OH Today Summer 2022

The 26th Ruth Alston Memorial Lecture Delivered

By Professor Dame Carol Black

Partners of OH Today

2

OH TODAY

Summer 2022

CONTENTS

Editor LYNN PRATT

From the President

4

The 26th Ruth Alston Memorial Lecture

6

Drugs and Alcohol in the Workplace An Introduction to Getting it Right

12

Spirometry

21

Assistant Editor JANET O’NEILL Production Editor IAN GARNER

What is normal and abnormal?

Drug & Alcohol Misuse in the working age population, where are we, where are we going?

26

Access to Mental Health Support Services

32

Screening for obstructive sleep apnoea in occupational health - a two-step approach

34

Monkeypox

41

email: admin@ioh.org.uk

The Interview

45

Views expressed in OH Today are those of the contributors and not necessarily those of iOH.

Book Review

48

Release Stress and Change the Groundhog Day

50

Copyright © iOH 2021

Published by iOH, The Association of Occupational Health and Wellbeing Professionals

ioh.org.uk

Nor does iOH necessarily endorse any of the products or services mentioned or advertised in the publication. ioh.org.uk

OH TODAY

3

From the President Neil Loach 2022 is racing away and things seem to

say that we need to rise to the challenge

be getting back to the new normal that

that she so eminently put to us and not

we anticipated. Health surveillance

bury our heads in the sand. Drug users,

protocols, policies and procedures have

ex-addicts and their families need our

been reviewed and there is a new dawn

support and advocacy in returning to

in the delivery of OH interventions.

the workplace where safety allows. The

Many of our members will have been

problem is not going away.

used to working remotely but for some,

Dame Carol recently tweeted this: An

it came as a shock back in 2020. As ever,

honest portrayal of drug dependency

we have risen to the occasion and

and the very difficult, and often lengthy,

embraced the digital age. I wonder if the

battle to recover. https://

software packages currently available

www.bbc.co.uk/iplayer/episode/

are now meeting the demands of a

p0c82r0v/addiction-addiction-the-road-

digitally-driven, ultra-modern, tech-

to-recovery

savvy OH service. By the amount of social media posts asking for advice and guidance and the feedback I am reading, I doubt that it really meets the demands required. A call to arms therefore to do something about that.

Back in March, I had the immense privilege of hosting the Ruth Alston Memorial Lecture (RAML) and Gala

I urge you to watch it.

According to The Office for Health Improvement & Disparities (2021) 276,000 adults were in contact with drug and alcohol services between April 2020 and March 2021. Other statistics are as follows: •

141,000 people. This is the largest

Dinner to mark our 30th Anniversary

group in treatment.

which takes place in October. I can honestly tell you that I was as quaking

•

in my boots and Imposter Syndrome was rife. Our guest of Honour and speaker, Professor Dame Carol Black gave a

•

important an issue drug use is, but I will

4

OH TODAY

Summer 2022

Treatment for Crack Cocaine (with and without Opiates was 30,000 people

us permission to publish that in full in thunder in any way and tell you how

Treatment for Alcohol use was 75,000 people

tremendous speech, and she has given this edition. I am not going to steal her

Treatment for opiate use was

•

Treatment for powder cocaine was 20,000

•

•

Treatment for Cannabis &

and will be instrumental in looking at

Benzodiazepines was 27,000 (on

this hot topic to inform best practice

the increase)

going forward. The stigma attached to

Treatment for Ketamine was increased to 1,444

Of those in treatment 110,000 left the programmes having successfully been treated. Whilst tragically there were 3726 who died whilst receiving treatment. The shocking thing is that these statistics only represent those in treatment. There are many more drug

users in the UK today.

Office for National Statistics (2021) gives us the following statistics.

•

•

Drug users, ex addicts and their families need our support and advocacy in returning to the workplace where safety allows.

•

offer support, guidance and advocacy to this misunderstood group of people.

I was proud to host our VIP guests Professor Dame Carol Black, Diana Kloss, Professor Anne Harris, Lucy Kenyon, Bashyr Aziz, Adrian Fineberg, Christina Butterworth and many more of

the movers and shakers in the world of OH. I cannot express how humbling this experience was. Many of my career heroes all in the same room at an event that I had the privilege to host. It

16 to 59 years had taken an illicit

beggars comprehension and is

drug in the last year

something that my younger self would

Around one in five adults aged 16

not have dared to dream.

to 24 years had taken an illicit

Going forward we will be hosting 6

drug in the last year

webinars this year. The first happened

3.4% of adults aged 16 to 59 years last year 7.4% of adults aged 16 to 24 years had taken a Class A drug in the last year 2.1% of adults aged 16 to 59 years and

•

profession we need to be on board to

An estimated 1 in 11 adults aged

had taken a Class A drug in the •

drug use needs to be addressed and as a

only a few weeks ago and was very well

received. Please look out for our forthcoming ones on our webinar page.

Finally, I am happy to have been involved in the formation of the new SCPHN Standards that were approved by the Nursing and Midwifery Council on 26th May 2022. Both as a representative

4.3% of adults aged 16 to 24 years

of iOH but also as an academic in my

were classed as “frequent” drug

role at the University of Derby. The 2022

users.

Standards can be found here. We will be

Professor Dame Carol’s Reports and the

Government’s responses can be found

reading them in full over the coming

weeks and will report back on

here:

developments as and when appropriate.

HSE offer the following guidance here.

Please enjoy this edition of OH Today.

At RAML I spoke after Professor Dame

Neil Loach

Carol on how important it was that this

President, iOH

often forgotten group of people are supported by OH Practitioners back into the workplace and therefore back into society. iOH will rise to the challenge

ioh.org.uk

OH TODAY

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The 26th Ruth Alston Memorial Lecture We were delighted that Professor Dame Carol Black was able to deliver the iOH Ruth Alston Lecture, which focused on her recent independent review of illicit drugs, commissioned by Government in January 2019 and researched and written in two Parts over two and a half years. This is a summary of her lecture.

I

t all started in 2015 with work, the

•

benefit system, drugs and

operation employment for our

alcohol. I was then Head of House

cohorts is impossible, reluctant to

at Newnham College in Cambridge, but

hire people with addiction and/or

still deeply engaged with the Health and

criminal records, so that decisions

Wellbeing agenda, and still advising

to recruit needed to be de-

Government in this space.

risked.

I received a phone call from Ian Duncan

We came to appreciate that work is

Smith, then Secretary of State for Work

crucial to recovery for many individuals

and Pensions, asking whether I would

– and we sought to understand the

undertake an independent review of

perspective of people experiencing these

long-term conditions, particularly drug

conditions.

and alcohol addiction and obesity, to

These complex, often disorganised,

consider how to support sufferers back

individuals have chronic health

into, or to remain in, work. The

conditions, are disabled in many ways,

Government wanted to understand the causes of worklessness and the associated costs; the barriers to work; the pathways taken through the healthcare and benefits systems and the role of providers and employers; and the availability and cost-effectiveness of treatments and interventions.

It was a tough assignment.

We identified three main areas for action: •

Treatment, in itself not ensuring employment;

•

The Benefit System, hampered by severe lack of information on health conditions, and poor incentives for staff to tackle difficult or long-term cases;

Employers, without who’s co-

We came to appreciate that work is crucial to recovery for many individuals

and in need of personalised services, of innovation and investment, and opportunity to find purpose in life. Their stories were powerful, and send a clear message – within and after treatment for addiction there must be meaningful activity, preferably work, otherwise the void and boredom will soon be filled by a return to old habits.

There is a mutually-reinforcing relationship between employment and recovery – being employed at treatment start improves chances of completing the treatment successfully, and completing treatment well improves the chances of finding work. Also employment can moderate relapse. Only 1 in 5 of those starting treatment are employed, and these tend ioh.org.uk

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26th Ruth Alston Memorial Lecture 8

OH TODAY

to stay in work throughout treatment –

trial of the IPS approach, including a

but few who enter treatment without

comparison with a time-limited version

being in work find employment during

(IPS-lite), with JobcentrePlus work

or after treatment.

coaches co-located in treatment services

I talked to many OH colleagues and employers at that time, and we took evidence. While I could see that good

providing employer support, with appropriate financial support for small employers”.

employers supported by OH colleagues

The Government did this, with a

would do their best to support their own

randomised trial in seven Centres across

workers who ran into trouble, especially

the country, commissioned by DWP and

with alcohol, drugs were not so easily

executed extremely well by PHE. It

tolerated. We knew from work by the

started in 2017 and finished in 2021,

UK Drugs Policy Commission a few years

with results to be published soon. This

earlier that employers are generally

is a vital part of the jigsaw, important to

reluctant to take on ‘risky’ applicants,

my continued interest and the

and that recruitment processes are used

subsequent review. From 2017 to the

to manage perceived risks, from ruling

end of the IPS trial I was in regular

out drug users altogether to taking more

contact with PHE and the Centres, and

discerning steps. In considering

visited them more than once. I learned

whether an individual is fit for the job,

of their work, and also learnt more

‘fitness’ was perceived in various ways,

about drug and alcohol dependency, and

with stereotypes and prejudices, and

was frankly upset by the ever-declining

some employers wanted updates on

quality and quantity of treatment. Thus

progress with rehabilitation or

the request in January 2019 to do the

treatment. A criminal record was also a

review of illicit drugs was welcome.

barrier.

I produced the drug report in two Parts,

Our work on the 2016 review confirmed

Part 1 published February 2020 looking

this – we needed to show employers and

at Supply and Demand, and Part 2

the OH community that giving such

published July 2021 exploring

people a chance was worthwhile and do-

Treatment, Recovery and Prevention.

able – but they needed more evidence, there was no easy fix. We came to the conclusion that we needed to find evidence that drug- and alcoholdependent people could return to work, and one of the most powerful recommendations in that review was to

During this work I became convinced that tackling drug misuse is the single most important thing that can be done to reduce crime.

Half of all homicides, and half of serious acquisitive crimes, are related to the

study the value of IPS for such

drugs market.

people, Individual Placement and

One third of our prison places are

Support being, as you know, an intensive

accommodating people who are drug-

employment support intervention with an

dependent.

established evidence base in the Mental Health sector.

I said: “Government should conduct a

Summer 2022

Drug-dependency is a complex stigmatised problem. Until now those dependent on illicit drugs have not been

expense but very rarely achieving

Department of State – they are too

recovery or finding meaningful work.

messy and difficult, while of course

Many of their children are taken into

causing personal, family and societal

care. Problem drug use is highly

misery, and costing the Government

correlated with poverty, and these

some £19 billion per year.

problems blight our most deprived

Let me tell you something about Part 1 of my independent Review.

