4. Payton, PBD testing for alcohol misuse, 24Apr13
4. Payton, PBD testing for alcohol misuse, 24Apr13
4. Payton, PBD testing for alcohol misuse, 24Apr13
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Testing <strong>for</strong> <strong>alcohol</strong> <strong>misuse</strong><br />
at work<br />
Colin <strong>Payton</strong><br />
Royal United Occupational Health<br />
Bath
How do we<br />
test <strong>for</strong><br />
<strong>alcohol</strong>?
Testing <strong>for</strong> <strong>alcohol</strong><br />
•Blood<br />
•Breath
Random <strong>testing</strong><br />
• Breath <strong>alcohol</strong><br />
• Liver function tests<br />
• Gamma glutamyl transferase (GGT)<br />
• FBC – MCV
No excuses<br />
• Signed agreement<br />
• Attend within 3 hours<br />
• Notify non-availability 1 week in advance<br />
• Abnormal results reported to manager<br />
• Refusal or failure to attend reported to manager
Support programme<br />
• Occupational physician<br />
• EAP – addictions counsellor<br />
• Local organisations<br />
• New Highway<br />
• DHI<br />
• AA
GGT<br />
Gamma glutamyl transferase<br />
• an enzyme on cell membranes<br />
• rises in<br />
• <strong>alcohol</strong> <strong>misuse</strong><br />
• drugs<br />
• anticonvulsants,<br />
• anticoagulants,<br />
• oral contraceptives and<br />
• some antibiotics<br />
• GGT 85% specific but useful<br />
• no liver disease<br />
• not taking medication<br />
• other indicators of <strong>alcohol</strong> <strong>misuse</strong>
Elevated GGT<br />
• substantial<br />
• variable<br />
• not likely after single episode<br />
• sustained <strong>misuse</strong><br />
• regular v episodic drinking<br />
• the greater the amount of <strong>alcohol</strong> consumed per day.<br />
• starts to fall within one week of cessation<br />
• rises more quickly after relapse in known <strong>misuse</strong>
AST and ALT – The Aminotransferases<br />
• useful as markers of hepatic damage from<br />
<strong>alcohol</strong><br />
• much less sensitive than GGT<br />
• can be elevated <strong>for</strong> a wide variety of reasons<br />
• do not rise after a single episode<br />
• ALT often correlates with GGT<br />
• of limited value
MCV<br />
• toxic effect on the bone marrow<br />
• 35-40% patients<br />
• a low sensitivity<br />
• other common causes of a high MCV<br />
• co-exist in <strong>alcohol</strong> <strong>misuse</strong>.<br />
• high MCV is 90-95% specific<br />
• falls when drinking stops - Slowly
CDT<br />
Carbohydrate deficient transferrin<br />
• raised in at least 80% of people who <strong>misuse</strong><br />
<strong>alcohol</strong>.<br />
• very specific<br />
• more expensive and not routinely available
RTP –benefits<br />
• Clarity<br />
• Honesty<br />
• Openness<br />
• Negative tests are evidence of sobriety<br />
• Increased awareness amongst employers<br />
• Alcohol <strong>misuse</strong> in workers<br />
• Our programme
Case 1<br />
Secretary 50<br />
“I drink a bottle of vodka<br />
every other night”<br />
“I have not had a drink now<br />
<strong>for</strong> 4 days”
250<br />
229<br />
200<br />
150<br />
100<br />
103<br />
<strong>alcohol</strong><br />
GGT<br />
MCV<br />
50<br />
67<br />
0
250<br />
229<br />
200<br />
150<br />
100<br />
103 105<br />
<strong>alcohol</strong><br />
GGT<br />
MCV<br />
67<br />
92<br />
50<br />
0<br />
0
250<br />
229<br />
200<br />
150<br />
<strong>alcohol</strong><br />
100<br />
103 105<br />
99<br />
GGT<br />
MCV<br />
67<br />
92<br />
50<br />
48<br />
0<br />
0 0
Case 2<br />
45 year old man in senior position<br />
• Referred by employer<br />
• Defaulted 6 times<br />
• Complaints<br />
• became unsteady and had to complete a<br />
presentation sitting down<br />
• Lot of travel
900<br />
800<br />
839<br />
700<br />
600<br />
500<br />
400<br />
<strong>alcohol</strong><br />
