For North American Occupational Safety and Health Week, we spoke with Dr. Karla Armenti, the principal investigator for the Occupational Health Surveillance Program within the New Hampshire Department of Health and Human Services. She has been analyzing poison center data to look for trends in workplace poisonings.

What are the main occupational safety and health issues for New Hampshire employees today?

Karla Armenti: Actually we are continuing to see a steady number of occupational poisoning exposures as reported to the poison center. The numbers have remained consistent for most substances, however upon analysis, we see an increase in exposures involving cleaning substances used in industrial or janitorial (cleaning industry) environments.

Other issues of concern involve ergonomic-related, or musculoskeletal injuries involving upper extremities and low back.

Our work-related fatality rate has increased, especially in 2012, where we had 14 fatalities.  Of these, 4 involved tree-cutting activities.

You recently did a survey of immigrants in New Hampshire to better understand the occupational health of this working population. What was the most important thing you learned in your research?

KA: 62% of those surveyed had never heard of workers’ compensation and did not understand what their rights were when injured at work.

Many of our immigrants (including refugees settled in New Hampshire) were highly educated in their home country, but the only job they could get here was in cleaning or home health care. They reported that they knew when conditions at work were not safe but were fearful of losing their job. They often reported no knowledge of OSHA or workplace safety regulations. There is a critical lack of understanding about their employer’s responsibilities in this country with regard to keeping them safe at work.

The NNEPC manages approximately 150 occupational poisonings a year in New Hampshire. You have been analyzing our data to better understand this issue. What are some interesting findings? How has this data been useful to your work?

KA: Yes, our New Hampshire poison center data are critical to our surveillance efforts. We recently completed a study looking at data from 2009 to 2011 and found that chemicals, household and industrial cleaning substances, fumes/gases/vapors, heavy metals, and hydrocarbons are among the top contributors to occupational exposures in New Hampshire. We also see that among all age groups, the number of cases was greater for males than for females and the most common age group for both genders was the 20s. The highest percent for exposure route was inhalation, with dermal and ocular exposures evenly distributed, while ingestion was the lowest.

Despite existing intervention and education efforts, reported occupational exposure rates have remained relatively steady since 2005. The substances involved in the most exposures are widely used in workplace environments, and should be a focus of public health injury prevention efforts. While safety training, better enforcement of safe practices, and improved preventive maintenance of equipment are important interventions for these risks, ultimately the most effective intervention would be to limit the use of potential poisons in the workplace.

It is noteworthy that a number of the poisonings in our study occurred during a cleaning activity, performed across different types of businesses. While cleaning is often necessary in many industrial sectors, specific cleaning chemicals are not essential per se to the production process or final product. Thus, cleaning could be targeted as a high priority for substituting toxic substances with less hazardous ones to prevent workplace poisonings.

What do you hope to see happen to improve occupational safety and health in Northern New England and the U.S. in the next 5-10 years?

I would like to see an increased focus on primary prevention that includes stronger efforts to eliminate hazards in the workplace through design and chemical substitution.

There is a lot of promise in workplace wellness and health promotion activities; however, there must be a concerted effort to integrate workplace safety and health into these strategies for a more holistic and successful approach. We often spend more than 8 hours a day at work.  We need to understand that what we do at work influences our health just as much as anything else we do–and maybe more!

Preventing suicides requires programs that reduce these negative factors and promote resilience and supportive relationships during difficult times. On a personal level, we need to be able to recognize warning signs of suicide and keep the person safe until they get help from a trained professional.

Warning signs of suicide include:

• Talking about wanting to die; feeling hopeless, trapped, or in unbearable pain; feeling like a burden to others
• Looking for a way to kill oneself
• Increasing the use of alcohol or drugs
• Acting anxious, agitated, or reckless
• Sleeping too little or too much
• Withdrawing or feeling isolated
• Showing rage or talking about seeking revenge
• Displaying extreme mood swings

The more warning signs a person has, the greater the risk of suicide. If you think someone is at risk, do not leave them alone. Be sure to remove firearms and poisons (such as medications), call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), and take the person to the emergency department or connect them with a medical or mental health clinic.

