National Authorised Health Professional Training Program Drugs and Alcohol

1. National Authorised Health Professional Training ProgramDrugs and Alcohol

2. Participating Rail Operators ARTC Brookfield Rail KiwiRail RailCorp

3. Session Objective To support doctors in developing the competencies required to Understand the drug and alcohol testing requirements in each state and of participating rail operators Undertake and interpret the results of drug and alcohol tests for participating rail operators Manage employees and contractors of participating rail operators who have drug and alcohol abuse and/or dependence Understand and be able to manage the rehabilitation and return to work of rail safety workers who have tested positive to alcohol or an illicit drug at work or at a medical assessment

4. Program National Standard requirements Legislative requirements Operator specific D&A policy requirements Conducting drug tests Interpreting drug tests Alcohol Rehabilitation

5. National Standard Requirements

6. AUDIT Questionnaire If the person has an AUDIT score of eight or greater the person may be classified Fit for Duty Subject to Review or Temporarily Unfit for Duty while causes are being assessed and managed. Workers with scores of 8-15 may be managed within the consultation by providing simple advice and information on the alcohol guidelines and risk factors. If the risk is assessed as being low certify fit subject to review Workers with scores of 16-19 should be managed by a combination of simple advice, brief counselling, and continued monitoring. Follow-up and referral to the worker’s general practitioner is necessary. Certify fit subject to review or temporarily unfit. Workers with scores of 20 or more should be referred to specialist services to consider withdrawal, pharmacotherapy and other more intensive treatments. Assess as Temporarily Unfit for Duty pending further assessment.

7. Item content of the AUDIT

8. Assessment of workers with substance misuse disorders Careful individual assessment must be made of workers who misuse or are suspected of misusing alcohol or other substances (prescribed or illicit). Assessment will require consideration of the worker’s substance use history, response to treatment and their level of insight. During clinical assessment, patients may understate or deny substance use for fear of consequences of disclosure. The acute and chronic cognitive effects of some substance use also contribute to difficulty in obtaining accurate history and identification of substance use. Assessment should therefore incorporate a range of indicators of substance use in addition to self-reporting. Secondary opinion from an appropriate specialist, such as an addiction medicine specialist or addiction psychiatrist, may be necessary, and further assessment such as neuro-psychological assessment may be indicated. In particular, people with combined substance use disorder and mental illness (‘dual diagnosis’) may have a level of complexity requiring specialist assessment. Chronic misuse of drugs is incompatible with safe working. Thus, generally workers would be classed as Temporarily Unfit for Duty while their condition is being investigated and treated.

9. Substance misuse A person is not fit for safety critical work If there is evidence of illicit drug use, or abuse or dependence of any substance. Fit for duty subject to review may be determined, subject to at least annual review, taking into account the nature of the work and information provided by an appropriate specialist (such as an addiction medicine specialist or addiction psychiatrist) as to whether the following criteria are met: the person is involved in a treatment program and has been in remission* for at least six months; and there is an absence of cognitive impairments relevant to safe working; and there is absence of end-organ effects that impact on safe working (as described elsewhere in this publication). the risk of further illicit drug use or other substance misuse is assessed as being low.

10. Remission A strong response to treatment and well-documented abstinence and recovery (remission) may enable determination of fit for duty subject to review. Remission is attained when there is abstinence from use of illicit drugs or where the use of other substances such as alcohol has reduced in frequency to the point where it is unlikely to cause impairment or to result in a positive test at work. The worker’s substance use history, response to treatment and level of insight should be considered, as well as the drug and alcohol and rehabilitation policies of the rail transport operator. Remission should be confirmed by biological monitoring over a period of at least 6 months for category 1 and 2. Patients with severe substance use problems who have had previous high rates of relapse and fluctuation in stabilisation would not be considered fit to return to safety critical work. Occasional use of drugs also requires very careful assessment, and consideration of the drug and alcohol policy of the rail transport operator.

11. Rail Legislation

12. Rail Safety National Law 6—Declaration of substance to be drug (2) A declaration under subsection (1)— (a) is to be published on the NSW legislation website in accordance with Part 6A of the Interpretation Act 1987 of New South Wales; and (b) will commence on the day specified in the declaration for its commencement (being not earlier than the date it is published); and (c) is to be published by ONRSR on its website.

13. Division 9—Drug and alcohol testing by Regulator 126—Authorised person may require preliminary breath test or breath analysis (1)Subject to this section, an authorised person may at any time require a rail safety worker who— (a) is about to carry out rail safety work; or (b) is carrying out rail safety work; or (c) is attempting to carry out rail safety work; or (d) has carried out rail safety work; or (e) without limiting a preceding paragraph—is involved in a prescribed notifiable occurrence, to submit to testing by means of a preliminary breath test or breath analysis (or both). Rail Safety National Law

14. 127—Authorised person may require drug screening test, oral fluid analysis and blood test (1) Subject to this section, an authorised person may at any time require a rail safety worker who— (a) is about to carry out rail safety work; or (b) is carrying out rail safety work; or (c) is attempting to carry out rail safety work; or (d) has carried out rail safety work; or (e) without limiting a preceding paragraph—is involved in a prescribed notifiable occurrence, to submit to a drug screening test, oral fluid analysis or blood test (or any combination of these). Rail Safety National Law