GGT<br />
ALT<br />
300<br />
200<br />
100<br />
99<br />
0<br />
17
900<br />
800<br />
839<br />
700<br />
600<br />
500<br />
400<br />
601<br />
<strong>alcohol</strong><br />
GGT<br />
ALT<br />
300<br />
200<br />
100<br />
0<br />
17<br />
99<br />
0<br />
52
900<br />
800<br />
839<br />
700<br />
600<br />
500<br />
400<br />
601<br />
<strong>alcohol</strong><br />
GGT<br />
ALT<br />
300<br />
200<br />
100<br />
0<br />
17<br />
99<br />
0 0<br />
190<br />
52 41
900<br />
800<br />
839<br />
700<br />
600<br />
500<br />
400<br />
601<br />
<strong>alcohol</strong><br />
GGT<br />
ALT<br />
300<br />
353<br />
200<br />
100<br />
0<br />
17<br />
99<br />
190<br />
52 41<br />
0 0 0<br />
87
900<br />
800<br />
839<br />
700<br />
600<br />
500<br />
400<br />
601<br />
<strong>alcohol</strong><br />
GGT<br />
ALT<br />
300<br />
353<br />
200<br />
262<br />
100<br />
0<br />
17<br />
99<br />
190<br />
52 41<br />
87<br />
153<br />
44 57<br />
0 0 0 0 0
900<br />
800<br />
839<br />
700<br />
600<br />
500<br />
400<br />
601<br />
<strong>alcohol</strong><br />
GGT<br />
ALT<br />
300<br />
353<br />
353<br />
200<br />
100<br />
0<br />
17<br />
262<br />
190<br />
153<br />
0 0 0 0 0 0<br />
102<br />
27
Foolproof ?
39 year old receptionist<br />
• Episodic binge drinker –<br />
• Sober <strong>for</strong> months at a time<br />
• ‘Self destructive’<br />
• Difficult marital relationship<br />
• Unfaithful<br />
• Duplicitous<br />
• Calculating<br />
• Disappears…<br />
• Reappears – UIA<br />
• Blood tests persistently normal
Fall back or<br />
alternative method<br />
Episodic binge drinkers<br />
When random <strong>testing</strong> not funded<br />
• Random breath <strong>testing</strong> or<br />
• Urgent <strong>testing</strong> when UIA
45 year old college lecturer<br />
• Referred October – concerns re heavy<br />
drinking and per<strong>for</strong>mance<br />
• OH assessment<br />
• Harmful use of <strong>alcohol</strong><br />
• Follow up offered<br />
• Urgent <strong>testing</strong> service offered<br />
• Telephone call January - ? UIA at work<br />
• Breath <strong>alcohol</strong> = 60μg/100ml<br />
• Issues?<br />
• Consent<br />
• Reporting<br />
• Advice<br />
• Driving
45 year old college lecturer<br />
• Issues?<br />
• Consent<br />
• Reporting<br />
• All covered by protocol/consent<br />
• Advice<br />
• Fitness <strong>for</strong> work – that day?<br />
• Further assessment – when?<br />
• Anything else?<br />
• Driving
Programme results
Alcohol <strong>misuse</strong> clients<br />
61<br />
total 61<br />
RTP 35<br />
complete 27<br />
on going 6<br />
35<br />
29<br />
5<br />
1<br />
total<br />
random <strong>testing</strong><br />
complete<br />
on going<br />
withdrawn<br />
total<br />
RTP<br />
complete
RTP<br />
<strong>alcohol</strong> use<br />
drinking<br />
12<br />
34%<br />
total 61<br />
RTP 35<br />
complete 27<br />
on going 6<br />
unknown<br />
1<br />
3%<br />
sober<br />
22<br />
63%<br />
Total = 35<br />
total<br />
RTP<br />
complete
RTP - work status<br />
resigned<br />
1<br />
3%<br />
unknown<br />
1<br />
3%<br />
dismissed<br />
9<br />
total 61<br />
RTP 35<br />
complete 27<br />
26%<br />
on going 6<br />
in work<br />
22<br />
69%<br />
Total = 35<br />
total<br />
RTP<br />
complete
Those in work - <strong>alcohol</strong> use<br />
drinking<br />
2<br />
total 61<br />
RTP 35<br />
complete 27<br />
on going 6<br />
sober<br />
20<br />
Total = 22<br />
total<br />
RTP<br />
complete
Conclusions<br />
• Intensive support programme<br />
• OH support + Therapy + Random <strong>testing</strong><br />
• Helps <strong>alcohol</strong>ic workers to stop drinking<br />
• Helps <strong>alcohol</strong>ics to remain in employment<br />
• Long term health benefits likely
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