If you live with someone who has a history of substance abuse or suicidal behavior, always keep firearms and other lethal items in a locked cabinet, and buy only small quantities of medications you need and store them in a locked box. Dispose of unwanted medications frequently – participate in local medication take back events.

To learn more about suicide prevention programs and recommendations read the 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action.

If you have questions about a possible poisoning, call the poison center at 1-800-222-1222 or chat online.

Nationally, males account for 79% of all suicides and are more likely to use a firearm. The rates are highest for males among those 75 years and older. Females are more likely to use poisoning and the rate of suicide is highest among those 45-54 years of age.

In 2010, there were an estimated 465,000 people with self-inflicted injuries treated in the emergency department, up from 374,500 in 2009.

According to the American Association of Poison Control Centers, in 2010 nearly 220,000 [PDF] suspected suicide attempt poisoning cases were managed by U.S. poison centers. The Northern New England Poison Center managed nearly 3,300 of these. Patients under 20 were more likely to use readily-available substances such as over-the-counter pain relievers, while patients 20 and older were more likely to use prescription medications, including benzodiazepines and painkillers.

Suicide is preventable. If you feel you are in a crisis or know someone who is, call the National Suicide Prevention Lifeline at 1-800-800-273-TALK (8255).

Mr. Yuk: No longer used

Many poison centers used to give parents Mr. Yuk stickers to put on poisonous things. The idea was that kids would learn to stay away from products that had the Mr. Yuk sticker on them. It was a good concept and very popular tool.

However, studies showed that Mr. Yuk wasn’t effective. Parents couldn’t realistically put stickers on every possible poison, so even if their child was really well trained to stay away from things with the sticker, they might think it was OK to play with products that didn’t have it. Some kids may have been attracted to the sticker, too.

Maybe more importantly, the kids targeted with the campaign—young school-aged kids—are not the real high-risk group. Children ages 13 months to 2 years are the most at risk for poisoning. In fact, they accounted for nearly 25% of all poisoning calls to the NNEPC in 2012.

Given all of this, most poison centers phased out using Mr. Yuk over a decade ago.

The sticker also couldn’t always help for medication. Medication is the most common cause of poisoning among young children, and they frequently get loose pills that have fallen to the floor. A study released this year by Safe Kids Worldwide found that among children treated for medication-related poisonings in an emergency room in 2011, 27% had found the medicine on the ground or misplaced. The next most common places they found medication were in a purse, bag or wallet (20%), on a counter, dresser, table or nightstand (20%), and in a bag of pills or pillbox (15%). The medications most often belonged to a grandparent (38%).

This report is a reminder to keep all medications in child-resistant packaging and out of the reach of children, and to be careful to not leave loose pills lying around. And programming your cell phone with the poison center phone number, 1-800-222-1222, is the best way to be prepared in case a child does get into some medication.

The FDA has called prescription drug abuse an “epidemic.” Do you agree with this based on what you are seeing in the emergency department?

TP: I have heard the terms epidemic and pandemic to describe the rapid rise in prevalence of prescription (primarily opioid) misuse. This problem is blatantly evident in my emergency department practice. I have seen a rapid rise in complications related to chronic opioid therapy including injuries and deaths, pain complaints related to opioid induced hyperalgesia and withdrawing patients with interrupted opioid supplies. The evidence is now clearer than ever that a steady dose of an opioid loses its efficacy after only several weeks while escalating doses to maintain efficacy causes an ever-increasing side effect profile. Also I have seen a general acceptance of sharing of prescriptions due to the high costs. When shared with others for non-medical purposes in particular, the risks are great for addiction, drug-related criminal activity and health endangering risky behaviors.

Do ED doctors get training on how to assess pain? What about training on how to address the risks of abuse?