15. 128—Offence relating to prescribed concentration of alcohol or prescribed drug (1) A rail safety worker must not carry out, or attempt to carry out, rail safety work (a) while there is present in his or her blood the prescribed concentration of alcohol; or (b) while a prescribed drug is present in his or her oral fluid or blood; or (c) while so much under the influence of alcohol or a drug as to be incapable of effectively discharging a function or duty of a rail safety worker. (5) prescribed concentration of alcohol means….any concentration of alcohol in the blood prescribed drug means delta-9-tetrahydrocannabinol Methylamphetamine (Methamphetamine) 3,4-Methylenedioxymethylamphetamine (MDMA) any other substance declared by the national regulations to be a prescribed drug for the purposes of this section Rail Safety National Law

16. 115—Drug and alcohol management program A rail transport operator must prepare and implement a drug and alcohol management program for rail safety workers who carry out rail safety work in relation to railway operations in respect of which the operator is required to be accredited that complies with the prescribed requirements relating to drug and alcohol management programs. Rail Safety National Law

17. Rail Safety National Law National Regulations 28—Drug and alcohol management program (1) For the purposes of section 115 of the Law, a D&A management program of a rail transport operator must include the following: (a) a D&A policy that sets out the objectives of the rail transport operator with respect to D&A management in the workplace; (b) systems and procedures for the provision of information and education to rail safety workers in relation to the drug and alcohol management program; (c) systems and procedures to ensure the confidentiality of personal information obtained from, or in respect of, a rail safety worker in relation to drug or alcohol testing, counselling, treatment or rehabilitation; (d) details of the drug and alcohol testing regime, including testing procedures and procedures for the management of rail safety workers in respect of the results of such testing;

18. Rail Safety National Law National Regulations (5) The drug and alcohol management program of a rail transport operator must provide for the following measures to be taken by or on behalf of the operator: (a) the establishment of rules relating to the use of drugs and alcohol by rail safety workers (including prohibitions and restrictions on use); (b) the identification of rail safety workers who have alcohol or other drug related problems and, where appropriate, referral of those workers to assessment, treatment, counselling or rehabilitation.

19. Rail Safety National Law National Regulations (6) The drug and alcohol management program of a rail transport operator must set out the obligations of rail safety workers with respect to the management of alcohol and other drug use and the actions that may be taken by the operator if there is a breach of those obligations, including the following: (a) a requirement that a rail safety worker notify the operator, or a nominated person, if the worker is aware that the ability of the worker, or another worker, to carry out rail safety work may be impaired by alcohol or any other drug; (b) the provision of education and rehabilitation measures for rail safety workers, including provision for information to be provided about referral to counselling, treatment and rehabilitation services where appropriate; (c) the provision of information to rail safety workers about their responsibilities and obligations in relation to alcohol and other drug use under an Application Act of a participating jurisdiction and the Law; (d) the provision of information to rail safety workers with respect to the effect of alcohol and other drugs and the possible disciplinary action and other penalties that may apply if a rail safety worker fails to comply with the drug and alcohol management program; (e) appeals and grievance mechanisms for dealing with complaints about the application of disciplinary action and other penalties, or the implementation of the drug and alcohol management program; (f) protocols for fair procedures relating to the operation of the drug and alcohol management program.

20. Rail Safety National Law National Regulations (2) For the purposes of subregulation (1)(d), the drug and alcohol testing regime of a rail transport operator required to be accredited in respect of railway operations carried out within NSW must include the following: (a) in relation to drug and alcohol testing (i) in each year on a random basis using risk management principles to select rail safety workers (being not less than 25% of all rail safety workers carrying out rail safety work within New South Wales in relation to the operator's railway operations), the operator must require the workers to submit to a preliminary breath test or breath analysis, or to provide a urine sample; and (ii) if a rail safety worker is involved, or is reasonably suspected of having been involved, in a prescribed incident while carrying out rail safety work within New South Wales in respect of the operator's railway operations, the operator must, unless there is a reasonable excuse for not doing so, require the worker to undergo, within 3 hours immediately after the incident, drug and alcohol testing; and (iii) that testing referred to in either of the preceding subparagraphs must be carried out by an authorised person engaged by the operator for that purpose;

21. Rail Safety National Law National Regulations (b) that the operator must notify the Regulator, in a form approved by the Regulator, of (i) an analysis of blood confirming the presence of a drug in the blood of a rail safety worker; and (ii) an analysis of blood confirming that the prescribed concentration of alcohol is present in the rail safety worker's blood; and (iii) an analysis of urine confirming the presence of a drug in the urine of a rail safety worker; and (iv) a breath test indicating that the prescribed concentration of alcohol is present in a rail safety worker's breath or blood; and (v) a breath analysis confirming that the prescribed concentration of alcohol is present in a rail safety worker's breath or blood; and (vi) any rail safety worker who, when required to do so under the D&A management program of the operator, fails to undergo a breath test, undergo a breath analysis, or provide a sample of blood or urine; and (vii) any incident or suspected incident involving the interference or tampering with, or the destruction of, a sample of a person's blood or urine provided or taken under the D&A management program of the operator in contravention of that program; and (viii) any incident or suspected incident involving something being done in contravention of the D&A management program of the operator to introduce, or alter the concentration of, alcohol or any other drug in a rail safety worker's breath, blood or urine before the worker submitted to a breath analysis or provided a sample of blood or urine under that program.

