The Medical Review Officer: An Addiction Medicine Perspective

1
The Medical Review Officer An Addiction Medicine
Perspective

• CSAM October 9, 2004
• By David E. Smith, M.D.
• Past President, CSAM
• Past President, ASAM

2
Addiction- Scope of the Problem

• In 1998 6.6 of employees reported current drug
  use
• Absent from the job 100 hours per year
• 3.5 times as likely to be involved in an accident
• 5 times as likely to file a Workmans Comp claim
• 3 times as likely to be fired
• Alcohol- 120 billion
• Nicotine- 60 billion
• Illicit drugs- 60 billion

3
The Drug Free Workplace Act

• 1996 Executive Order 12564
• A comprehensive program prohibiting workplace
  drug use
• Employees will be educated about drug use
• Supervisors will be trained regarding their
  responsibility
• EAP helping hand programs will be available
• Ability to identify drug users including urine
  testing

4

• Civil and Criminal Aspects of Addiction and the
  Expert Witness

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The Role of the Medical Review Officer

• A positive test does not always identify and
  illicit drug user
• Must be a licensed Medical Doctor
• Knowledgeable of substance abuse disorders
• Knowledgeable about how to interpret positive
  tests
• Verify is there is a legitimate medical
  explanation
• Gatekeeper (Narrow) vs. Addiction Medicine
  Specialist (Expanded) Role

6
Types of Tests

• Pre-employment
• For Cause
• Return to Duty and Follow-up
• Random- Most controversial
• Not triggered by workplace impairment

7
Toxicological Considerations

• Screening and Confirmatory tests
• Types of Samples- Urine, Hair, etc.
• Detection Windows
• Screening levels and cutoffs
• Drug testing technologies
• Validity testing- dilution, temperature,
  contaminants
• New Regs- Stand downs and PIEs and NOPEs

8
Scope of Addiction Expert Witness

• Criminal and civil cases
• Family custody disputes
• Return to work
• Appeals evaluations
• Professional re-entry evaluations
• Complicated workplace situations
• Following an accident
• Interpretation of toxicological test results
• Compliance with governmental regulations

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Workplace Issues

• Case may be criminal followed by civil
• Employer often becomes the deep pocket
• Post Accident
• - Exxon Valdez Case

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Criminal Issues

• Toxicity
• Developmental Model Issues
• Recall
• Amnesia
• Non-toxic psychiatric co-morbidities
• Intent issues
• New Brain, Old Brain dilemma

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Validity Testing

• Verify a urine specimen is consistent with normal
  human urine
• Adulterated
• Diluted
• Substituted

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Validity (2)

• Treated the same as a confirmed positive
• The adulterant got there by physiologic means
• Employee can produce the dilute specimen by
  physiologic means
• MRO must use best professional judgment
• Employee may be directed to get a medical
  evaluation by another MD

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Americans with Disabilities Act

• What is covered
• Illicit drugs are not covered under ADA
• A using heroin addict is not covered
• A heroin addict stabilized on methadone is
  covered
• A recovering (abstinent) addict is covered
• Alcohol is covered under ADA
• However, if there are other federal regulations
  re alcohol the employer must comply i.e. B.A. gt
  .02
• A person falsely accused is also covered

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• The HHS Certified Laboratory

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HHS CERTIFIED LAB

• Introduction
• Chain of Custody Procedures
• Overview of Testing Procedures
• Drugs Included in the Testing
• Adulterant Testing
• Summary

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Chain of Custody

• Custody and Control Form
• Tamper Evident Bag and Tamper Evident Bottle
• Secured Laboratory
• Internal Chain of Custody

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Introduction

• HHS Certified Lab Procedures
• Two Step Testing Procedure
• Screening Test
• --Confirmation Test
• HHS Drugs or Drug Metabolites
• HHS Specimen Validity Testing

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Overview of Testing Procedures

• Screening Test or First Test
• Immunoassay
• Enzyme Multiple Immunoassay (EMIT)
• Florescent Polarization Immunoassay (FPIA)
• Kinetic Immunoassay (KIM)
• Radio Immunoassay (RIA)

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Overview of Testing Procedures

• Confirmation Testing
• Separate aliquot of the Specimen
• Gas Chromatography Mass Spectrometry (GC/MS)

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Quality Controls

• Open Quality Controls
• B Quality Controls for the Analyst
• Minimum 10 Quality Controls

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Overview of Testing Procedures

• Review all the Chain of Custody
• Review the Quality Controls
• Review the Blind Controls
• Review the Screening Test Data
• Review the Confirmation Test Data

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DHHS Drugs

• Cannabinoids
• Cocaine
• PCP
• Opiates
• Amphetamines

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Marijuana metabolites

• Screening 50 ng/ml
• Confirmation 15 ng/ml

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Cocaine Metabolites

• Screening 300 ng/ml
• Confirmation 150 ng/ml

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Phencyclidine (PCP)

• Screening 25 ng/ml
• Confirmation 25 ng/ml

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Opiates

• Screening 2000 ng/ml

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Opiates Codeine

• Confirmation 2000 ng/ml
• Quantitation if Concentration 1500 ng/ml
• Codeine Metabolites to Morphine

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Opiates Morphine

• Confirmation 2000 ng/ml
• Quantitation if Concentation 15000 ng/ml
• Heroin Metabolites to Morphine
• Coedeine Metabolites to Morphine
• Morphine as a drug

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Opiates Heroin6- Monoacetyl Morphine

• An Intermediate Metabolite of Heroin
• Confirmation 10 ng/ml
• Heroin Metabolites to 6- Monoacetyl Morphine and
  also to Morphine

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Amphetamines Amphetamine

• Screening 1000 ng/ml

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Amphetamine

• Confirmation 500 ng/ml
• Methamphetamine Metabolites to Amphetamine

32
Methamphetamine

• Confirmation 500 ng/ml
• Note In addition 200 ng/ml Amphetamine present
• Methamphetamine Metabolites to Amphetamine
• D- isomer or L-isomer

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AmphetaimesD L Isomers

• D- Amphetamine
• L- Amphetamine
• D- Methamphetamine
• L- Methamphetamine

34
Adulterant Testing

• Creatinine Normal- greater than 19.9 mg/dl
• Specific Gravity Normal greater than 1.001 or
  less than 1.020
• pH Normal 4.5-9
• Nitrite and Other Oxidants
• Soap
• Bleach
• Others

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Reporting Adulterants

• Adulterated Nitrite 500 mcg/ml or greater. pH 3
  or less pH 11 or greater. Chromium VI 20 mcg/ml
  or greater (Lab has the option for cut off)
• Substituted Creatinine 5.0 mg/dl or less
  Creatine 5.0 mg/dl or less and Specific Gravity
  1.020 or greater. Challenge 3.8

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Invalid Result

• Creatinine 5.0 mg/dl Sp. Gr. Sp. Gr. 1.003
  lt 1.020
• Specific Gravity 1.001 Creatinine gt 5.0 mg/dl
• Abnormal pH (outside 4-10)
• Possible (Characterize as Oxidant, Halogen,
  Aldehyde, or Surfactant) Activity
• Immunoassay Interference
• GC/MS Interference
• Abnormal Physical Characteristics (Specify)
• Bottle A and Bottle B Different physical
  Appearance

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Rejected for TestingFatal Flaw

• Specimen ID number mismatch / missing
• No collector printed name no signature
• Tamper- evident seal broken
• Insufficient specimen volume
• Wrong CCF used
• Collector signature not recovered

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Conclusion

• Chain of Custody
• Two Step Testing Protocol
• Five HHS Drugs
• Adulterant Testing
• Reviewed and Certified Results