TP: Emergency doctors provide crucial acute symptom relief in the setting of multiple painful diagnoses. The relief of suffering is a patient’s right and a primary obligate of a physician. They generally understand the pharmacology of pain relief not just with opioids but other adjunctive therapies. Pain however is a subjective negative stimulus that is experienced differently by different individuals. There are no good objective measures and thus physicians have had to rely upon subjective biased views to validate the patient’s pain. Physicians have been taught an overly simplistic single axis yardstick of pain from zero to ten. Now more sophisticated analyses take into consideration functional impairment and the amount of psychological suffering that often accompanies pain.

Physicians are generally better doctors than detectives, regardless of media hyperbole. They neither have the time nor resources to perform exhaustive investigations into patient’s histories to attempt to catch them at misrepresentation. Also, folklore around drug-seeking behavior identification is poorly validated in research literature. Now more tools than ever are available, however, to assist in identifying patients who may exhibit obvious patterns of medication misuse, such as shared electronic medical records, prescription monitoring programs and adulteration-proof prescriptions.

Do EDs have policies related to prescribing pain medication to patients? Do you think professional associations or hospitals should have policies or recommendations on prescribing prescription pain medications?

TP: Most hospitals, emergency departments, professional associations and physician practices have adopted policies to support the limited distribution of opioid therapy. Some policies are geared toward educating patient groups and adjusting expectations. Policies that are robust and flexible can support a balanced approach to pain management while those that are inflexible and extreme do not allow for individual concerns and treatment options.

Do you think prescription monitoring programs are used as much as they should be?

TP: The current prescription monitoring programs are an excellent idea with only mediocre implementation. The concept that a physician prescriber can check a database of past prescriptions for their patient is an obvious safety tool that prevents doctor-shopping or medication duplication. On the other hand, states have turned to low-cost vendors to deliver the needed information technology solutions. Access to the information becomes clunky and difficult. So much information is needed regarding the patient to avoid misidentification that the search becomes cumbersome and time-consuming. Striking a balance between patient privacy, accuracy, security and rapid access has yet to be achieved.

Do you think ED doctors can or should play a role in educating patients and families about medication safety—proper storage and disposal, not sharing, etc.?

TP: ED doctors must play a key role in educating patients regarding the safety of the medication they prescribe. Generally in the past we have limited the scope of the discussion to the safety of the patient taking the medication; however, it is clear that environmental safety issues are of equal concern, for example, if there are small children or teens in the house. Opioids are a target for home burglaries and an important source of unintended exposures. Educating patients about proper product stewardship including medication disposal is very important.

Are there ways ED doctors and poison centers are working together on this issue? Is there more that they can do?

TP: Poison centers have traditionally served as the virtual EDs of the pharmacology information world. They have primarily provided treatment information after the misuse or overdose has occurred. I think that EDs could better reinforce the idea that poison centers exist not just for toddlers who accidentally ingest things in their environment but also for adults who have questions about dosing, drug interactions and side effects. Other resources such as doctors’ offices and retail pharmacies can provide similar information; however, they may involve the inconvenience of waiting on the line or being unavailable after hours. Ideally, in the future health records should be shared among poison centers so that staff can assist patients with the most accurate information.

In fact, medications are the leading cause of poisonings—regardless of how old you are. The number of people dying from medication-related poisonings has been increasing in recent years. The bulk of these deaths occurred among adults and were caused by prescription drugs.

Prescription painkillers account for nearly three out of four prescription drug overdoses. In 2008, the US Centers for Disease Control determined there were 14,800 prescription painkiller deaths. But these deaths were just the tip of the iceberg. There were more than 475,000 visits to the emergency department related to prescription painkillers, and more than 12 million people reported using painkillers in a way other than prescribed by a doctor.

Many things are being done nationally and locally to address this growing problem. To learn about what emergency rooms and emergency doctors are doing, read tomorrow’s Q & A with NNEPC Medical Director Dr. Tamas Peredy.

Prescription painkillers

• An 18-month-old boy gets into a purse and gets cortisone skin cream all over his hands, face and neck.
• A 2-year-old girl gets into her vitamin bottle and her mother doesn’t know how many she’s eaten.
• A 1-year-old girl is playing with a tube of diaper cream and bites on the tube, getting a mouthful of cream.

