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Medication-Assisted Treatment: New Innovations and Opportunities for Opioid and Alcohol Use Disorders

Improving Access to Programs and Treatments for Employees With Opioid and Alcohol Use Disorders: A Q&A With Craig Heligman, MD

AJMC®: Do you find that the number of employees with substance and opioid use disorders in your organization reflects that in the general US population? If so, what measures are you taking to help your employees?

Craig Heligman, MD: What we’re seeing is really no different than what is being seen nationally. We’ve seen an increase in opioid use disorder [OUD] specifically, and continued presence of alcohol as a substance of choice. Our statistics aren’t that much different than what you would see in the general population; however, it’s an impact on the business because we’re a safety-sensitive organization given that we transport many goods and commodities including potentially hazardous material by rail. We have to be cognizant of any issue that may cause an impairment on our crews and employees that are managing that whole process.

Outside of the regulatory environment, we also have a fairly robust peer prevention and voluntary review process. If someone wants to call in and advise us if they feel they have a problem, we will help them get assistance through a 24-hour employee assistance hotline that CSX provides. We may also see referrals from a coworker or self-referral through our peer prevention program—we call that Operation Red Block. It’s a long-standing program we’ve had for many years. It allows employees to work with their peers to identify individuals that may be in distress or have problems that may benefit from initially a peer interaction and subsequent referral to a licensed professional for evaluation and potentially treatment for a substance abuse problem.

AJMC®: What is the process within your organization for employees to receive care for substance or opioid use disorder via your Employee Assisted Program (EAP)?

Heligman: By regulation we are required to do drug testing on individuals prior to placement in safety-sensitive or safety-critical positions. We have an ongoing random testing program for both drugs and alcohol. And then if there’s any reason to test—for example, if there’s a rule violation, we call that a for-cause test. There’s some guidance on how we do that. A reasonable suspicion drug test is when we have individuals that may demonstrate behaviors suggestive of impairment and could be under the influence. We have a process in place that we use for doing that kind of testing. Should anyone have a positive test while at work, then we refer them to our EAP [employee assistance program] and by regulation, they have to be assessed by a substance abuse professional. We then have that document sent to us, and we have to follow the instructions, as does the employee, for any education, treatment, or whatever is recommended by that substance abuse professional.

It’s just a matter of making a phone call. Once an employee makes that phone call, if they’ve identified themselves as needing assistance, we will get them in for treatment.

AJMC®: What are your back to work policies? And are employees monitored? If so, how?

Heligman: When they return to work, all cases, whether off work for opioid or alcohol use disorders or any other medical reason, they will go through a review with our EAP manager and myself. We will review for general fitness for work measures. The basic issue there is to assure that they have received the recommended treatment, whether it’s through regulatory or self-referral or a voluntary process. We confirm that they are being recommended for a follow-up and after-care relapse prevention-type program, and we’ll do an agreement between our employee and the EAP manager—essentially it’s with the company, but it’s through the EAP manager—that lays out their relapse prevention plan, whether it’s being recommended for additional outpatient, individualized care, AA/NA participation, or obtaining a sponsor if they’re in those programs. Those elements of the relapse program will be stated in writing and signed off by both the EAP manager and the employee, so we all know exactly what the expectations are. And then the EAP manager will follow up with the employee to make sure they’re staying on target with the relapse prevention plan. If they fail to maintain compliance—we have a process that tells us at what point we would declare them noncompliant—then we would either do a medical disqualification or, if it was a regulated-type issue, there’s potential disciplinary action that could occur, and we would advise the appropriate members there. In addition to that, all individuals returning to work would be involved in a follow-up test plan. What that means is, depending on what the recommendations have been made by the substance abuse professional, a regulated testing environment, or with the treating substance abuse professional and the EAP manager in a volunteer status. We would put them on a test plan from anywhere from 1 to 5 years.

AJMC®: Once employees have returned to work, how can you tell if it’s going well?

Heligman: That’s a really good question. The only way we really know that it’s going well is by maintaining open channels of communication with the employees themselves and to monitor our follow-up testing plan. We also will be in communication with our peer prevention group. While managers may not necessarily know who is or is not involved in a follow-up testing program, they do need to be aware of signs and symptoms of potential issues of impairment, and we do regular training of our managers in regard to recognizing signs and symptoms of impairment as related to substance use.

AJMC®: What is the process like for employees to utilize medication-assisted treatment (MAT) therapy? Once employees get treatment, how are they monitored?

Heligman: If they’re on a medication-assisted treatment plan, we would work with our EAP group to do an initial follow-up for usually a year, but they’ll be in the test plan, as I said, from anywhere from 1 to 5 years. We rely on that. The employees also, of course, because the nonopioid based treatment may require an injection, would be allowed time off to see their physician; they can use their FMLA time period for that purpose as needed. For the opioid based, we would have to look at whether or not they’re in a safety-sensitive or safety-critical position, and that would preclude its use. Then we would have to work with the employee and the prescribing provider. We’ve had a number of people that have been placed on the opioid-based treatment plan, and we’ve had to go back to the employee and their prescriber and discuss the safety issues with them and try to redirect for alternative treatments if at all possible. We encourage them to work with their doctor to ween off that and get onto a different mode of treatment.

AJMC®: Do benefits designers understand the nuances between the currently available MAT options, do you think?

Heligman: I think the benefits advisors do. I’m not 100% certain that the prescribers and the lay population understand the differences in how that applies to our review for fitness for duty. There are some differences in the medications that are recommended for medication-assisted treatment. The research that I’ve reviewed shows that there’s not a big difference in relapse rates regardless of which MAT mediation you use. However, because we’re in a safety-sensitive environment, we prefer nonopioid-based medication-assisted treatment. There’s been literature out there that talks about the potential impairment for all categories of opioids, and it doesn’t really matter whether it’s long acting or short acting. There are some problems with putting someone on an opioid-based medication-assisted treatment and allowing them to operate trains and be placed in other safety-sensitive or safety-critical environments. We have a preference for nonopioid-based treatments, whether it’s other alternative medications or an abstinence-based program.

AJMC®: How can your current protocol for rehabilitation of employees be improved, if at all?

Heligman: I think as far as improvement, there’s a large variety of treatment programs that are out there, and as an employer we cannot necessarily require that employees go to any particular treatment program. We like to ensure that if they’re going to receive treatment, that they receive it from high-qualified and high-quality programs that will work with us in helping this person come back to work safely. If there’s any way we could improve it, it would be if we were able to be a little more directive as to where and which programs people would choose to go to. We do have a program that we use very frequently, and we believe they give high-quality services. They’re very much aware of the transportation industry—they kind of specialize in some of the transportation groups, not just railroads, but also truck driving and for airlines. We feel they have an understanding of our particular business and safety requirements of a regulated transportation business. We like to direct, if possible, and if it makes sense, we try to help our employees get to that program for evaluation, because we trust them, they understand our business, they do a good job, and they communicate well with our employee assistance program in expediting the return to work process. On the other hand, if an employee chooses to go to a different program, we’re certainly willing to work with them. We just want to make sure that people get the best treatment possible.

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