Market Part 1 addressed supply and demand for illicit drugs, and involved many months of rigorous and ground-breaking analysis to understand the complex and overlapping markets for illegal drugs. I took a market approach because the supply of drugs is driven by profit, and violence is often the result of competition for market share. Only by understanding the market and the drivers behind it could Government hope to disrupt it. For example, the growth in county lines appears to be largely caused by market saturation in

the big cities. It has exploited vulnerable people, especially the young. Some 27,000 young people in London identified as gang members, many drawn into drug dealing, often with deadly consequences as the supply and distribution of drugs have become increasingly violent.

Human story There is a very tragic human story

behind this market analysis. Drug deaths in 2018 were the highest on record, and they are now even higher. Since 2012 heroin-related deaths have more than doubled, while

communities – highlighting the need for ‘levelling up’.

A perfect storm I saw first-hand, in prisons, schools, youth clubs and charities, the effects of increasing supply, greater drug purity

and easier availability. This has combined, due to cuts in Police, border control, the National Crime Agency, schools and local authorities, with the loss of many protective factors that had kept children, young people and at-risk families away from danger – resulting in a perfect storm, to abate only if the Government takes action.

Austerity

I noted that treatment services had been curtailed by cuts in local government funding. The total cost to society of illegal drugs is around £20 billion per year, but only £600 million was spent yearly on treatment and prevention. So the amount of un-met need was growing, some treatment services are disappearing, and the treatment workforce is declining in number and quality. I said that we need to transform our approach to treatment, investing in it but also innovating so that treatment services are able to respond to today’s drugs market and future developments.

deaths involving cocaine have increased

Previous Governments have de-

five-fold. We have the highest number

prioritised these problems - from

since records began of rough sleepers

preventing drugs entering the country

dying on our streets from drug

right through to helping drug users

poisoning. Long-term drug users often

access appropriate treatment and

cycle in and out of our prisons, at great

achieve recovery. I intended Part 1 to ioh.org.uk

26th Ruth Alston Memorial Lecture

properly ‘owned’ by any one

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26th Ruth Alston Memorial Lecture 10

OH TODAY

provide a firm platform for decisive

appropriate. In the last seven

action by the Government.

years referrals to treatment from the criminal justice system have

In Part 2 of the Review, on treatment,

fallen substantially, and there has

recovery and prevention, I found a

been marked decline in use of

system unfit for purpose and broken : •

community sentences with Drug

funding cuts have left treatment

Rehabilitation Requirements.

and recovery services on their knees, with little MH or trauma

•

•

treatment, and inadequate

release from prison is

support for housing or help into

challenging. Those released,

employment;

often driven by renewed desire for drugs, are at high risk of overdose

commissioning has been

and re-offending. Only a third of

fragmented, with little

those referred for further

accountability for outcomes, and

treatment in the community go

partnerships between local

on to receive it within three

authorities, health and criminal

weeks. Delays in accessing

justice agencies have

benefits also contribute to an

deteriorated; •

individual’s vulnerability to

workforce depleted and

temptation and relapse. Housing

demoralised, with falling numbers

support and opportunities for

of professionally-qualified people; •

•

The period immediately after

work or training have been

services cut back, particularly in-

negligible. Shortcomings noted

patient de-toxification,

in the crucial Probation Service

residential rehabilitation,

have been confirmed in the recent

specialist services for young

report by the Chief Inspector of

people, and treatment for users of

Probation.

cannabis etc; and

With this dreadful picture of where we

Ministers and departments had I

are now, and the challenges ahead, my

believe not worked sufficiently

report recommends a whole-system

well together in a determined and

approach. I put the drug-dependent

sustained way.

persons at the centre, and asked: What

The situation is intolerable, and significant changes must be made in several areas.

do they need to stand a reasonable chance of successfully moving off

drugs ?

They need:

In addition, too many drug offenders go to prison, with no positive outcome.

•

Pharmaceutical medical intervention to replace e.g. the

•

A more cost-effective alternative

heroin

to short prison sentences is needed, with more people diverted into drug treatment and recovery services where

Summer 2022

•

A recovery plan and support

•

Mental Health and traumainformed services

Clinical medicine for additional

problems – HIV, ulcers, hepatitis,

•

Research.

lung disease etc

The Government responded to my

•

Housing support

new ten-year strategy against drugs,

•

Work – as they seek something meaningful to do

This requires six Departments of State to work together in a co-ordinated way with a Central Unit, conductor of the orchestra, linking to local delivery of

services and treatment.

My ‘whole system’ approach leads to 32 recommendations. I will not – you will be relieved to hear – read them all out,

Review on 6th December 2021, with a accepting 31 of the 32 recommendations and allocating an additional £782 million over the first three years to support Treatment, Recovery and Prevention.

Work is now an integral part of this. Every area of the country will have

an Individual Placement and Support service – but this will require more employers to step forward. There will also be peer mentors in each Job Centre.

but to give you a flavour, when

The question I leave with is: What

consulting the Review you will find:

should be the role of Occupational Health professionals in supporting and

•

Central Unit (the Joint

enabling this highly-stigmatised group

Combatting Drugs Unit, JCDU

of individuals to get the opportunities

•

Allocated money ring-fenced

•

Commissioning reformed, with standards and outcome frameworks

•

Accountability strong

•

Workforce rebuilt

•

Treatment and Recovery revitalised, with innovation and a new workforce strategy.

•

Diversion from prison, and care after release

•

Housing, more and targeted

•

Work or at least activity

•

IPS for the whole country – the trial is positive, it was worth doing and worth waiting for

•

that they and society need them to have? Will you get engaged with this

agenda, and enable them to find work?

Written by Professor Dame Carol Black Professor Dame Carol Black, DBE, FRCP BSD, was the Principal of Newnham College, Cambridge, until 2019. She was an adviser to the British Government on the relationship between work and health from 2006-2016. She is a medical practitioner and an expert on the disease scleroderma. She is currently Chair of the British Library, the Centre for Ageing Better, and Think Ahead, the Government’s fast-stream training programme for Mental Health Social Workers. She co-chairs NHS England/Improvement’s Expert Advisory Group on Employee Health and Wellbeing.

26th Ruth Alston Memorial Lecture

•

Prevention ioh.org.uk

OH TODAY

11

Drugs and Alcohol in the Workpla

An Introduction to Getting it Right

By Matt Taylor Why do organisations / companies test?

D

rug and alcohol testing in the workplace has been commonplace in the UK for

over 20 years now. It became “mainstream” within the Rail industry following the Cannon Street rail crash of January 8th, 1991, which killed 2 people and injured (some seriously) 542 others

considerable risk.

drug and alcohol testing program can

and/or alcohol us

help your company: •

•

Supervisors and a

individuals who may pose a

clear and concise

higher safety risk.

what is/what is no

•

concern of the company or organisation •

•

•

Comply with spec

regulations and le

problems and help them seek

and alcohol testing can

help, recover and return to the

Depending on the goals

workplace safely.

requirements you have t

Collect data to reduce Assure and retain responsible

improve health, safety and welfare

safety and welfare.

Summer 2022

requirements.

There are various situat

employees who value health,

OH TODAY

specific insurance

developed substance misuse

workplace is therefore done primarily to •

To win valuable c

(“compliance”) an

Identify employees who may have

organisational risk and liability.

Safety amongst other things.

12

•

Investigate and answer any

substance misuse.

– wherever that may be – it becomes the

put themselves and others at

when required.

sites or specific employees around

However, when they enter the workplace

influence of drugs or alcohol at work will

consistent interve

allegations of information about

usually the concern of their employer.

situations, people who are under the

them leading to a

Investigate accidents, incidents or

contributing factor.

•

Give Directors, M

Avoid employing or engaging

and alcohol as being a

business critical reasons.

within the work environment. In many

•

near misses and rule in/out drugs

workplace both for safety critical and

Drug and alcohol testing in the

Reduce absenteei

presenteeism foll

many other industry sectors have

that is responsible for their Health and

•

with the right training, education and

cannabis in his system. Following this,

What people do in their own time is not

drug and/or alcoh

and legally defensible Policy and

crash. The driver was also found to have

risks of Drugs and Alcohol in the

“hangover/comed

out drug and alcohol testing. A robust

was found that the driver of the train

realised the benefits of managing the

including “mornin

companies and organisations may carry

Procedures (including support) together

Reduce accidents

due to drug and/o

There are many other reasons that

despite happening at only 10 mph. It had failed to brake properly, causing the

•

might want to do testing of these situations. The reasons for testing are: •

identify candidate pose a risk to the

Demonstrate corporate and social responsibility to the communities you work within.

Pre-employmen

employees etc.

•

Site Induction t

identify people w

ace

t

s and incidents

or alcohol use –

ng after” and

down” periods

hol use.

ism and

lowing drugs

se.

Managers,

all Employees guidelines of

ot expected of

a more timely and

ention as and

contracts

nd to meet some

e cover

cific industry

egislations.

tions when drug be done.

s and the

to meet, you

g in all or some most common

t testing: To

es who could business / other

testing: To

who could pose a

•

risk before giving them access to a

services) and also products that are “fit

work site (may include visitors

for purpose”, meet specific relevant “cut

and contractors etc).

-off” levels (i.e., UK/European standards

For Cause testing: To determine possible contributing factors of a workplace accident, incident or near miss and to help prevent future incidents.

•

With cause testing: Following up on information or when there are visible signs and symptoms of substance use impacting upon

You should not dismiss an employee or take definitive action based solely on the initial screen result

•

required etc. Only UK Home Office Approved breathalysers should be used where positive results may lead to disciplinary procedures.

Like anything in life, quality has a cost, and you tend to get what you pay for.

Random / Un-announced

There are usually two parts to a standard

deterrence of substance use and enhance safety policy compliance by regularly testing a random sample of the workforce.

Employee compliance / followup testing: Where an employee has come forward asking for help

to ensure compliance with the agreement.

drug test. Most drug testing for workplaces is undertaken as a urine test or an oral saliva test and are broken down into these two stages: •

Initial screening stage (qualifiable result – either a Negative, NonNegative, or Invalid result with no measure of levels at this point),

this can be a Near Donor Immunoassay (often referred to as a POCT or Point of Care Test)

Guidelines and Quality Standards

where the screening is carried out

Drug tests should be performed in

the workplace.

accordance with strict legal and

This is the initial test to find

workplace testing guidelines. In the

traces of drugs or their

U.K., it is standard practice to follow the

metabolites within the sample.

EWDTS (European Workplace Drug

Screening is not 100% accurate

Testing Society Guidelines) for the

and is a qualitative result only

appropriate testing format. In addition

(there is no definitive level found

to this, employers and Occupational

at this point – just that there has

Health (OH) services should always

been a reaction or not). Think of it

check for quality assurance and

as the “Lateral Flow COVID test”.

accreditations of both the products and

Initial screening procedures can

services used.

include Laboratory screening

For example, compliance to recognised quality standards such as ISO9001, ISO14001 and ISO17025 (for laboratory

OH TODAY

(In Vito Diagnostic Regulations) if

Two Parts to a Drug Test

Policy and return to work

14

soon to be UKCA) marking, meet IVDR

safety and possible performance. testing: To help ongoing

•

and not USA standards), carry CE (or

Summer 2022

in front of the donor using an “instant/rapid” test and can be at

methods (various) where you will need to wait for the result from the laboratory.

etc. are all elements that make up what

•

Where a screen result shows a

is actually the whole Chain of Custody

“positive” (this should be referred

process which is essential for supporting

to as a “non-negative” or

a workplace drug test.

