For this is this is Carl once again we're back to you get another hour with me and then we'll we'll we have some other speakers as well just a few minutes and so we're talking a little bit about drug testing for the non-MRO and this is intended if you're an MRO you there's there's more depth and almost everything we're going to go into and you're welcome to ask everybody's welcome to ask questions feel feel free to interrupt okay so if this is one of the things that there's a this is kind of bread and butter for a lot of occupational medicine providers um if you have anything any comments you want to share please go ahead and chime in on the audio thing that way we kind of get them as we're going along one of the things that is a people want to know about and it seems to be a topic that the board wants to know about when you take might take a test from them but didn't still didn't click this in the right way is a little bit about drug abuse and how common this is these are current statistics mostly so as you can see down lower right hand corner there's a lot of money spent on health care because of both tobacco alcohol and the use of illicit drugs now tobacco is the biggest player obviously but all of them are important um now the the one thing i've found an interesting i everybody the employer motivation for drug testing is always sort of been ephemeral to me um nida the national institute for drug abuse which is i think now sam they've changed their names two or three times since then um is uh finds that about uh 70 of all illicit drug users are employed or work full-time and supposedly studies show they don't reference this so i don't know where the studies are but studies supposedly show that people who are substance abusers change jobs more frequently or less productive uh file more workers compensation claims um than people who are not drug users um and i they said i don't know where their studies are but that's that's what they claim still a sprite um i have to move my slides that way anyway for uh so well these this is this is a fun thing that uh our friends at quest uh diagnostics put up every year they do the positive this is their annual report it's on their website you can download it and then i steal slides from them because it gives me current information with the assumption that they're kind of the normal um they would they're representative of the u.s workforce so what you'll notice here is this is the number of positivity for anything anything abnormal and so the purple is the federally mandated safety sensitive people the uh yellow is the general u.s workforce and then combined is the black or dark gray whatever that color is and as you work your way across you notice that the rates are continuing to increase it was the general u.s workforce was about five percent maybe we're now five and a half or six percent for 2021 that's the last year the data is available for this comes out usually in the middle of the year reflecting the data through last year so this is as of um there's my problem i have the wrong one okay what do i have two clippers i don't know anyway um so positivity rate the key the key thing to take home from this slide for what is being tested positive for is to look at the purple line or magenta wherever that color is that's way higher than everything else that's marijuana now the other one that's kind of interesting as a comparison is the the the second highest one that's kind of that gray color um is the amphetamines one so amphetamines if you look has been like 1.1 or 2 percent and that really hasn't changed keep in mind if you are this is laboratory positives so if you're prescribed adderall or stratera or one of those medicines you'll be in a laboratory positive that should then most of the time will be an mro negative um marijuana though keeps going up and up and up um i suspect relating to the fact that it's been legalized in a number of states for all sorts of uses um now the overall positivity rate it went was going went down from like 12 when they first started keeping track of this down to all the way just above three percent um in like 2008 2009 2010 um but we're on our way back up again um people who have been in this in this game for a while i remember there was there was a time when we actually decreased the percentage of truck drivers that we tested because the rates got so low they didn't stay low but they dropped down for a while we decreased the percentage from 50 percent of your workforce every year to 25 for about three years and it went back up because the rates went back up um in an uncommon thing for our government they actually had written something that had triggers that could go both ways so it would trigger so when it dropped low enough they decreased the rate when it went back up they increased the rate back up um so the other thing to think about is there's also validity testing that they do and these are the the the these are the things uh the the causes of living out i the thing to notice is the left hand side of this this is an invalid test from the laboratory it's never higher than 0.25 percent not a quarter 0.25 of one percent so it's it's pretty uncommon regardless and the most that most common cause is invalid which usually means that the specific gravity is out of range so it's did they just dip water and turn it in um uh substance use basics this is this is a different way of looking at the data but um marijuana and this is old this is from 2014 before marijuana was legal pretty much anywhere um but alcohol and cigarettes are still a much bigger problem than marijuana is at that time this is self-reported data of new users um so they asked a question of people and said you know is is smoking marijuana harmful what is it a great risk and you notice that those numbers heading down and down and down and down and down this is only up through 2014 so trying to keep marijuana effects out of the workplace i think it's going to be an uphill battle over time so this is the one that always drove me nuts this is from the american council of for drug education which is an industry group um encouraging drug testing and all they claim all these things are true um other than it being a list on their website i've had a hard time substantiating that beyond they made a list of words um if you're going to include mro work or drug testing in your practice i recommend you be careful um there are because you're taking away somebody's job potentially and if you don't do it exactly by the book the way everybody else would do it you're at risk for a lawsuit keep in mind this is not malpractice this is a civil lawsuit and you're a medical malpractice coverage may or may not include this you need to make and if you're doing mro work you make sure that you're that this is an included service because they're not your patient there's no doctor physician patient physician patient relationship with that person and some malpractice carriers