22. Other legislation NSW Rail Safety (Adoption of National Law) Act and Regulation 2012 NSW enable random and targeted testing of rail safety workers for drug and alcohol use and set out the procedures for breath testing, breath analysis and for blood, oral fluid and urine drug testing. In the case of urine drug testing AS/NZS 4308:2008 must be followed New Zealand Road limits < 20 = 0% > 20 = 0.08% Health & Safety in Employment Act 1992 and Railways Act 2005 Urine Opiates, amphetamine type substances, cannabis metabolites, cocaine metabolites, benzodiazepines

23. Operator-specific drug & alcohol policy requirements

24. Drug & Alcohol Policy

25. ARTC Drug and Alcohol Policy – Health Assessments If a pre-employment, periodic or targeted health assessment returns a positive drug test result, report this as follows: indicate in Part B (Health Professional to Complete) that the drug screen result is positive; tick “temporarily unfit for duty”; and inform the People Culture and Development representative immediately. For all positive alcohol results, inform the People Culture and Development representative immediately and provide notification in writing.

26. ARTC: D&A screening only Where a health assessment is not requested, if a pre-employment drug and alcohol screen returns a positive result: inform the People Culture and Development representative immediately; and Provide notification in writing.

27. Kiwirail Drug and Alcohol Policy KiwiRail and RMTU Drug and Alcohol Collective Agreement KiwiRail Drug and Alcohol Policy and a new policy currently in consultation process to introduce random testing

28. RailCorp – Positive Cases • If a pre-employment is positive report this by ticking “drug test positive” and also tick temporarily unfit • If an employee is positive inform RailCorp’s CHO on (02) 98221956 or the Manager Drug and Alcohol Detection on (02) 89224176 • If a contractor is positive • tick “D&A test positive” and also tick temporarily unfit • email the health assessment report to petersham_competencycards@railcorp.nsw.gov.au or fax (02)9752 8951 • Re-testing of positive cases is not permitted unless part of a rehabilitation program

29. Drug Testing

30. AS/NZS 4308:2008 • Urine drug tests must follow AS/NZS 4308:2008 • NATA accreditation of the collecting agency to part 2 of AS/NZS 4308:2008 • chain of custody • standard cut off values for screening and confirmation • mass spectrometry confirmation required for all immunoassay detections • Ensure the testing laboratory is specifically accredited by NATA to conduct testing to parts 4 and 5 of AS4308:2008 www.nata.asn.au • Witnessed collection is not required by AS4308 and the collection must NOT be witnessed unless this has been specifically requested • Order “AS/NZS 4308:2008 UDS” to ensure that the laboratory follows the correct procedures and maintains chain of custody • Do not order simply a “UDS” or “D&A test” • Consider adding urine urea to check for synthetic urine

31. Synthetic Urine Contains: Water Colour Creatinine Measuring another constituent of urine such as urea can be a useful screening test

32. Creatinine Cr ≥1.76mmol/L - acceptable Cr 0.44 – 1.76mmol/L - repeat test Cr <0.44mmol/L - not consistent with human urine

33. Dilution Effect of consuming 1L of water in 15 minutes Acknowledgement Dr John Lewis

34. AS4308 immunoassay screening test cut-off levels

35. AS4308 confirmatory test cut-off levels

36. AS4308 confirmatory test cut-off levels

37. Reviewing Laboratory Reports check name is temperature in range? (33-38°C) check urinary Cr (≥1.76mmo/L) check urine urea (normally approx 10-40x Cr) adulterant screen any declared medications immunoassay result GCMS confirmation result

38. Drug Testing - medications • Ask carefully about prescription and over-the-counter medications before testing but you may also need to contact the worker for further history once the result is received • pain killers eg Panadeine, Nurofen Plus, Mersyndol • codeine is metabolised to morphine • cough mixtures and lozenges - pholcodine • cold and flu tablets – pseudoephedrine • appetite suppressants - phentermine • benzodiazepines • Positive means that an illicit drug has been detected or there is evidence that a prescribed drug is being abused. Prescribed and over-the-counter medications that have been declared should generally be reported as negative

39. Benzodiazepine metabolism

40. Major benzodiazepine metabolites Alprazolam – α hydroxyalprazolam Clonazepam – reduction to 7 aminoclonazepam Flunitrazepam – 7 aminoflunitrazepam Nitrazepam – 7 aminonitrazepam

41. Medication positives • Cocaine eye drops (extemporaneous) • Dexamphetamine • not Ritalin (methylphenidate) • Selegiline is metabolised to l-methamphetamine and then to l-amphetamine • Vicks inhaler (USA) contains l-methamphetamine • Marinol (USA)

42. Drug detection times