Substance Use Disorders

Overview of Medical Evaluation

The medical evaluation consists of the following elements:

• Suspicion of substance abuse or dependence;
• Impairment due to substance abuse or dependence;
• Assessment; and
• Recommendations regarding duty status and work restrictions.

Suspicion of Substance Abuse
The employer may contact the police physician regarding work behavior suspicious for substance use or abuse. Possible signs of substance (including alcohol) abuse include recurrent “Monday” lateness, unscheduled absences, unkempt appearance, involvement in accidents, inappropriately aggressive behavior, worsening performance, unreliability in someone previously reliable, and the inability to concentrate.3 By the time substance-related problems are identified in the workplace, the individual has a high probability of meeting the criteria for substance dependence.4 If, after initial consideration, the suspicion for substance abuse is substantiated, the police physician should recommend modified duty until a clinical evaluation determines whether the LEO has met DSM-IV-TR criteria for substance abuse or substance dependence (see Appendix A).

Acute Impairment Due to Substances
LEOs whose substance use has been detected at work (e.g., odor of alcoholic beverages, signs suggestive of intoxication or of withdrawal) will require appropriate work restrictions until a clinical evaluation has been performed to determine whether the LEO has met DSM-IV-TR criteria for substance abuse or substance dependence (see Appendix A).

Assessment

• LEOs identified as possibly having substance abuse or substance dependence must undergo a substance use disorder evaluation starting with a comprehensive medical history and physical examination. Obtaining collateral information is recommended. This evaluation should also include an assessment for evidence of:
  • polysubstance abuse;
  • recent impairment due to a substance;
  • withdrawal;
  • substance-related medical co-morbidity – e.g., liver disease, cardiac conditions, seizures (see Appendix C, section 4);
  • substance-related psychiatric comorbidity, both as precipitants and consequences – e.g., depression, anxiety, PTSD, suicidal behavior (see Appendix C, section 4);
  • current coping skills;
  • risk of ongoing use before treatment and risk of relapse following treatment (see Appendix C, section 6); and
  • medications (pre-existing and treatment).
• Some departments may utilize substance abuse professionalsa (SAPs) in return-to-work evaluations. The SAP is a certified health care provider (e.g., MD, DO, psychologist, or social worker) who evaluates persons with substance abuse issues and may also recommend treatment.a

Recommendations Regarding Duty Status and Work Restrictions

1. The treating addiction specialist physicianb or other clinician knowledgeable regarding substance use disorder management should provide a narrative report certifying whether the LEO has or has not met the return-to-work criteria set out below. In this report, the clinician should acknowledge reading the department’s LEO job description, and the LEO chapter on Essential Job Tasks.
2. Different return-to-work criteria exist for the different DSM-IV-TR diagnoses of substance abuse and dependence. Denial may cloud the distinction between the diagnosis of abuse and dependence. This is important because the return-to-work criteria for dependence are more stringent. Denial is common in assessment of substance use disorders. The evaluator should be skilled in the detection and handling of denial.

Return-to-Work Criteria for Substance Abuse
LEOs meeting DSM-IV-TR diagnostic criteria for substance abuse (see Appendix A) will require appropriate restrictions until all the following return-to-work criteria have been met:

1. The LEO is under the ongoing care of an addiction specialist physician or other clinician knowledgeable regarding substance use disorders.
2. The LEO meets the DSM-5 diagnostic criteria for early remission with regards to substance use disorder.c
3. There is documentation provided of abstinence from all abused substances (with the exception of tobacco) for 1 to 3 months.d
4. The treating clinician provides a written report with a recommendation for unrestricted duty (see Appendices E and G). The treating clinician should have been provided with and read the LEO’s job description and the LEO chapter on Essential Job Tasks).
5. The LEO demonstrates compliance with a relapse prevention agreement (see Appendices D and H).
6. If applicable, the LEO participates in agency-mandated alcohol and/or drug testing. The SAP and/or police physician or medical review officer (MRO) may be consulted in developing such testing.e
7. Multiple classes of medication may be used in the treatment of substance use disorders – e.g., antidepressants, atypical antipsychotics, anticonvulsants, methadone, buprenorphine, acamprosate, disulfiram, naltrexone, varenicline, and others). See the LEO Medications chapter for information regarding duty status while taking these medications.

Return-to-Work Criteria for Substance Dependence
LEOs meeting DSM-IV-TR criteria for substance dependence (see Appendix A) will require appropriate restrictions until all the following return-to-work criteria have been met:

1. The LEO is under the ongoing care of an addiction specialist physician or other clinician knowledgeable regarding substance use disorders.
2. The LEO meets the DSM-5 diagnostic criteria for early remission with regards to substance use disorder.f
3. There is documentation provided of abstinence from all abused substances (with the exception of tobacco) for three (3) months.5,6,7,8,g
4. The treating clinician provides a written report with a recommendation for unrestricted duty (see Appendices E and G). The treating clinician should have been provided with and read the LEO job description.
5. The LEO demonstrates compliance with a relapse prevention agreement (see Appendices D and H).
6. The LEO has completed an appropriate addiction treatment program.h However, consideration should be given to avoiding substance abuse treatment programs with high criminal offender participant rates. It may be advisable to consider an out-of-jurisdiction treatment program.
7. If applicable, the LEO participates in agency-mandated substance testing. The SAP and/or police physician or MRO may be consulted in developing such testing.i
8. Multiple classes of medication may be used to treat substance use disorders – e.g., antidepressants, atypical antipsychotics, anti-convulsants, methadone, buprenorphine, acamprosate, disulfiram, naltrexone, or varenicline (see the LEO Medications chapter for information regarding duty status while taking these medications).