“presumptive positive”) confirmation is needed and MUST be confirmed by laboratory analysis. The sample is subjected to analytical procedures such as GC/MS [Gas Chromatography/

Speed, Accuracy and Reliability of Initial Results with “for cause” testing

Mass Spectrometry], LC/MS

Getting a quick initial screen result is

[Liquid Chromatography/Mass

often paramount. Why? – because it is

Spectrometry] etc to both qualify

an immediate “risk assessment”. It

and quantify the initial screen

allows you to make an informed decision

result. Think of this as the “PCR

about whether to remove a person from

COVID test”. This is measured

duties until the confirmation result is

against any medication declared.

known. These initial results need to be

It is the Confirmation stage that is considered the ‘legally defensible’ result. You should not dismiss an employee or take definitive action based solely on the initial screen result. In an attempt to cut costs some employers or organisations will only use POCT drug screen results and not send “non-

as accurate as possible (all screening methods have a degree of in-accuracy) and reliable. Traditional screening of samples at a laboratory, mean initial results are not usually known for 2448hrs. This means you have a very difficult decision to take: •

Do I remove that person from

negative” samples to the laboratory for

duties until the initial results are

confirmation analysis. This will not give

known –usually on full pay?

them a fully legally defensible result and therefore is not recommended as results are easily, and frequently, successfully challenged.

•

Do I allow them to carry on with duties only to find out 48hrs later that they have possibly been working while “under the

Many people refer to the laboratory and/

influence”? As a company – you

or confirmation stage as a “Chain of

may have therefore exposed them

Custody Test”, but it should be noted

and others to further risk.

that “Chain of Custody” should actually be applied to every element of any drug test – even if the initial screening result is NEGATIVE and therefore does not require laboratory screening/ confirmation. Collection officer/ technician training and competency records, equipment calibration records, paperwork, donor selection, donor information, donor consent, sample collection techniques, results reporting

It is therefore more common to now use “Instant” or “Point of Care” screening devices within workplace drug testing unless the industry standard states otherwise for example Rail. These devices are highly accurate and reliable and can give an initial screen result in around 3-5 minutes. Paired with a breath test for alcohol using a UK Home Office approved breathalyser, an immediate risk assessment can be made ioh.org.uk

OH TODAY

15

by the employer/organisation without

for the confirmation stage in urine is

having to wait for laboratory screening

lower at 15 ng/ml because the lab

results.

specifically looks for one of the many

What Do Drug Tests Look For (“The Science Bit”!)?

It is important to understand that drug tests don’t just look for the actual drug itself, but often also the drug metabolites.

Drugs go in the body in the psychedelic

metabolites - Tetrahydrocannabinol-11carboxylic acid (THC-COOH). This metabolite can also be referred to as 11nor-9-Carboxy-THC, also known as 11nor-9-carboxy-delta-9tetrahydrocannabinol, 11-nor-9-carboxy -delta-9-THC, 11-COOH-THC, THCCOOH, and THC-11-oic acid.

•

Tetrahydrocannabinol-11-

form and come out as a metabolite. For

carboxylic acid (THC-COOH)

example, the psychoactive ingredient in

<15ng/ml will be reported as

marijuana is THC (delta 9 tetrahydrocannabinol). This is oxidised by the body and comes out as many

NEGATIVE (PASS).

•

carboxylic acid (THC-COOH)

prevalent form is Tetrahydrocannabinol

>15ng/ml will be reported as

-11-carboxylic acid (THC-COOH).

POSITIVE (FAIL) unless

Cannabis is passed from the lungs to the

overturned by a Medical Review

bloodstream, and while the drug is

Officer (a trained individual,

freely floating in the body in sufficient liposoluble, meaning it absorbs into fat cells. The drug is stored in the fat cells indefinitely until the body burns the fat cells for energy. When the cell is burned,

At this point, you can then act upon this result (e.g., disciplinary) as it is now a legally defensible and a QUANTIFIABLE result unlike the screen QUALIFIABLE result of just “Non-Negative”.

back into the bloodstream. This is why

The Limitations of Point of Care Devices

to 30 days after chronic and frequent usage.

The EWDTS guidelines’ cut off for cannabis in urine on the screen stage is 50 ng/ml, which is a composite of all cannabis metabolite concentrations. If the sample is below this level the test is classed as a NEGATIVE and therefore a PASS result.

If the sample is over 50 ng/ml it is sent to a laboratory for confirmation analysis. The EWDTS guidelines’ cut off

OH TODAY

usually a doctor).

the drug is metabolised and released cannabis can be detected in urine for up

16

Any result for Tetrahydrocannabinol-11-

different metabolites. The most

quantity a high is felt. Cannabis is

Any result for

Summer 2022

1.

The Point of Care Drug Test provides only a qualitative,

preliminary analytical result. A bit like a “Lateral Flow COVID test”.

A secondary analytical method must be used to obtain a confirmed result (a bit like a “PCR COVID test”). Laboratory analysis via GC/MS or LC/MS etc are the preferred confirmatory methods.

These should be done by a UKAS ISO17025 accredited laboratory.

2.

3.

There is a possibility that

therefore experience a very small

technical or procedural errors, as

amount of “false positives” and “false

well as other interfering

negatives”. You will never know about

substances in the urine/oral fluid

“false negatives” as the donor is unlikely

(“saliva”) specimen may cause

to argue that they should not have

erroneous results.

passed their drug test (although this

Adulterants, such as bleach and/ or alum, in urine specimens may produce erroneous results

4.

method used. If adulteration is

sample falsely being reported as

suspected, the test should be

showing positive for drugs and or

repeated with another urine

metabolites. This can occur for several

specimen and a new test device.

reasons including: improper procedure,

A “non-negative” result does not

sample, or the route of drug administration.

A Negative result may not necessarily indicate a drug-free sample. Negative results can be obtained when a drug is present

but below the cut-off level of the test.

Tests do not always distinguish between drugs of abuse and

7.

actually in their system).

A false positive is defined as a drug free

the concentration of drug in the

6.

confirm and expecting to see if a drug is

regardless of the analytical

indicate intoxication of the donor,

5.

does occur where we are testing to

mixing up samples, and passive inhalation. But the most common cause of drug testing false positives are cross reactants. A cross reactant is a substance which because of its similar chemical structure to a drug or its metabolite can cause a false positive screen result.

The following substances can cause

cross reactivity on a “screen test” but are highly unlikely to be mistaken on a “laboratory confirmation test”: Ibuprofen

certain medications – and further

Ibuprofen is a common pain reliever and

analysis may be required.

anti-inflammatory which even in low

A “non-negative” test result may be obtained from certain foods or food supplements.

False “Positives” and False “Negatives” During the screening stage of the drug test, the result is never 100% accurate.

There is a degree of in-accuracy based around “specificity”, “sensitivity” and “accuracy”.

Point of Care test kits can often be > 99% accurate (this can differ depending on the drug types tested for). You will

doses used to cause a false positive for marijuana/cannabis on a screen test.

The screen test has been changed to use a different enzyme to eliminate these drug test false positives. But recent evidence suggests that Ibuprofen taken in very high doses, along with other anti -inflammatories such as Naproxen could still interfere with a screen test result.

Decongestants and Cold Remedies Phenylpropanolamine and ephedrine are both substances found in many overthe-counter cold remedies. They can result in a drug test false positive for

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amphetamines on a screen test.

Antitussives, to suppress coughs, such as dextromethorphan and pyrilamine may cause a drug test false positive for opiates.

Effexor

Tablets (venlafaxine hydrochloride) a treatment for depressive, anxiety and social disorder have shown to cause false positive urine results for

Anti-depressants

Phencyclidine (PCP).

Aside from when this class of drugs is

Tramadol

specifically tested for, some of them including amitriptyline can test positive for opiates for up to three days after use.

Even quinine in tonic water can very occasionally also cause a positive result

for opiates. The antidepressant Wellbutrin, and tricyclic antidepressants can trigger false-positive results on tests for amphetamines Antibiotics Certain newly developed antibiotics including amoxicillin and ampicillin have been reported to cause false

Tramadol can give a false positive for Methadone. This is because they are both “synthetic” opiates (otherwise known as opioids).

NOTE: It is recommended that you refer to the specific POC testing device “Product Insert” that you are utilising for your testing program. This will contain further information regarding known cross reactivity for that device.

In summary •

positives for cocaine. However, false

you are likely to encounter a very

positives for cocaine are highly

small degree of false positives and

infrequent.

false negatives. You are unlikely to know about false negatives.

DHEA This treatment developed for use by

•

analysed by confirmatory

positive for anabolic steroid use.

methods at a UKAS 17025

Medication for the treatment of HIV/

accredited laboratory.

AIDS (Sustiva) can also cause a false positive for cannabis.

•

•

A small fraction of the population excretes large amounts of certain enzymes in their urine which may produce a positive drug test. The enzymes in question are endogenous lysozyme and malate dehydrogenate, which according to research may run as high as 10% of false positive samples.

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Summer 2022

False positives are mainly caused by cross-reactivity.

PCP. Enzymes

It is the confirmation results that are definitive.

Benzodiazepines Diazepam may cause a false positive for

All positive (“non-negative”) drug screen results should be further

patients with AIDS will cause a false

18

In any drug screening process,

•

Occasionally false positives can be caused by operator error.

•

Nothing should be inferred by a false positive screen result.

Therefore, we recommend calling it a “non-negative” or “presumptive-positive” screen result.

Choosing the right specialist provider / partner is paramount. It can ensure a legally defensible, robust and

consistent service using high quality “fit for purpose” products that can help protect all stakeholders - including Employers and Employees.

For further information about this subject or any other subject regarding Drugs and Alcohol in the workplace, please contact the author: Matt Taylor Director Innovative Testing Solutions Ld W: www.itstestkits.com E: matt@itstestkits.com T: +44 (0)1782 358058 M: +44 (0)7821 116117 LINKED IN: https://www.linkedin.com/in/matt-taylor-itstestkits/

Matt is Managing Director of Innovative Testing Solutions, a quality led business delivering innovative, evidence based, high quality diagnostic products to customers in the UK, Ireland and further afield. Matt has been described as a “focussed, dynamic and highly motivated entrepreneurial Director” with a deep industry knowledge and over 18 years of “hands-on” experience within the Drugs and Alcohol Policy, Training and Testing sector. Matt has specialist knowledge within Policy, Point of Care testing and Sample Collection – including application of those skills during the last 18-24 months to COVID testing (PCR & LFD).

