The Role of the Medical Review Officer

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The Role of the Medical Review Officer

• Michelle Alexander, MD

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Random Drug and Alcohol Testing Rates 2008

• Drug testing rate was reduced from 50 to 25 in
  2007
• Alcohol testing rate remains the same at 10

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MROs Role

• Independent and Impartial Advocate
• Gatekeeper for the integrity and accuracy of the
  drug testing process
• Quality assurance review
• Timely Flow
• Confidentiality

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Qualifications

• Licensed physician
• Basic knowledge of SA disorders
• Qualification training
• Certification examination
• Continuing education

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Confidentiality

• Results released only to authorized persons or
  parties (DER, SAP, DOT, C/TPA etc.)
• Results released only after verification
• Quantitative results are only released to the SAP
  and employee
• Confidential retention of records

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Relationships

• Laboratory
• Designated Employer Representative (DER)
• Collectors
• Substance Abuse Professionals (SAP)
• Third Party Administrators (TPA)

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MRO Functions

• Review of negative tests
• Personal review of 5 of all CCF and
  all results that require a corrective action
  quarterly up to 500 tests

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Negative tests

• Immunoassay results are below the initial test
  cutoffs or
• GC/MS results below the confirmatory cutoffs, and
  
• Specimen validity test results in the acceptable
  range.

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MRO Functions

• Review of all laboratory confirmed drug tests
• Positives
• Adulterated
• Substituted
• Invalid

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MRO Miranda

• Explain at the start of the interview that the
  information provided to you in the course of
  determining if a legitimate medical explanation
  exists can be shared with the employer, DOT and
  other agencies. In addition, if such information
  affects workplace safety or indicates that the
  employee is otherwise not medically qualified the
  employer can be notified.

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Positive Drug Tests

• Direct contact with the employee or candidate
• Verify the test as negative, positive, or test
  cancelled

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Cocaine Positive

• 2nd most common drug of abuse for workplace
  testing programs
• Medical uses uncommon (topical, nasal and dental)
• Used in combination with many other drugs
• Snorted, inhaled, injected and used orally

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Urine

• Cocaine is metabolized to benzoylecgonine
• Rapid excretion within in as little as 1-3 days

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Hair

• Test for benzoylecgonine, cocaethylene, and
  norcocaine
• Hair washing is performed to eliminate issues of
  passive exposure
• Some evidence of metabolite must be present to
  confirm positives
• Single use is unlikely to result in a positive
  test
• Hair color

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Marijuana

• Cannabis sativa plant
• Cannabinoid
• THC
• Medical uses Marinol
• Schedule III drug
• Approved for treatment of nausea, appetite
  stimulant

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Marijuana Decriminalization

• 11 states- Alaska, Arizona, California, Colorado,
  Hawaii, Maine, Montana, Nevada, Oregon, Vermont,
  and Washington
• Does not establish system for providing marijuana
• Federal law it remains illegal

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Marijuana Effects

• Schedule I drug
• Hallucinogen
• Drowsiness
• Impaired concentration and perceptual skills
• Withdrawal- nausea, insomnia, irritability,
  anxiety

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Urine

• About 30 metabolized to THCA
• Urine positive for 1-21 days (infrequent vs.
  frequent use)

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Hair

• Lower cutoffs
• Single use is unlikely to result in a positive
  test

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Oral Fluid

• Target parent drug THC
• Deposited in the oral cavity during use
• Concentration rise quickly and fall rapidly in
  the first hour
• Cutoff are recommended very low

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Amphetamines

• Amphetamine
• Methamphetamine,
• Methylenedioxyamphetamine (MDA) and
• Methylenedioxymethamphetamine (MDMA).

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Opiate Positive

• 6-AM verify positive
• In the absence of 6-AM
• At 15,000 ng/ml or gt verify positive unless
  legitimate medical explanation
• At levels lt 15,000 ng/ml determine if clinical
  evidence exists

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Adulterated or Substituted Tests

• Direct contact with the employee or candidate
• Determine the factual information from the
  laboratory
• Verify the test as refusal to test

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Dilute samples

• Creatinine gt or equal to 2 and lt 20mg/dl and
• Specific gravity gt 1.0010 but lt 1.0030

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Substituted sample

• Creatinine lt 2 mg/dl and
• Specific gravity lt or equal to 1.0010
• or gt or equal to 1.0200

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Adulterated samples

• pH lt 3 or gt or equal to 11
• Nitrite concentration gt or equal to 500 mcg/ml
• An exogenous substance is present

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Adulterated or Substituted Tests

• Direct contact with the employee or candidate
• Determine the factual information from the
  laboratory
• Verify the test as refusal to test

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Common Adulterants

• Nitrites (Klear, Whizzies)
• Alkylephoxysulfonate (Mary Janes Super Clean)
• NaCl (table salt)
• UrinAid (Glutaraldehyde)
• Urine Luck (Pyridine)

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Invalid specimens

• Creatinine concentration specific gravity
  results are discrepant
• Creatinine lt 2 mg/dl specific gravity gt or
  equal to 1.0010 and lt 1.0200
• Creatinine gt or equal to 2mg/dl
• specific gravity lt or equal to 1.0010

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Invalid specimens contd

• pH outside acceptable range
• pH is gt or equal to 3 and lt 4.5 or
• pH gt or equal to 9 andlt 11
• Nitrite present
• Nitrite gt or equal to 200mcg/ml

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MRO Verification without Interview

• Employee expressly declines to speak with you.
• After 3 unsuccessful attempts to contact the
  employee (both day and evening) over a 24 hour
  period and the DER has made such contact and more
  than 72 hrs have elapsed.
• Neither you or the DER has been able to make
  contact with the employee and more than 10 days
  have elapsed

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Common Errors

• Correctable
• Collector
• Donor ID number omitted or incorrect on CCF
• (unless refusal)
• Collectors signature missing certification
  statement
• Incomplete COC block (at least 2 signatures and
  dates, shipping entry)

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Common Errors

• Correctable
• Donor signature missing from certification
  statement (unless refusal)
• Using incorrect CCF (DOT vs. non DOT)
• Lab
• Certifying scientist signature omitted on
  positives

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Fatal Flaws

• Specimen ID missing from specimen bottle or fails
  to match
• Volume less than 30 ml
• Specimen seal is broken or shows evidence of
  tampering
• Specimen shows obvious adulteration
• (color, foreign objects, unusual odor, etc)

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Blind Samples

• Submitted with donor samples
• These samples should be verified
• Negative
• Drug Positive
• Adulterated
• Substituted

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Shy Bladder Collection

• After the first failed attempt of less than 45 cc
  urine (split)
• 3 hour window
• Instructed to drink 40 oz of water over the 3
  hours (8 oz of water/30 minutes)

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Failure to provide sufficient sample for testing

• Obtain a detailed medical history ASAP.
• Refer to an appropriate trained physician
  acceptable to you.
• Consider information provided to you by this
  physician and make your determination.

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Other samples for testing

• Not currently approved under 49CFR 655
• Oral Fluid
• Sweat
• Hair

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Recommendations

• Education!
• Collectors and DERs
• Physicians used to make medical determinations
  (shy bladder, lung/refusals)

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Preventive measures

• Routine
• Forms
• MRO checklist

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Interesting websites

• http//www.passyourdrugtest.com/
• http//www.cleartest.com/
• http//www.detoks.com/