On-going Monitoring Following Return to Full Duty
Monitoring is usually required in return to work planning in safety-sensitive positions. Successful programs include random alcohol and drug testing via an ongoing monitoring program. For physicians, these commonly taper in frequency over a period of 5 years. Monitoring components can include regularly scheduled face-to-face visits with a clinician providing support, screening for impending relapse, reviewing compliance with treatment, and testing breath and body fluids to verify abstinence. For most safety-sensitive positions, monitoring typically includes 24 unannounced tests or monitoring sessions over 2 years, based on the substance use disorder and a consulting physician’s input. Monitoring dates should be unpredictable. A certified medical review officer (MRO) should interpret drug testing results (see Appendix C-6 and C-7).

At minimum, an addiction specialist physician or substance use disorder treatment provider should assess the LEO very soon after discharge from residential treatment. The purpose of that appointment is to review the discharge summary for prognostic indicators and to approve, or revise, the relapse prevention plan/agreement.

Although ideal, continued regular care under an addiction specialist physician or substance use disorder treatment provider may not be possible locally. Safety-critical employees such as LEOs treated for substance use disorder will ideally require treatment by an addiction specialist physician or substance use disorder treatment provider for a minimum of 24 months. The addiction specialist physician or substance use disorder treatment provider should provide an opinion on the frequency of visits.

Alternatively, continued care for a substance use disorder may be provided by suitable primary care provider on a monthly basis for at least 6 months. Addiction specialist physician follow-up is then individualized as needed. The addiction specialist physician may recommend a definitive period of follow-up based on prognostic factors or treatment adjustments.

Alternatively, the LEO and/or the treating clinician may request an addictionology reassessment based on significant changes in clinical status such as increased substance cravings, increased stressors taxing current coping skills, decreased social support or significantly disrupted sleep. A relapse to recurrent substance use likely requires reassessment by an addiction specialist physician; however, a single self-identified lapse and self-correction by the LEO may not necessarily require reassessment by an addiction specialist physician.

aSee https://www.transportation.gov/odapc/sap for full definition/job responsibilities of a SAP. Accessed May 18, 2018.

bAn addiction specialist physician is a physician certified as an addiction specialist physician by the American Board of Addiction Medicine. See www.abam.net; accessed May 18, 2018.

cDSM-5 diagnostic criteria for early remission: None of the criteria for substance use disorder have been met for at least 3 months but for less than 12 months, with the exception of craving.

dThe 1-3 month abstinence period is a group consensus. The LEO Task Force is not aware of specific academic references on LEOs or other safety sensitive workers recommending documented abstinence for 3 months before affecting a return to safety sensitive work.

eAlcohol and/or drug testing mandated in recovery is intended to assist the LEO in maintaining abstinence. At a minimum, it should test the specific substance(s) of abuse, and commonly abused substances of the same class. If an agency has a written post-offer or random workplace alcohol and/or drug testing program, these routine tests are not a substitute for mandated testing in that they may not test for the abused substances.

fDSM-5 diagnostic criteria for early remission: None of the criteria for substance use disorder have been met for at least 3 months but for less than 12 months, with the exception of craving.

gThe 3-month abstinence period is a group consensus. The LEO Task Force is not aware of specific academic references on LEOs or other safety-sensitive workers recommending documented abstinence for three months before affecting a return to safety sensitive work. The 3-month concept is supported by the following sources:

• DSM-5 defines early remission in the context of DSM-5 Alcohol Use Disorder (moderate to severe DSM-IV-TR Alcohol Dependence), for instance, as at least 3 months with none of the clinical criteria of alcohol use disorder being present. Early remission parallels the addiction medicine concept of the patient being “stabilized” where new relapse prevention behaviors are regularly incorporated into lifestyle. This is the goal before a return to safety-sensitive work.
• Approximately a quarter of all people who are going to relapse, relapse within the first 4 weeks, and an additional 15% relapse by the 12-week mark. Ergo, of those individuals who are going to relapse in the year post treatment, 40% have relapsed in the first 3 months suggesting that this is the period of peak vulnerability.5,6,7,8
• This 3-month requirement is also in parallel with the Railway Association of Canada’s medical guidelines for returning those with a DSM-IV-TR diagnosis of substance dependence to a safety critical role. In Canada, this guideline is used in the context of federally required reporting of unfitness to work in safety critical railway workers.

hSince there is significant safety risk associated with relapse in LEOs and because inpatient treatment may have better outcomes with decreased risk for relapse, inpatient treatment should be strongly considered in treating LEOs with substance dependence. The period in residence may count toward the documented abstinence period.

iAlcohol and/or drug testing mandated in recovery is intended to assist the LEO in maintaining abstinence. At a minimum, it should test the specific substance(s) of abuse, and commonly abused substances of the same class. If an agency has a written post-offer or random workplace alcohol and/or drug testing program, these routine tests are not a substitute for mandated testing in that they may not test for the abused substances.