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Spirometry What is normal and abnormal?

By Charlene Mhamgami BSc Hons , Vitalograph

T

he aim of workplace spirometry

is normal and abnormal, the approach of

is to identify workers who may

interpretation needs to be decided.

have lung disease and require

further evaluation. Determining what

constitutes an abnormal, versus a normal, spirometry result is particularly important when spirometry is performed in relation to the workplace.

An ‘abnormal’ spirometry result can impact a worker’s job (e.g., determining job placement)’1, as well as prompting further evaluation of the worker’s lung health and possible workplace exposures. Therefore, to determine what

The occupational health practitioner performing spirometry should ensure

that technically acceptable and repeatable spirometry results are obtained according to the current 2019 ATS/ERS spirometry guidelines. It is important to highlight interpretation of spirometry doesn’t provide full diagnosis of lung diseases, but it can begin to paint the overall diagnostic picture. Spirometry interpretation

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should specify whether the workers lung

function is within the normal range or whether it shows an obstructive, restrictive, or mixed impairment pattern using a system which compares the measured result to the predicted result.

results, by using a fixed value of 0.70 for

the FEV1/FVC ratio, and 80% of predicted for FEV1, FVC, as a cut off for the lower limit of normal (LLN). It has been highlighted that the use of the fixed value of 0.70 as the LLN for the

Selecting reference values

FEV1/FVC ratio is not accurate as the

The interpretation involved in

in younger workers (25-45 years age)

spirometry depends on two factors.

and false-positive results in older

First, is selection of an appropriate

workers (men older than 45 year and

predictive value reference equation to

women younger than 55years)3. This is

determine the normal range. The

also evident for FEV1, A scatter plot

reference equations are summarized

showing the relationship between FEV1

data of previous spirometry tests

and age in healthy non-smokers shows a

collated from healthy, non-smoking

change in the scatter as the FEV1

individuals of varied age, gender, and

declines with age. Therefore, the

ethnic backgrounds. The reference

method for defining the LLN should

equations create the predicted value,

follow the same pattern. The raw data

lower and upper boundaries of the

scatter (Graph 1) shows the use of 80%

normal range based on the worker’s

predicted LLN, as well as a progressively

gender, age, height, and ethnicity.

higher increase in LLN as age increases.

Overall, looking at whether the lung

Using this as a marker of abnormality

function is within normal range. The

would create a large percentage of false-

second factor is use of an appropriate

positive results in both young and

algorithm to categorize the worker’s

elderly people. With an ever-increasing

ratio declines with age. Using the fixed value will result in false-negative results

spirometry results as normal or abnormal, with the commonly used algorithm being the ‘ATS/ERS interpretive strategies for lung function’ 2

. The most widely used predictive

reference equation for spirometry is the 2012 Global lung initiative equation (GLI,2012). This equation can be applied

more accurately to our current population, as it is multiethnic and has a wide age range from 3 – 95 years.

Use of percent predicted After choosing the predictive reference equation, the next step is choosing a way to define what is normal and abnormal. Percent predicted was widely used in the interpretation of spirometry

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Figure 1. Showing data scatter of FEV1 and age. The comparison of the 80% Predicted and 1.64SD LLN (5th Percentile).

ageing population, it could be regarded

(Figure 2). The method of using z-scores

as problem when diagnosing and

determines how normal a result is, how

monitoring respiratory disease. Whereas

far the result is from the mean

the ‘1.64SD LLN (5 Percentile)’ shows a

(predicted) value and expresses it in the

lesser increase in FEV1 as age increases.

terms of a dimensionless number. The z

th

Use of LLN and Z-score Z-scores provide a comparison between measured and predicted values by determining whether the difference between the measured and predicted is compatible with the “normal distribution” of the data from predictive value reference equations. Z-scores provide a way of viewing the 5th percentile LLN of -1.645, 5% of abnormal results are expected to fall within the area and 90% represents the majority of the healthy population

-score represents how many standard deviations the result differs from the predictive mean value.

The ATS/ERS spirometry guidelines have recommended the LLN as 1.645 SD below the mean value applying 5th percentile LLN. The ‘Z-score’ or

Standard Residual (SR) shows the number of standard deviations a result is from the mean value. By using LLN of 1.64 SD abnormal results lower than 1.64 would occur in 5% of the reflected population.

Standard deviation “The STANDARD DEVIATION (SD) is a measure of how spread -out numbers are from their expected mean value”

Figure 2. A bell-curve of normal distribution showing the commonly used 5th percentile LLN of 1.64 SD accepting a false positive of 5%.

Benefits of LLN and Z-score Using 1.64 SD as a statistical marker for abnormality of a result could have a beneficial effect in assistance in respiratory diagnosis and monitoring, potentially having an effect on the worker respiratory evaluation. Whereas percent predicted can have the potential to over diagnose those older and underdiagnose those younger. An example of this is shown in table 1.

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Table 1 shows that subject (a) had a measured FEV1 which would be considered ‘normal’ when implementing an 80% LLN but shows that this result would be considered ‘abnormal’ as it is in the 5th percentile of their population normality. Conversely, subject (b) shows an FEV1 of 75% predicted but is within a statistical LLN (90th percentile) based on their given population normality.

It is recommended to implement the use of Z-score when considering a workers spirometry result. A non-proven LLN of 80% predicted for FEV1 and fixed value of 0.70 for FEV1/FVC as a ‘cut off’ for normality may prove to be costly for both the worker and job role. Visualizations of Z-score on reports can aid in increased use of the zscore, as it provides a visual reference as shown in figure 3.

Figure 3. Showing a Z-score pictogram.

References 1

Townsend, M., 2020. Spirometry in Occupational Health—2020. Journal of Occupational &amp; Environmental

Medicine, 62(5), pp.e208-e230.

2

Quanjer, P., Stanojevic, S., Cole, T., Baur, X., Hall, G., Culver, B., Enright, P., Hankinson, J., Ip, M., Zheng, J. and

Stocks, J., 2012. Multi-ethnic reference values for spirometry for the 3–95-yr age range: the global lung function 2012 equations. European Respiratory Journal, 40(6), pp.1324-1343.

Pellegrino, R., 2005. Interpretative strategies for lung function tests. European Respiratory Journal, 26(5), pp.948 -968.

3

Redlich, C., Tarlo, S., Hankinson, J., Townsend, M., Eschenbacher, W., Von Essen, S., Sigsgaard, T. and Weiss-

man, D., 2014. Official American Thoracic Society Technical Standards: Spirometry in the Occupational Setting. American Journal of Respiratory and Critical Care Medicine, 189(8), pp.983-993.

Quanjer, P., Pretto, J., Brazzale, D. and Boros, P., 2013. Grading the severity of airways obstruction: new wine in new bottles. European Respiratory Journal, 43(2), pp.505-512.

24

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Drug & Alcohol Misuse in the working age po A personal view from a GP/Occupational Physician with

By Dr Rob Hampt

What is it about drugs & alcohol?

M

ankind is drawn towards intoxication. Edward Slingerland’s new book

Drunk investigates human’s enduring

Alcohol Are we heading for a ‘lockdown liver’ pandemic?

need for mind altering substances,

As a portfolio GP and Occupational

particularly our relationship with

Physician with an extended role in the

alcohol, and comes to the startling

treatment of drugs & alcohol addiction,

conclusion that far from being merely a

I have seen hundreds of people

pleasure or a vice, alcohol might be

impacted by the covid pandemic. The

vital to civilization itself . The first

story given by one of my patients to the

recorded wine was brewed over 6,000

BBC in August 20202 was typical of many

years ago and there is archaeological

other service users at Steps Together

evidence of consumption long before

Rehab, one of many residential drugs &

that.

alcohol treatment centres in the UK.

Alcohol is the only legally sanctioned

Chris worked as a Salesman and

mind-altering substance for general

described how his relationship with

use in most industrialised societies and

alcohol changed during the first

its’ consumption positively encouraged

lockdown: "I suppose I've always been a

in western culture. A visit to any card

social drinker - I was never within the

shop will reveal that over half the

recommended limits, and so yeah, I used

humorous birthday cards, aimed at

to enjoy a drink, sometimes a little bit

women in particular, extol the virtues

more than I should, as a lot of people do.

of alcohol intoxication as a necessity

I was in a good place before lockdown, I

for celebrating the day.

was keeping fit, I was swimming five

1

days a week, I was doing well at work and I was in a good mindset to be honest."

26

OH TODAY

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opulation, where are we, where are we going? a practice in the treatment of drugs & alcohol addiction.

ton RHH Medical

Chris goes on to describe how the

and, following medical detoxification, has

isolation and uncertainty affected his

been abstinent for several months. He

relationship towards dependency.

was lucky that his employers supported

"Although I wanted to cut down and

him throughout his fall into dependency

stop at that point, I wasn't in control of

and allowed him the time to attend

that. And that was the frightening part.

residential detoxification and

I've never been like that in my life and I

rehabilitation. He is now back to full-time

had to admit that to myself. I was

work and thriving. Others aren’t so

drinking very early in the morning to

fortunate. I would estimate that more

stop withdrawal symptoms”.

than 50% of the clients I see in residential

Chris’ story is typical of so many people we’ve admitted for alcohol detox. When listening to their stories, these are people who, a few weeks previously, were functioning well, holding down

detoxification have lost their work as a result of their addiction.

Alcohol related deaths are rising

jobs, living normal day-to-day lives.

Across the UK, the number of alcohol

Within a few weeks of lockdown, they'd

related deaths rose by almost twenty

become dependent alcohol drinkers.

percent in 2020-2021, the highest year on

One patient described it perfectly when

year increase since records began in 2001.

telling me that lockdown had made,

(79.8%) were caused by alcoholic liver

“every night was a Friday night”. Other

disease. The Covid Pandemic has been a

factors contributing to increased

significant factor in this increase and the

drinking were feelings of job insecurity

main increase is working age people (45-

and general uncertainty for the future.

60 years old)3. In other words, people at

Even those who were furloughed, or not

risk of alcohol related liver disease have

isolated, had their children at home,

been drinking more during the covid

getting involved in home schooling and

pandemic.

"there was just that need for a stressbuster every day."

Chris recognised that he needed help

As early as May 2020, the British Medical Journal revealed that alcohol consumption had increased during the

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27

first covid lockdown4. Although the total

typically considered in workplace

sales of alcohol actually fell during the

screening: ketamine, pregabalin and

early stages of the pandemic, the

synthetic cannabinoids.

volume of home sales increased by up to 67%. Many people’s alcohol consumption changed in this period, some reducing their consumption.

