Transcript The Role of the Medical Review Officer

Improving America’s health, one patient at a time.
Urine Drug Screening Update
and the Role of the Medical
Review Officer
Joseph C. Eshelman, MD,MPH
Area Medical Director
Concentra Medical Centers
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Majority of Drug Users are Employed
75.3%
80%
70%
60%
50%
40%
30%
24.7%
20%
10%
0%
Not Employed
Employed
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Illicit Drug Use Among Full-Time Workers
Trends by Major Occupation/Industry Code:
2002-2004
Occupation /Industry
Food Services and Preparation
Construction
Arts, Entertainment, and Recreation
Information
Management of Companies, Admin, Services
Retail Trade
Professional, Scientific, and Technical Services
Mining
Transportation and Warehousing
Health Care and Social Assistance
Educational Services
Utilities
% Illicit Drug Use
16.9
13.7
11.6
11.3
10.9
9.4
8.0
7.3
6.2
6.1
4.0
3.8
Source: Worker Substance Use and Workplace Policies and Programs, 2007
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Percent Past Month Use of Any Illicit Drug by Age
Percentage of Past Month Use
30.0
25.0
19.7 %
20.0
15.0
9.5 %
5.8 %
10.0
5.0
0.0
12-17 y.o.
18-25 y.o.
26 or older
Source: National Survey on Drug Use and Health: 2007
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US Workforce Urine Tests for Drug Use
96.40%
86.40%
100%
90%
80%
Percent
70%
60%
50%
40%
30%
13.60%
20%
3.60%
10%
0%
1988
2008
Year
Pos i ti v e
N egati v e
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Non-Negative Rates By Drug Category - Urine Drug Tests
Other
23.6%
PCP
0.6%
Am phetam ines
11.1%
Cocaine
10.0%
Opiates
8.7%
Amphetamines
Marijuana
46.1%
Cocaine
Marijuana
Opiates
Other
PCP
Quest Diagnostics Incorporated, 2009. "Cocaine Use Among U.S. Workers Declines Sharply in 2008,
According to Quest Diagnostics Drug Testing Index™." The Drug Testing Index. (c) 2009.
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Overall Reduced Costs
Decrease
Substance
Abuse
Increase
Health &
Wellness
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Historical Perspective
Workplace testing evolved after military
testing began in the late 60’s, early 70’s
1986 Ronald Reagan’s War on Drugs
Mandated drug free workplace in all federal agencies
1988 HHS published Mandatory Guidelines
for Federal Workplace Drug Testing
Programs
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History Continued
1996 Drug Free Workplace Act
2004 DHHS proposed testing hair, sweat and
oral fluids
2010 New (5th) Revision of Mandatory
Guidelines for Federal Workplace Drug
Testing Programs
Effective date changed from May 1 to October 1.
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Collection Procedures/Sites
Split specimen Collection Only (no single)
Procedures now consistent with DOT Regs.
Enhanced proficiency training of collectors
mandated including refresher training
Enhanced security of stored specimens
Annual Inspections Randomly of 5% of Sites
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Laboratory Testing
Ecstasy added to the original 5 drugs
Ecstasy – hallucinogenic amphetamine
AKA: MDMA (Methylenedioxymethamphetamine)
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New Confirmatory Test Technologies
Federal law requires HHS to establish
comprehensive standards for federal drug
testing programs requiring the use of the best
available technology to ensure accuracy of
the test
Current test is GC/MS
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New Type of Testing Permitted
Instant testing at the collection facility now
permissible
Instant tests negative will be reported as such
All other specimens must be sent to HHS
certified lab, ie drug positive, adulterated, etc.
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Revised MRO Requirements
Must be an MD or DO who has undergone
formal training and passed a nationally
recognized exam
Currently 2 organizations fulfill criteria for
formal training and exam:
AAMRO
MROCC
Currently recognized as being equivalent
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Elements of New Guidelines Unchanged
Urine remains the only substance that can be
collected by federal workplace drug testing
programs.
Permitted Reasons for Testing
Pre-employment, Random, Reasonable Suspicion, Post
Accident, Return to Duty, Follow-up Test, Voluntary Test
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MRO’s Role
Independent and Impartial Advocate
Gatekeeper for the integrity and accuracy of
the drug testing process
Maintenance of Confidentiality
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Confidentiality
Results released only to authorized persons
or parties (DER, SAP, DOT, TPA etc.)
