Transcript The Role of the Medical Review Officer Michelle Alexander, MD

The Role of the Medical
Review Officer
Michelle Alexander, MD
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%
MRO’s Role
• Independent and Impartial Advocate
• Gatekeeper for the integrity and
accuracy of the drug testing process
• Quality assurance review
• Timely Flow
• Confidentiality
Qualifications
• Licensed physician
• Basic knowledge of SA disorders
• Qualification training
• Certification examination
• Continuing education
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
Relationships
• Laboratory
• Designated Employer Representative
(DER)
• Collectors
• Substance Abuse Professionals (SAP)
• Third Party Administrators (TPA)
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
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.
MRO Functions
• Review of all laboratory confirmed
drug tests:
• Positives
• Adulterated
• Substituted
• Invalid
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.
Positive Drug Tests
• Direct contact with the employee or
candidate
• Verify the test as negative, positive, or
test cancelled
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
Urine
• Cocaine is metabolized to
benzoylecgonine
• Rapid excretion within in as little as 1-3
days
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
Marijuana
• Cannabis sativa
plant
• Cannabinoid
• THC
• Medical uses
Marinol
Schedule III drug
Approved for
treatment of nausea,
appetite stimulant
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
Marijuana Effects
• Schedule I drug
• Hallucinogen
• Drowsiness
• Impaired concentration and perceptual
skills
• Withdrawal- nausea, insomnia,
irritability, anxiety
Urine
• About 30% metabolized to THCA
• Urine positive for 1-21 days (infrequent
vs. frequent use)
Hair
• Lower cutoffs
• Single use is unlikely to result in a
positive test
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
Amphetamines
• Amphetamine
• Methamphetamine,
• Methylenedioxyamphetamine (MDA)
and
• Methylenedioxymethamphetamine
(MDMA).
Opiate Positive
• 6-AM verify positive
In the absence of 6-AM
• At 15,000 ng/ml or >
verify positive unless
legitimate medical
explanation
• At levels < 15,000
ng/ml determine if
clinical evidence exists
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
Dilute samples
• Creatinine > or equal to 2 and <
20mg/dl and
• Specific gravity > 1.0010 but < 1.0030
Substituted sample
• Creatinine < 2 mg/dl and
• Specific gravity < or equal to 1.0010
or > or equal to 1.0200
Adulterated samples
• pH < 3 or > or equal to 11
• Nitrite concentration > or equal to 500
mcg/ml
• An exogenous substance is present
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
Common Adulterants
• Nitrites (Klear, Whizzies)
• Alkylephoxysulfonate (Mary Jane’s
Super Clean)
• NaCl (table salt)
• UrinAid (Glutaraldehyde)
• Urine Luck (Pyridine)
Invalid specimens
Creatinine concentration & specific
gravity results are discrepant:
• Creatinine < 2 mg/dl & specific gravity
> or equal to 1.0010 and < 1.0200
• Creatinine > or equal to 2mg/dl &
specific gravity < or equal to 1.0010
Invalid specimens cont’d
pH outside acceptable range
• pH is > or equal to 3 and < 4.5; or
• pH > or equal to 9 and< 11
Nitrite present
• Nitrite > or equal to 200mcg/ml
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
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)
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
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)
Blind Samples
• Submitted with donor samples
• These samples should be verified:
Negative
Drug Positive
Adulterated
Substituted
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)
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.
Other samples for testing
Not currently approved under 49CFR 655
• Oral Fluid
• Sweat
• Hair
Recommendations
• Education!
• Collectors and DERs
• Physicians used to make medical
determinations (shy bladder,
lung/refusals)
Preventive measures
• Routine
• Forms
• MRO checklist
Interesting websites
• http://www.passyourdrugtest.com/
• http://www.cleartest.com/
• http://www.detoks.com/