However, a pattern has emerged that people who were already risky drinkers (AUDIT-C score ≥ 5) were drinking more and the number of risky drinkers increased from 25% of adults between

April 2019 and February 2020, compared with 38% during lockdown in April 20205. Another fact that could influence the burden of liver disease, is that older age groups tend to be those drinking more, a long-term trend that continued

younger adults misusing ketamine.

Although the numbers are relatively low, the numbers entering treatment with ketamine problems is 3.5 times higher than it was in 20157 . Ketamine abuse can result in severe mental health deterioration, increased the risk injury

and life-changing urological complications Pregabalin. Since April 2019, pregabalin has been categorised as a class-C controlled substance. Although very helpful in the management of

during the covid pandemic6.

neuropathic pain and anxiety, it can

Drugs

benzodiazepines. It is often used

There is a mixed pattern when looking at drug misuse in the working age

population. It is estimated that around 70% of people addicted to drugs are in employment. It may surprise many readers that drug misuse overall is fairly static, or even falling for crack, cocaine and ecstasy. However, drug-related

give a high similar to that of alongside opioids or diazepam and I’ve come across a few cases where opioid

users take this to minimise withdrawal symptoms, in order to achieve a negative urine opioid screen at work. I would recommend an occupational health department to screen for this substance where workplace intoxication

deaths have been rising. Death by drug-

is suspected.

related poisoning was 60.9% higher in

Synthetic cannabinoids. (commonly

2020 than in 2010. The rates of drug-

known as mamba/spice). These used to

misuse death peaks among those born in

be classified as ‘legal-highs’ but since

the 1970s, with the highest rate in those

2016 are banned for sale by the

aged 45 to 49 years. This so-called

Psychoactive Substances Act. This is

‘generation X’ are far more likely abuse

typically a drug used by the homeless

heroin than any other age-group.

and prisoners due to the low price and

Are there drugs we’re missing on occupational health screens?

difficulty in urine screening. The

The main 3 drugs of abuse to watch out for are that in my experience or not

28

Ketamine. There is a rapid increase in

OH TODAY

Summer 2022

chemical formulations are continually changing, making urine screens a moving target. I’m not aware of any evidence of the impact at the workplace, but these drugs are worth bearing in mind where intoxication workplace at

the workplace is suspected.

Hair or nail testing: The future of screening?

I would predict that the major advance in screening at the workplace will be an increased use of hair or nail testing, particularly for workers in safety critical roles. A recent addition to my occupational medicine practice has been

Psychoactive substance (drugs and alcohol) testing for pilots is only a recent requirement following the introduction of new regulations by European aviation regulatory bodies that now require all pilots to be tested prior to employment and randomly throughout the course of that employment. This provides a 3-month history of drug & alcohol use.

to provide support to pilots whose hair

David Whiffin, MD of OdiliaClark, an

testing has revealed drugs or alcohol

organisation that provides a testing and

misuse. It strikes me that the

rehabilitation service said, “In the world

occupational health community, and

of aviation, safety is paramount, and at

particularly the DVLA, should consider

the heart of an organisations safety

such testing for LGV and public

management system are the people

transport drivers. The advantages and

within the organisation. Part of the

disadvantages of hair or nail testing are

testing programme is to ensure that

laid out in table 1

staff are at their best, both mentally and physically. We believe that no employee wants to come to work under the

Advantages:

influence of a psychoactive substance,

Exceptionally difficult to cheat

questions to ask around education and

so when we find something, we have

Indicates patterns of drug or alcohol use

mental wellbeing. When problems are

over weeks and months

found, for many clients it’s the start of a

Highly sensitive; highly accurate Simple, non-invasive collection

journey with that employee and depending on what is found a range of support services can be introduced. Not only to support the employee but most

Disadvantages:

importantly to give the employer the confidence that the employee is

Samples cannot indicate substance use

mentally and physically fit to carry out

less than 7 days after the incident.

their role.”

No near patient testing.

Where can healthcare professionals signpost those at risk?

Needs laboratory analysis

Table 1

If a healthcare professional is keen for a patient to reflect on hazardous drinking, there is likely to be a group that appeals to the patient’s specific life goals and aspirations. A good starting point would

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be Alcohol Change UK https://

middle-aged workers. Several new

alcoholchange.org.uk/ or the

substances are emerging in younger age

Drinkaware Trust https://

groups that are not typically considered

www.drinkaware.co.uk/. As with any

or tested in most workplaces. However, I

addiction or substance misuse, I would

would predict that the growth of hair or

also encourage someone to reflect on

nail testing will continue and, if adopted

their consumption before making the

more widely, should lead to safer

change. ‘Alcohol Know your limits’ is a

workplaces, and targeted opportunities

superb downloadable guide produced by

for lifestyle change and rehabilitation.

the NHS https://tinyurl.com/y57uafwd and the NHS live well site https:// www.nhs.uk/live-well/alcohol-support/

References

could be an alternative starting point

1

towards change.

Sipped, Danced, and Stumbled Our Way

The numbers seeking support through

to Civilization, Little, Brown August

local drugs & alcohol treatment services

Edward Slingerland, Drunk: How We

2021, (ISBN: 9780316453387)

reduced during the covid pandemic. Yet,

2

analytics from Alcohol UK showed

53807908 (accessed 3rd June 2022)

significant spikes of people accessing the ‘get help now’ section of their website during the lockdowns8.

3

https://www.bbc.co.uk/news/healthhttps://www.ons.gov.uk/

peoplepopulationandcommunity/ healthandsocialcare/causesofdeath/

Self-help communities are emerging,

bulletins/

with many moving away from ‘alcohol

alcoholrelateddeathsintheunitedking-

as an illness’ approach towards a move

dom/registeredin2020(accessed 3rd June

to dissociate fun, hedonism and

2022)

relaxation from drugs or alcohol. This approach could be helpful to risky, but non-dependent drinkers. For example, Club Soda9 promotes a mindfulnessbased approach to reducing alcohol and

4

Covid-19 and alcohol—a dangerous

cocktail, BMJ 2020; 369 https:// doi.org/10.1136/bmj.m1987. (accessed 3rd June 2022) Jackson, S. E., Garnett, C., Shahab, L.,

is a champion for the growth of alcohol-

5

free drinks for people who want to

Oldham, M., and Brown, J. (2020) Asso-

continue their love of beer, wine and

ciation of the COVID-19 lockdown with

spirits. The Sober Girl Society reaches

smoking, drinking and attempts to quit

out to women who want ‘all of the fun,

in England: an analysis of 2019–20 data.

none of the alcohol!’10

Addiction, https://doi.org/10.1111/

In summary, the landscape of mild-

add.15295. (accessed 3rd June 2022) ONS. Quarterly alcohol specific deaths

altering substance use in the working

6

age population is changing and we are

in England and Wales: 2001 to 2019 reg-

likely to see more problems with alcohol

istrations and Quarter 1 (Jan to Mar) to

-related problems at the workplace in

Quarter 3 (July to Sept) 2020 provisional

the next few years, particularly in

registrations. February 2021.

Www.ons.gov.uk/

30

OH TODAY

Summer 2022

peoplepopulationandcommunity/

7

birthsdeathsandmarriages/deaths/

tistics 2020 to 2021: report - GOV.UK

bulletins/

(www.gov.uk) accessed 27th May 2022

quarterlyalcoholspecificdeathsineng-

8

landandwales/2001to2019registrationsa ndquarter1jantomartoquarter3julytosep t2020provisionalregistration. (accessed September 30th 2021)

Adult substance misuse treatment sta-

https://alcoholchange.org.uk/help-and-

support/ (accessed 3rd June 2022) 9

https://joinclubsoda.com/(accessed 3rd

June 2022)

Rob Hampton is a GP and Occupational Physician. His portfolio includes roles in drugs & alcohol treatment, health & work tribunals, and medico-legal assessments. He has worked in collaboration with several Occupational Health Nurse Advisors in recent years to assist in sickness absence medicals for complex cases and ill health retirement assessments.

A member of the BMA Occupational Medicine Committee and founder of the SOM GP Interest Group. He currently leads an NHS project to improve report writing skills for GPs involved with medico-legal assessments.

His preferred mode of working is to work collaboratively with Occupational Health Nurse Advisors and is always ready to receive referrals for work in London or the Midlands.

He can be contacted through rhhmedical@outlook.com or www.rhhmedical.com

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Access to Work Mental Health Support Service: Personalised support to complement Occupational Health provision

M

by James Seton ental health remains the

The Access to Work Mental Health

at work), and provides th

leading cause of sickness

Support Service, delivered by Remploy, a

personalised tools to co

absence, with an estimated

Maximus company, and funded by the

difficulties they may fac

70 million work days lost annually due

Department for Work and Pensions,

workplace.

to mental health problems in the UK,

provides mental health support to any

costing employers approximately £2.4

employee in paid employment

billion per year*.

struggling with their mental health. The

The pandemic has accentuated the problem - with more employees experiencing mental health difficulties and longer waiting times for clinical support. While clinical interventions

free, confidential service offers 9 months of individual, personalised support, including 1-to-1 support from an expert Vocational Rehabilitation Consultant.

may be necessary for employees

Occupational Health professionals can

experiencing mental health issues,

refer employees to the service including

additional practical and motivational

contact details, or alternatively,

support is available - which can

employees can self-refer.

complement, and in some cases avoid, the need for further clinical

interventions.

Businesses from major C

NHS trusts and even For

such as Williams F1 hav

value of the Access to W

Health Support Service i

the mental wellbeing of

and apprentices within t

*Mental Health Foundat

The service explores and addresses the employee’s specific challenges (for

example, poor sleep, anxiety, or burnout

Access to Work Mental Health Support Service offers significant benefits for Occupational Health practitioners. The first is its emphasis on light-touch workfocused support, which can lighten the load for OH professionals and allow them to focus on delivering clinical support.

The service can also provide an effective follow-on from rehabilitation. When an employee is receiving clinical support and is ready to return to the workplace, a referral can be made to Access to Work, providing advice for employers and support with adjustments to help employees stay in work and avoid recurring periods of sickness absence Chris Kingsbury, National Partnerships Manager at Remploy

You can view Chris’s recent Webinar given to iOH Members here

32

OH TODAY

Summer 2022

hem with

ope with any

ce in the

City banks to

rmula One teams

ve recognised the

Work Mental

in supporting

f both employees

their workforce.

tion.

Screening for obstructive sleep apnoea in occupational health- a two-step approach.

