHL) is a permanent injury and has no remedy, prevention is the only solution. HCP is an effective means of primary prevention which is one of the main functions of occupational health services(OHS).
HCP as the primary prevention activity has the following components :
1. Auditable written policy with financial commitment and must be signed by top management
2. Comprehensive noise exposure assessments
3. Noise control measures following the hierarchy of controls
4. Workers' education and training
5. Audiometric testing program
6. Medical Evaluation & Treatment
7. Provision, training and utlilization of Hearing Protective Devices (HPD)
8. Good records keeping