Rather than going to the emergency room and waiting hours to get help for poisonings like these, you can call the poison center at no charge and get immediate help. Poison centers are available 24 hours a day calls are answered by trained health care professionals, who can save you time and money in an emergency.

Just call 1-800-222-1222 or visit www.nnepc.org to chat online.

Alisa Zapp Machalek, writing for the Inside Life Sciences series at the National Institute of General Medical Sciences website, has some interesting news about how porcupines could end up helping your health.

Researchers in Massachusetts have been studying the barbed quills of porcupines to see if they might have uses in medicine. So far they have created medical tape with tiny barbs that they think could help fix hernias or close surgical wounds. If their tests are successful, these patches of tape could replace the meshes and staples hospitals currently use.

On top of that, they think studying the barbed quills could help them design needles that hurt less. Interesting stuff!

Here at the Northern New England Poison Center, we have our own helpful health-promoting porcupine. Spike, the poison prevention porcupine puppet, has been the center of our National Poison Prevention Week activities for five years now.

Spike is the star of Spike’s Poison Prevention Adventure, a video for children in preschool through about first grade, that centers on the simple message of “If you don’t know what it is, stay away.” Through songs and games, Spike shows kids that his quills go up as a warning when he’s around something that might not be safe, but go back down around safe items.

In conjunction with National Poison Prevention Week, the NNEPC has been holding its own Spike Education Program for schools each March since 2009, reaching more than 47,000 students over the last four years. Participating schools get a copy of the video, a plush Spike hand puppet, and take-home poison prevention materials for their students. They can also report on their events for a chance to win individual plus finger puppets for their students. For this year’s Poison Prevention Week, March 18-22, we had nearly 70 schools sign up for the program across Maine, New Hampshire and Vermont.

For more information or to download program materials, see our Spike program page. You can also order your own Spike Education Kit in our store.

To bolster my arsenal of symptom-relieving tricks (and to give my husband something else to do when he’s reaching for the cough syrup), I talked to the NNEPC hotline staff, did a little research and tried a few home remedies.

Humidifier: Putting a humidifier in your child’s room while they sleep can help relieve congestion. It can also help prevent colds because the cold virus thrives in dry air. Just make sure to keep the humidifier out of your child’s reach to prevent burns. And change the water every day to prevent mold growth.

Chicken noodle soup: Maybe Grandma was right? It’s very important make sure your child gets plenty of fluids when they are sick. Plus there’s lots of nutrition in the yummy vegetables and it will warm their little tummy.

Honey: Score another one for Grandma! Honey has long been thought to relieve sore throats—it turns out it might suppress coughs, too. Pennsylvania State University’s College of Medicine looked at the effectiveness of honey versus dextromethorphan. Parents rated their children’s cough and sleep quality after giving a dose of honey, DXM, or nothing before bed. Honey did better than both doing nothing and giving DXM. Start with a teaspoon. But don’t give honey to child under a year old. 

Nasal aspirator: If your kid’s mucus is goopy, suck it out. I know, its gross, and they hate it, but clearing those little nasal passages will help them breathe better. And if it’s dry and crusty and causing clogging, try softening it by putting over-the-counter saline drops in their nose before using the aspirator.

Chest rub: Using a mentholated rub on your child’s chest, especially before bedtime, can help them breathe a little better. Only use a rub that says it’s for kids on the package (these do not contain camphor).

Extra cuddle time: The positive health benefits of touch are being clinically confirmed time and time again. Snuggling with a blankie, a favorite stuffed animal and a parent can often be the best medicine of all.

Raising the head of their bed: This drains the mucus from their head and into their tummy and helps them sleep better. What works the very, very best (in my experience) is to put a pillow or book under the head of the mattress. Just make sure you have the pillow under the mattress, not in bed with them!

If you are worried, go ahead and call your doctor. Your doctor knows your child and will be able to help figure out if you should come in. They can also recommend a home remedy or suggest pain and/or fever reducing medicine if needed.