By Dr Werner Stipp

T

he pathophysiology of

occupational accidents (2) has been reported. OSA is associated

obstructive sleep apnoea relates

with reduced in work performance. (3)

to respiratory effort to

overcome the critical pressure in the nasopharynx, caused by airway obstruction during sleep resulting in arousal and/ or a drop in blood oxygen levels. (1) of chronic diseases such as hypertension and ischemic heart disease, stroke, diabetes mellitus and depression. (2) A seven-fold increased risk of road traffic accidents (10) and an increased risk of OH TODAY

to 1 billion cases worldwide. The prevalence increases with increasing age and obesity. (4) A population-based study using diagnostic polysomnography (PSG), the gold standard for diagnosis, demonstrated a high confirmed prevalence of OSA in men (49.7%), and in women (23.4%) of middle age. (5)

OSA is associated with the development

34

There is an estimated 8 million cases of OSA in the UK and close

Summer 2022

Legislation requires screening of drivers for OSA, which could also be applicable to other safety critical workers: A position paper by the British Thoracic Society and DVLA provides guidance on OSA and driving in the UK. (6) The EU produced a directive mandating drivers to have OSA screening. (7) US

legislation states that the driver must have “no established

OSA could be managed with

medical history or clinical diagnosis of respiratory dysfunction

conservative measures including weight

likely to interfere with the ability to control and drive a

loss, reduced alcohol intake and

commercial motor vehicle safely’ and recommends OSA

smoking cessation. Body positioning

screening following sleep related incidents and BMI parameters

during sleep is a factor in airway

in combination with chronic disease (8)

collapse with increased body fat playing

.

Polysomnography is the gold standard in diagnosis, but needs to be done in hospital and is costly. Home based sleep testing (HBST) could be used to diagnose moderate to severe OSA but cases that test negative with symptoms would still be referred

a part. Minimal weight loss of a few kg can improve OSA severity and reduce morbidity associated with the condition.

for PSG studies. Moderate to severe OSA, once diagnosed, is

The severity of OSA is expressed as the

generally treated with CPAP (continuous positive airway

Apnoea Hypopnoea Index, or AHI,

pressure) and mandibular devices. (2) Other measures such as

which is used in diagnostic reports

surgery and implantable pacemakers are less often used. Mild

(mild, an AHI of 5 to <14.9; moderate, ioh.org.uk

OH TODAY

35

an AHI of 15 to 29.9 and severe, an AHI

less than five 3% desaturation events

of 30 and over). The AHI is measured

per hour (a 3% ODI<5) together with a

with an airflow probe at the nose. A key

negative questionnaire response in a

parameter in oximetry to describe

two-step approach, has been shown to

oxygen desaturation events in OSA is

reduce the referral rate to sleep centers

the oxygen desaturation index, or ODI,

for PSG, while no cases of OSA were

which is defined as a 3% - 4% reduction

missed if oximetry is combined with a

in blood oxygen saturation (SpO2) from

questionnaire response. (15) Other

baseline, lasting for 10 seconds or more

causes of symptoms of sleepiness, such

per hour. An ODI of 5 or more is

as insufficient sleep, restless legs

considered abnormal. The ODI alone is

syndrome, shift work, sedating drugs

not accepted to make a diagnosis but it

and psychological conditions should be

could be used to screen for OSA.

excluded in the patient history. A

Using screening questionnaires only has been shown to be inadequate to screen for OSA. (9) The sensitivity and specificity percentages for questionnaires to identify OSA are 77 (73-81) and 44 (38-51) for the Berlin questionnaire; 90 (86-93); 36 (29-44) for the STOP-BANG questionnaire and 47 (35-59); 62 (56-68) for the Epworth sleepiness scale. (10)

The usefulness of combining oximetry with clinical scoring in screening for OSA has already been demonstrated by Williams in 1991, with the cyclical desaturation pattern of oximetry recordings being highly specific for OSA. (11) Smartphone apps (with an external probe) or devices not medically certified should not be used in assessment of oxygen parameters. Only medically

certified oximetry devices should be used; these devices are subjected to rigorous testing against blood gas analysis over an SpO2 range of 70%100% before FDA and CE certification.

A two-step approach, combining a sleep apnea questionnaire response with oximetry that is able to identify mild cases of OSA, has been suggested (12,13,14) A negative oximetry result of 36

OH TODAY

Summer 2022

negative oximetry response alone is not sufficient to exclude a diagnosis of OSA, and patients with a positive history still require investigation. A negative oximetry result is more prevalent with a lower body mass index (a BMI< 25) and younger patients, and these cases should especially be assessed for other causes of upper airway obstruction.

Cases with significant underlying

cardiorespiratory disease, hypoventilation or respiratory muscle weakness, severe insomnia or chronic opioid medication use should not be included in OSA screening programs using oximetry, and such cases need to be referred directly to sleep centers for further assessment.(16) Employees do not always report symptoms at employment related medical assessments because of their

concerns of potential impact on their job; it is therefore necessary to encourage self-reporting of symptoms, raise awareness of the impact on safety and to use objective measures in OSA screening programmes., for example body mass index,, neck circumference, witnessed episodes of apnoea and SpO2 parameters.

A suggested screening programme is outlined in Figure 1.

Figure 1 ioh.org.uk

OH TODAY

37

Take home points for the Occupational Health setting: •

38

OH TODAY

Obstructive sleep apnoea (OSA) is a highly prevalent condition, almost 1 billion worldwide and an estimated 8 million having the condition in the UK, obesity, age over 50 years, male gender and obesity is associated with increased prevalence.

•

OSA reduces quality of life, causes fatigue and sleepiness, cognitive impairment, insomnia, OSA is associated with depression, heart disease, stroke and diabetes

•

OSA is treatable with CPAP, mandibular devices and surgery in selective cases, mild sleep apnoea could respond to conservative measures such as smoking cessation, limited alcohol use, weight loss and exercise.

•

OSA causes disturbed sleep at night affecting daytime functioning significantly in some cases, the condition affects job performance and safety, one study showed an almost seven fold increased risk in accidents.

DVLA guidance is based on selfreports of sleepiness.

•

Occupational health nurse (OHN) is in a key position to screen for OSA and improve the health of their workforce, screening questionnaires are insufficient.

•

Two-night oximetry based screening has been shown to screen adequately in populations with a high prevalence of obstructive sleep apnoea and low comorbidities, in combination with a screening questionnaire

•

The less complicated the screening process the better, a wrist sensor device improves patient compliance and comfort

Summer 2022

over fingertip and nasal probes •

The OHN could provide wellbeing education such as weight loss, smoking and drinking habits and follow cases up over time

References: 1. Dempsey JA, Veasey SC, Morgan BJ, O’Donnell CP. Pathophysiology of Sleep Apnea. Physiological Reviews. 2010 Jan;90(1).

2. NICE. Obstructive sleep apnoea syndrome. 2021. Available at: https://cks.nice.org.uk/topics/ obstructive-sleep-apnoeasyndrome/ Date accessed: Nov 2021 3. Ulfberg J, Carter N, Talbäck M, Edling C. Excessive Daytime Sleepiness at Work and Subjective Work Performance in the General Population and Among Heavy Snorers and Patients With Obstructive Sleep Apnea. Chest.

1996 Sep;110(3).

4. Benjafield A v, Ayas NT, Eastwood PR, Heinzer R, Ip MSM, Morrell MJ, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. The Lancet Respiratory Medicine. 2019 Aug;7(8).

5. Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N, et al. Prevalence of sleep -disordered breathing in the general population: the HypnoLaus study.

The Lancet Respiratory Medicine.

2015 Apr;3(4).

6. British Thoracic Society.

Position statement driving and obstructive sleep apnoea (OSA) 2018. https://www.britthoracic.org.uk/qualityimprovement/clinical-resources/ sleep/. 2018.

7. Commission Directive 2014/85/ EU. https://eur-lex.europa.eu/legalcontent/EN/TXT/PDF/?

uri=CELEX:32014L0085&from=EN Jul 1, 2014.

8. Hartenbaum N, Collop N, Rosen IM, Phillips B, George CFP, Rowley JA, et al. Sleep Apnea and Commercial Motor Vehicle Operators. Chest. 2006 Sep;130(3).

9. Behar JA, Palmius N, Li Q, Garbuio S, Rizzatti FPG, Bittencourt L, et al. Feasibility of Single Channel Oximetry for Mass Screening of Obstructive Sleep Apnea.

EClinicalMedicine. 2019 May;11.

10. Gottlieb DJ, Punjabi NM. Diagnosis and Management of Obstructive Sleep Apnea. JAMA. 2020 Apr 14;323(14).

11. Williams AJ, Yu G, Santiago S, Stein M. Screening for Sleep Apnea Using Pulse Oximetry and A Clinical Score. Chest. 1991 Sep;100(3).

12. Eijsvogel MM, Wiegersma S, Randerath W, Verbraecken J, Wegter -Hilbers E, van der Palen J. Obstructive Sleep Apnea Syndrome in Company Workers: Development of a Two-Step Screening Strategy with a New Questionnaire. Journal of Clinical Sleep Medicine. 2016 Apr 15;12(04).

13. Chai-Coetzer CL, Antic NA,

Rowland LS, Catcheside PG, Esterman A, Reed RL, et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care. Thorax. 2011 Mar 1;66 (3).

14. Gurubhagavatula I, Maislin G, Nkwuo JE, Pack AI. Occupational Screening for Obstructive Sleep Apnea in Commercial Drivers.

American Journal of Respiratory and Critical Care Medicine. 2004 Aug 15;170(4).

15. Fabius TM, Benistant JR, Pleijhuis RG, van der Palen J, Eijsvogel MMM. The use of oximetry and a questionnaire in primary care enables exclusion of a subsequent obstructive sleep apnea diagnosis.

Sleep and Breathing. 2020 Mar 6;24 (1).

16. Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine. 2017 Mar 15;13(03).

Dr Stipp is a full time consultant occupational physician practicing in the UK private sector with an interest in sleep conditions. He is the co-founder of Divity Health, a UK company aiming to do digital transformation in occupational health

ioh.org.uk

OH TODAY

39

How do we best apply the learnings from COVID-19 to Monkeypox?

By Lucy Kenyon

Defining a population group and the role of the Occupational Health professional in the management of public health and control of emerging zoonotic communicable diseases.

Introduction

A

t the end of the first wave of

applied knowledge and expertise to

the COVID-19 pandemic, a

standardise and manage our response to

Belgian systematic review

the re-emergence of an Orthopoxvirus

identified the need for a comprehensive

that is spreading more rapidly than our

risk assessment strategy “more

historical experience of the disease has

systematic approach to prevent

ever predicted.

biological risks among non-healthcare employees”.

Monkeypox is the fourth in recent a series of emerging sylvatic zoonotic

Never in the history of Public Health

viruses that have spread with pandemic-

(PH) has its sibling’s expertise,

type speed. You will by now all have

Occupational Health (OH), been more

seen headlines about a new

important. Following the pandemic

Orthopoxvirus that has emerged and

planning and response for H1N1 and

spread outside its normal region, host,

COVID-19, we need to pull together

environment and population.

again to support each other and share

ioh.org.uk

OH TODAY

41

Date 1958

History First symptoms identified and named Monkeypox in laboratory monkeys

1968

1978

Smallpox is eliminated in some regions of the Democratic Republic of Congo (DRC) through vaccinia-based vaccines, which also protected against Monkeypox.