Results released only after verification
process is complete
Quantitative (numerical) results are only
released to the SAP and employee
Employer may receive quantitative results in the event of a
legal challenge
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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 all laboratory confirmed drug tests
Positive
Adulterated
Substituted
Invalid
Dilute
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MRO Functions cont.
Review CCF for validity
Interview employee/candidate
Determine if legitimate explanation for test
result exists
Report the test as negative, positive, or
cancelled.
If Test +, Rx legitimate: MRO negative
If this presents a potential safety risk employer and/or
appropriate agency is notified.
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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 cont.
Urine positive: 1-21 days (infrequent vs.
frequent use)
Using current cutoff values an infrequent user will test
positive for only about 3 days.
Effects:
hallucinogenic, drowsiness, impaired concentration and
perceptual skills
Withdrawal:
nausea, insomnia, irritability, anxiety
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Marijuana Decriminalization
13 States so far:
Alaska, California, Colorado, Maine,
Massachusetts, Minnesota, Mississippi,
Nebraska, Nevada, New York, North
Carolina, Ohio and Oregon.
Under Federal Law it remains illegal
No effect on interpreting UDS results
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Cocaine
2nd most common drug
of abuse for workplace
testing programs
Medical uses
uncommon (Topical,
and ENT procedures)
Snorted, inhaled
(Crack), injected, and
used orally
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Cocaine cont.
Urine positive: 2-4 days
Effects:
stimulation and euphoria
Overdose:
Confusion, paranoia,seizures,respiratory depression, cardiac
arrhythmias, death
Withdrawal:
fatigue, inc. appetite, depression
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Amphetamines
Amphetamine/Methamphetamine
Adderall, Ritalin
MDMA (Ecstasy) Methylenedioxymethamphetamine
Snorted, injected, inhaled, taken orally
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Amphetamines cont.
Medical Use: ADD, Narcolepsy
Urine positive: 2-4 days
Effects:
Inc. alertness, excitation, euphoria, loss of appetite
Overdose:
paranoia, psychosis, violent behavior, irregular heart beat,
heart failure, death
Withdrawal:
apathy, depression, excess sleep, disorientation
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Opiates
Injected, snorted,
inhaled, taken orally
Codeine
Morphine
Heroin
Oxycontin
Percocet
Vicodin
Darvocet
Fentanyl
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Opiates cont.
Urine positive: 2-4 days
Medical use: pain relief; cough suppressant
Effects: euphoria, drowsiness
Overdose:
confusion, respiratory depression, unconsciousness, death
Withdrawal: agitation, anxiety, insomnia, abd.
Pain, nausea, vomiting, diarrhea
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Phencyclidine (PCP)
Medical use: None
Smoked, injected or swallowed
Effects:
hallucinogen (illusions, hallucinations, altered perception)
Urine positive: 2-4 wks
Overdose:
panic, aggression, violence
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Adulteration
Definition:
Addition to the urine of an “exogenous”
substance (not normally found in the human
body)
OR presence of a “normal” substance at
extremely high or low levels not consistent
with human urine
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Detecting Adulteration:
Specimen Validity Testing
Lab Tests Performed
pH
Creatinine
Specific Gravity
Adulterants
Nitrites
Chromium
Halogens
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Common Adulterants
Acids, Bases and Salt
Rarely used today; easily detected by pH and specific gravity
Oxidants
React with drug metabolites preventing detection
Most effective with marijuana
Some effect with morphine
Little or no effect regarding other drugs
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Common Oxidants
Nitrites
Clean X, Clear Choice Instant Clean, Whizzies, Urine Luck
6.4
Elevations by Rx meds and various medical conditions
Concentrations > 500ug/ml = adulterated
Chromium (VI)
LL418, Randy’s Clear II, Sweet Pea Spoiler
Concentrations > 50ug/ml = adulterated
Halogens
Urine Luck 6.5
Concentrations > 100ug/ml = adulterated
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Interesting websites
http://www.passyourdrugtest.com/
http://www.cleartest.com/
http://www.detoks.com
http://www.thealsshop.com/
(Warning: considered graphically adult in
content)
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Questions & Answers