First human case identified in DRC (Central African Clade) where Smallpox had been eradicated followed by cases in Benin, Cameroon (both clades), Central African Republic, Gabon, Cote d’Ivoire, Liberia, Nigeria, Sierra Leone and South Sudan.

Travel related case reported in Benin

1996-7

DRC outbreak reported with higher transmission but lower fatality rate

2003

First non-endemic outbreak in USA, linked to prairie dogs imported from Ghana

2017-

Largest outbreak in endemic country with mortality rate of 3%

2018

Outbreaks in Israel and UK linked to travel from endemic countries

2019

Outbreaks in UK and Singapore

2021

Outbreaks in USA

1970

How is it diagnosed?

The first 5 days of infection include the distinctive and diagnostic feature of lymphadenopathy, with the skin eruption

What is Monkeypox?

Monkeypox is a sylvatic zoonotic disease

appearing on extremities within 1-3 days of fever, which can severely affect the head, genitalia, mucous membranes and

that is normally found in non-human primates and rodents in Central and the West Coast of Africa. It is an Orthopoxvirus genus of the Poxviridae family. It has an incubation period of between 5 and 21 days and becomes untransmissible once the scabs have fallen off the spots.

There are two distinct genetic clades of the Monkeypox virus – the Central African (Congo Basin) clade (CBC) and the West African clade (WAC).

Thankfully this outbreak appears to be the usually self-limiting WAC, which

may look like a bad case of chickenpox or a syphilis rash.

At the time of writing, more than 120 confirmed or suspected cases of WAC Monkeypox have been reported in at least 11 non-endemic countries in the last week1, 20 of which are in the UK.

conjunctiva. Other symptoms include intense headache, back pain, myalgia and intense asthenia.

The rash evolves sequentially from macules (lesions with a flat base) to papules (slightly raised firm lesions), vesicles (lesions filled with clear fluid), pustules (lesions filled with yellowish fluid), and crusts which dry up and fall off. The number of lesions varies from a few to several thousand. In severe cases, lesions can coalesce until large sections of skin slough off.

Diagnostic testing samples need to be taken from the lesions and subject to Category B transportation. Although PCR testing is possible, it is not sufficiently reliable to provide asymptomatic or pre-rash diagnosis.

42

OH TODAY

Summer 2022

How is it transmitted?

professionals need to convene and

partner closely with these colleagues to

Transmission occurs via direct contact

rapidly apply our learnings of the last 3

with blood, bodily fluids, lesions on the

years. The COVID-19 pandemic has seen

skin or internal mucosal surfaces, such

the prevalence of mental ill-health

as in the mouth or throat, respiratory

increase by more than 25% and we now

droplets (aerosols / aerosol generating

need to support our healthcare

activities or procedures AGPs) and

colleagues once again as they deal with

objects contaminated with any of the

a high consequence infectious disease

above.

(HCID)3. We now have an opportunity to

Who is at risk?

develop and offer consistent standards

Healthcare workers are among the

support to prevent and manage

of health monitoring, education and

populations currently most at risk of

occupationally acquired infection whilst

contact with people incubating the

supporting our health protection

disease before definitive symptoms

colleagues.

indicate differential diagnosis.

Control of pathogens within the

Pregnant workers and their unborn and

workplace falls under the Control of

young children and those with underlying immune deficiencies at the time of infection are at risk of complications and are known to lead to worse outcomes. Risk reduction for vulnerable workers is an important

occupational issue, which is explored in the proposed vulnerable worker health risk assessment below.

The World Health Organisation (WHO) reports that health workers caring for patients with suspected or confirmed monkeypox virus infection, or handling specimens from them, should , if possible, be previously vaccinated against smallpox when selected to care for the patient2.

The role of Occupational Health Whilst our Public Health, Infection Prevention and Control (IPC) and Sexual Health (SH) colleagues will have been busy implementing the WHO’s recommendations for passive surveillance and early differential diagnosis of compatible symptoms, OH

Substances Hazardous to Health

Risk reduction for vulnerable workers is an important occupational issue

Regulations (COSHH) and recent events are an important reminder of the need to maintain our professional knowledge and engage in reflective practice.

A 2018 review4 of the occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak found that they need to be prepared for the potential psychological impact and a supportive workplace environment with specific support in place for those most at risk.

Once again, our role requires us to research, analyse, interpret and apply

emerging evidence, to lead on and roll out proactive evidence-based health monitoring including vulnerable worker health risk assessment (VWHRA), screening, immunisation and health education, post-exposure prophylaxis, and case management.

Since writing the UK governments have issued control guidance which can be found here.

ioh.org.uk

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43

2022 Monkeypox timeline:

A case tracker is available here and a new one is being developed by UK scientists.

2022

Details

Case total

7 May

First case reported by UKHSA linked to travel from an endemic country

13 May

West African clade of Monkeypox identified via RT PCR5

14 May

Two more, apparently unrelated, cases identified not linked to travel

3

16 May

Four human to human cases reported via sexual health services confirmed

by BASHH6 and BHIVA7 as amongst men who self-identify as MSM8

8

18 May

Two new cases with no known connections to previous confirmed cases

10

1

BASHH holds a webinar attended by 900 people 20 May

10 more cases reported by UKHSA

20

27 May

Global Health tracker developed https://monkeypox.healthmap.org/

106

iOH Members can read more at https://ioh.org.uk/resources/how-do-we-best-apply-the-learnings-from-covid-19to-monkeypox/

Sources 1

UBC and Jülich (FZJ), 2022. “Monkeypox Goes Global: Why Scientists Are On Alert”. Nature.Com. https://

www.nature.com/articles/d41586-022-01421-8.

2

https://www.who.int/news-room/fact-sheets/detail/monkeypox

3

WHO, 2022; “Introducing Mental Health And Psychosocial Support (MHPSS) In Emergencies”.

OpenWHO. https://openwho.org/courses/mental-health-and-psychosocial-support-in-emergencies.

4

Brooks, S; Dunn, R; Amlôt, R; Rubin, G; Greenberg, N; 2018. “a systematic, thematic review of social and

occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak”. Journal of Occupational and Environmental Medicine, Volume 60, Number 3, March 2018, pp.

248-257(10). https://doi.org/10.1097/JOM.0000000000001235 5

Reverse transcriptase polymerase chain reaction, commonly known as PCR in the context of COVID-19 testing

6

British Association for Sexual Health and HIV https://www.bashh.org

7

https://www.bhiva.org/BHIVA-rapid-statement-on-monkeypox-virus

8

MSM: Men who have sex with men

Lucy Kenyon is our immediate past-President and Non-exec Director. She was involved at the start of the COVID-19 response and, mindful of the importance of planning for the emerging evidence, she has drafted this to start the dialogue within OH to reduce risks to and support the healthcare workers that we protect.

44

OH TODAY

Summer 2022

The Interview OH Today Editors, Janet and Lynn caught up with Warren O’Neill to find out about his career as an OH Technician with PAM Group

How did you get into Occupational Health (OH)?

sector gave me good communication

I started in OH in 2008 with great

Working in the NHS gave me an

trepidation and uncertainty. I had no

understanding of the health care system

idea what OH was or how this was

and health in general which was very

encompassed in a business. I had

useful. Also completing the Access to

previously enjoyed a variety of roles

Nursing course and starting my nurse

ranging from Management, Healthcare

training was beneficial. Sadly for

and Customer Service. I soon realised

personal reasons I didn’t complete the

that I had lots of transferrable skills to

training. However, I had a good

draw on.

understanding of medical conditions

My first role was working for a car

and also how to interpret basic

manufacturing company covering Health Surveillance and Medicals. It was a brand-new role in the company which

and customer service skills and an understanding of dealing with people’s varying needs.

information and recognise symptoms for further escalation. It taught me the importance of accurate documentation

I had the opportunity to develop. I was

and obtaining a good history.

petrified but knew that if I didn’t try it, I

What essential skills do you feel a technician would need?

would never know if it was the profession for me. Since then, I have never looked back! 14 years on, each day is a learning curve and no one day is the same.

Well-developed communication skills, especially listening and accurate written

What skills were you able to transfer to an OH Technician?

documentation skills. Also, a friendly

Working in Management and the Retail

to recognise when to escalate queries

personality who puts people at ease and enjoys team work. Being able to work within your competency and to be able

ioh.org.uk

OH TODAY

45

are also critical skills. It's a practical job

the first person at will identify any

so good "common sense" helps too!

potential risk or harm to the employee’s

Do you need any formal qualifications to be an OH Technician?

It's not essential, but it can help build your knowledge and confidence. Most training is "on the job". I completed an accredited OH course with the University of Glamorgan. Unfortunately, this is no

longer running. I've been part of the Society of OH Medicine (SOM ) technician working group. Other health providers such as PAM are supporting the development of an accredited course

identified risk which is the business’s responsibility under health and safety legislation.

The technician is at the forefront of promoting health and wellbeing in the workplace and identifying the early signs of illness. This is facilitated during one-to-one health surveillance.

We also do assessment checks looking for hypertension, diabetes, hearing loss, occupational-related asthma, and musculoskeletal problems. We educate, guide and signpost employees for proactive prevention.

launching an OH technician course.

Promoting good health supports

Cumbria University delivers an OH

individuals to make healthier choices in

Diploma which is open to OH

their physical health and general well-

technicians – more information can be

being. It also reduces sickness in the

found here.

workplace. We use the principles of

What were your main challenges?

“making every contact count” or MECC

curve. Believe me, when you come into this role you will make errors but with good support and a willingness to learn, they can be turned into a positive.

for improving health.

What do Health Surveillance and Health Assessments involve?

Health Surveillance is an assessment that is undertaken in line with the

Legislation can be a challenge to keep

Health and Safety at Work Act 1974 and

up with but the HSE website became a

is based on risk assessments and the

valuable source with a wealth of

hierarchy of controls. This is broken

information for reference.

down into various assessments such as:

What does a technician’s role entail?

•

Audiometry

•

Spirometry (Resp Assessment)

The role varies depending on the

•

Skin

business you are working in. Being on

•

HAVS (Hand Arm Vibration

the frontline with employees, we generally get to know them well by carrying out regular health surveillance, assessments and reviews. We are often

OH TODAY

assess an individual’s health against the

via Open Awards. Cordell Health is also

Initially, the role was a fast-learning

46

health in the work environment. We also

Summer 2022

Syndrome) There are others based on risk assessments and exposure. Information

can be found on the HSE website with

another invaluable source of

and keep me on my toes!

Health Assessments assess the person

What is your advice to others thinking about being an OH technician?

to ensure that they are fit for their role.

I'd highly recommend it. Consider your

information being the SOM (Society of Occupational Medicine).

This requires a bit of more in-depth questioning. There are numerous levels of assessments that can be undertaken by a trained technician. Fork Lift Truck (FLT) Medicals, Crane Driver Medicals, Rail Workers, Freezer Workers, the list

transferable skills and be willing to learn. It’s a role that will continue to develop your skills. If you like working as part of a team, it may well be the role for you.

defined clinical colleague for further

Are there any networking groups that may help OH Technicians?

advice.

I belong to iOH (Association of

Where do you get your support from?

Occupational Health and Wellbeing

My Occupational Health manager and

development opportunities with

goes on! Working with standard policies and procedures, the technician will escalate any abnormal finding or health concern to a line manager or

colleagues are a huge support. Being

part of a team helps me to ask questions, look for the answers, and get different perspectives! It's so important to feel well supported.

How do you see your future?

OH Technician roles will keep developing and will differ for different

Professionals) which provides support, professional networking, learning and educational webinars and Continual

Professional Development. I’ve also joined the SOM OH Technician working group which means I can help guide the development of the profession. There are plenty of opportunities to be involved as a technician.

Any further resources that may help others?

employers and businesses. I keep

https://portal.e-lfh.org.uk/

learning even after spending 14 years in

SOM technician pathway

different industries.

I currently work for People Asset Management (OH Solutions), part of the PAM Group. I feel supported and able to thrive. PAM Group is a national company that covers all aspects of Preventative Healthcare, including

Occupational Health toolkit – IOSH Occupational Health topics HSE Health surveillance and work EUOSHA – Ill health identified through health surveillance

Occupational Health. It has a wealth of knowledge from its diverse employee workforce to enable me to keep learning

ioh.org.uk

OH TODAY

47

Book Review

by Karen Lever RNA, PG Dip Adv HCP.

Mental Health in the Workplace. A Practical Guide for Occupational Health Practitioners on Consultation and Report Writing, by Libby Morley-Hassanali.

I

n March this year a new book,

reflective piece as it encourages ways to

aimed at Occupational Health (OH)

consistently improve case management

Professionals and providing insight

and report writing.

to those working in HR and H&S roles, about mental health in the workplace was launched. It provides practical guidance on assessing an employee’s mental health, making clear clinical notes, and writing a report back to the business. Karen Lever, a final year student in OH, has this to say about the book: My initial thoughts were that I wished I had this book sooner! It provides clear advice, resources, and guidance on how best to support someone with mental health concerns, and how to complete the report in a clear non-biased manner”.

Suggesting a stress risk assessment to a manager can feel daunting, however with the excellent examples of how best

to communicate this, and an actual stress risk assessment and action plan towards the back of the book, it helps to ensure that the advice within the report is non-inflammatory. I particularly liked reading the case studies, and the

The book addresses and provides excellent examples of how to broach the more challenging subjects of self-harm and suicide in an honest and empathic way, and I feel I have started to bridge some of the gaps in my own knowledge.

The resources signpost to further reading, national organisations,

wellbeing Apps and sector-specific information; this is great and provides additional support and guidance to us as the reader, which we can then pass on to the employee and the employer.

I have read hundreds of OH books over the last 2 years and this one stands out a mile. The structure means it is great for those new into OH but also provides plenty to learn for those who have been in OH for a while.

I would highly the book to anyone working in OH. There is so much relevant content. I feel much more confident in my own practice having this book as a valuable “go to resource”.

I feel much more confident in my own practice having this book as a valuable go-to resource 48

OH TODAY

Summer 2022

Mental Health in the workplace; A Practical Guide for Occupational Health Practitioners on Consultation and Report Writing

Mindshift is proud to announce the launch of a brand-new book, aimed at Occupational Health Practitioners, but highly insightful for those working within HR, H & S and Management.

It will be selling for £34, and available via https://mindshiftconsultancy.co.uk/ 5% of any profits will be shared between MIND and Nurse Lifeline

My aim within this book is to fill any knowledge-gaps you may have around the subject of mental distress and to increase your confidence and competence…

This book is packed with helpful information including : • risk factors for and signs of mental distress • supporting someone experiencing anxiety, depression, self-harming or suicidal behaviour,

an eating disorder or psychosis

• tips on getting the most of your assessment • useful phrases to use in your report • templates for your notes and your report • adjustments to support a recovery • case studies • detailed stress risk assessment and action plan • recommendations on wider reading • signposting to key resources

Release Stress and Change the Groundhog Day Nikki J. Owen, Founder of The Healing Hub Are you feeling trapped in a never-ending Groundhog Day of busyness, work overload, crisis, and exhaustion?

You’re not alone.

A

ccording to a report by Mind*

odds, aged eighteen. (Nicola Owen –

85% of adults and 91% of

Wikipedia).

young people surveyed are

suffering from acute mental health issues, intensified by the fear and anxiety around the pandemic. These findings are corroborated by evidence from the UK Household Longitudinal Study** that tracked changes in levels of psychological distress during the pandemic.

restored back into balance, the trauma of the past few years triggered a spiral of mental health issues and increased stress and anxiety. Looking back, it was

a defining moment in my life that has taken me on a journey of self-discovery

loneliness, sleep, and stress are

and emotional healing.

Occupational Health Practitioners who witnessing these issues more frequently in their patients/clients and struggling with their own mental health challenges.

It took ten years to feel in control of my life rather than feeling that life was controlling me. I studied different healing interventions from psychotherapy and hypnosis to breathwork and energy releasing tools.

My own mental health issues began with

After turning my own life around, I

the onset of menstruation when my

began applying the tools and techniques

unstable hormone levels caused

that had helped me. For three decades

depression, a tendency towards violent

I’ve worked with thousands of people,

and psychotic behaviour, panic attacks

helping them to make small daily

and addiction. I ended up in prison,

changes so that their lives are easier to

where I was kept in solitary

navigate.

confinement. My case made legal history on 22nd December 1978 at The Old

OH TODAY

Even when my hormone levels were

Anxiety, depressive symptoms, becoming a growing nightmare for

50

I was given a second chance.

The root of stress

Bailey, when the judge accepted

Many people try to resolve stress based

premenstrual syndrome as a mitigating

on what’s happening in the current

factor and I was freed against all the

moment. This is like trimming a weed

Summer 2022

and expecting it not to grow again. The

Often it takes a harsh blow, a major

root of stress and mental health issues

illness, or a devastating event to

comes from pent up emotions from the

recognise that unless we prioritise our

past that we have not been able to

own emotional wellbeing, we cannot

express, process and release.

truly empower, support, and help

If you have young children, you’ll have witnessed their temper tantrums.

Occasions when they express their pentup feelings by screaming, pummelling their fists, and stamping their feet.

others. But it’s hard to work on ourselves. The fear about opening our ‘can of worms’ often stops us from addressing past issues in the belief that it’s best not to rehash painful situations.

Moments later they are calm. All human

But the mountain of negativity living

beings have this natural ‘tantrum’

inside our body, needs soothing. We find

mechanism that brings us back into

coping strategies such as escapism

homeostasis. In mammals this

through work, excessive exercise,

mechanism is observed as shaking and is

shopping addiction, taking solace from

referred to as a neurogenic tremor.

alcohol, drugs, food, or sex.

As we grow up, we learn to push down

Over-thinking, overanalysing.

our emotions. This maybe a conscious suppression of how we feel. For example, if a little boy falls over and cries, his

As negative thoughts multiply and

father may say “big boys don’t cry” and

gather momentum they stampede into

the child learns to hold their emotions

our lives with such force that we are

in check. During intense moments of

often left stunned by the overwhelming

fear, instead of activating the fight or

sense of despair and frustration. Toxic

flight response, we experience a freeze

thoughts from our past, contaminate

response. We push down the emotions

our happiness in the present moment.

associated with that event, and it

Thoughts about the future create fear

remains repressed within our emotional

and anxiety now. Our minds become so

and physical body.

full of these hallucinations around what

Over the years, levels of unprocessed emotion build up, layer upon layer.

might happen that we feel impotent in our ability to tell illusion from reality.

Then, something in the present

Releasing unprocessed emotions helps

moment, triggers the eruption of a

to restore our autonomic nervous

lifetime’s worth of emotions. Therefore

system back into balance so we feel

we feel overwhelmed, and our emotional

lighter, calmer, more at peace with life,

reactions become out of proportion.

even when it becomes challenging.

Ignoring the signs

But how can this be done in a way that’s

When we are so busy caring for other people, we sometimes fail to recognise the needs of ourselves. In today’s culture of ‘busyness,’ we don’t have time to squeeze self-care into our daily routine.

When we are so busy caring for other people, we sometimes fail to recognise the needs of ourselves.

easy and comfortable?

The way we breathe influences how we feel Wilhelm Reich MD in the 1920s, was an Austrian psychotherapist who used open mouth breathwork to soften ioh.org.uk

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Quick way to release stress

unprocessed emotions, making it easier

to release them. Stanislov Grof, M.D, a Czech psychiatrist, developed this

1.

technique and evolved it into

Take 5 deep open-mouth breaths.

Holotrophic Breathwork.

When you inhale push out your

This style of breathing transports vast

stomach.

quantities of oxygen into the

2.

bloodstream and changes the 50 trillion

10.

cells in our body from an operating

3.

mechanism of survival to one of growth. emotional and physical health. Would built from crumbling bricks? Many of us are living in a body built from unhealthy cells that have entered a cellular lockdown. This means that our cells are unable to receive nourishment from serotonin or oxytocin.

Every individual holds their life story in their physical body.

Over the years we have adapted the way we breathe to keep emotions buried. As the musculature tightens, our breath becomes shallow. If there were no ‘old emotions’ held in the body, then our muscles can relax, and we have more

Imagine pummelling a boxing ball for the count of 10

Cells are the building blocks of

you feel safe and secure living in a house

Hold your breath for the count of

4.

Over the years we have adapted the way we breathe to keep emotions buried

Hold your left wrist and repeat the

word “peace” three times

Since the turbulent events from my youth, I recognise that if we want to get more from life, then we must be prepared to work on ourselves. Every difficulty we encounter gives us a unique opportunity to wake up our potential and experience a better version of who we are and how we show up in the world.

You don’t have to keep battling stress when there is an array of powerful tools that can be used in the comfort of your own home. If you are ready to prioritise your own self-care, then now is the time

space to breathe.

to do so.

Watch a tiny baby sleeping and you’ll

For more information about the

observe that their whole body is breathing – their back, belly and chest move together effortlessly. This natural

ebb and flow to the breath usually changes when life’s challenges, change

transformational tools Nikki J. Owen has been using for three decades visit www.thehealinghub.uk and to learn

more about her story visit www.nikkijowen.com

breathing patterns. Every trauma, every belief, every experience has danced along your breath, altering, and shaping it until it becomes an accurate representation of the way you flow, or

*Coronovirus: the consequences for mental health. July 2021 published by Mind **Longitudinal changes in mental health

not, through life.

and COVID-19 pandemic

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OH TODAY

Summer 2022

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