go to throw their hands up there and start screaming when that's the case just be make sure you know what you're that you're okay to add this to your practice um little vocabulary first word for these are vocabularies the donor is the person that that provides the specimen not a patient they're a donor um they provide a you collect a matrix usually urine but it could be saliva it could be hair it could be sweat a lot of other choices the collector is the person that collects the specimen um they will complete a ccf or custody and control form uh the medical review officer is a physician that reviews the tests and determines if it's medically appropriate or not um or if it indicates drug abuse a substance abuse professional is somebody who who sees these people after a positive test to look into causes and put together a plan for their care um a regulated test is one that's required by the government the federal government um think truck driver airplane pilot um ship captain those are regulated tests nuclear worker um unregulated tests is everybody who's not a regulated test um so most common thing we collect is is uh urine as of today i think this is still true um it's midday so it could change someday soon saliva will become an option for dot testing but not yet and it's they're they're they're drafting those regulations at government speed so someday maybe um best literature supports the interpretation of urine testing because we've been doing it for the longest time um it one of the things that so for some drugs they can be positive immediate almost immediately within probably minutes for opiates um that get you know from if they administer an ivy opiate from the time they give you the you know the ivy morphine in the er until they can see it metabolites in your urine is probably under 10 minutes and maybe faster than that but maybe a lot faster than that um so hair sees things that are for very long periods of time but um it also has the process the potential for substitution i'm sorry potential for missing recent use like like recent in like the last three weeks because hair grows slowly um and there's a lot of issues as far as as cleaning and hair care products and stuff could may change this testing um saliva maybe someday for dot maybe the donors like this more because but there's no there's no substitute specimen you have to worry about that because you you collect the saliva from that person's mouth um positive detection rate parallels urine they figured out when i took my mro class a long time ago the biggest problem we had was marijuana didn't show up in saliva they fixed that and found a metabolite that does show up in saliva so that's now viable um sweat is difficult to collect because it just it's too hard they put a patch on and leave it there for like two weeks and these things always seem to fall off um at least that's been my understanding i've never i've never been in the environment where we did them they use them in like the nuclear industry sometimes does that and especially in warm weather it's a problem people that actually sweat for a living it's a problem and so this has become a this has become difficult um breath is used for alcohol only um it is at is as good as blood and way better than using urine for alcohol um you do need to become certified as a breath alcohol technician if you're going to collect breath um and it's device specific you can use saliva for truck drivers for alcohol as a screening test and if that one's negative you don't do anything else if it's positive you still have to have the lethalizer that you can test with to make sure that you that you're still okay um so matrix used for most things uh for dot we use uh urine for drugs uh breath for alcohol saliva is for alcohol screening only right now standby that will change probably sometime soon for unregulated testing you can use it whatever you want and and and employers do and this sometimes even ends up as a thing that will be negotiated as part of the union contract that we're going to switch from urine testing to hair testing or whatever or they'll go maybe the other way so real fast on how to do it how to do your drug screening um the the dot is is we use the word dot testing it includes everybody that's listed up there and it also includes the maritime people who are officially they that used to be in the dot the coast guard used to be part of the department of transportation september 11th they moved those to homeland security to give them some group in there that knows somewhat what's going on in the world um and so but there's they're still under the dot testing regimen for drugs um lots of other federally regulated testing the military mc does some the military there's a lot of different options there so non-rate non-regulated testing can be whatever the employer wants if the employer wants to do the full monty that's up to them if they want to not test for marijuana because they think marijuana is just a fine way to spend your free time that's fine they're allowed to make it anything they want it to be um if they want to add drugs subtract drugs test at other times um that's all okay there's also something what i call legally required um after a car wreck or a truck accident there's specific testing you have to do um and then also upon incarceration many places test that's actually more for medical purposes like they want to know why you pass out in your cell and the drugs help understand what drugs are in your system when they put you in jail they help them understand that um and they may watch you differently if you have a positive test uh so uh there's also if people have had trouble in the past with substance abuse maybe in parole or family court or uh or health care professionals all that is all non-regulated testing there may be rules from the agency that's doing it but it's not you don't follow the federal rules the one thing i'll say is that almost everybody um when they collect a urine specimen follows the dot collection rules because there's no reason to reinvent the wheel um so almost every follows that so that because it already deals with like what do you do if it's a cold specimen what do you do if they don't provide a specimen although that's all in there so you have to make it up as you go along um how do you do drug testing so there's pre-employment kind of know when that is random really does require that it be random and that people are some you've got some way of selecting people who are going to be tested every so often if anybody's been in the military talk to people in the military um every company commander was issued a 10-sided die that i think they got from the uh dungeons and dragons set and they roll it in front of the guys the first thing or the other company the first thing on the first morning and if it's a three everybody listed your social security numbers of three is going to get tested today that's how they do it that's randomized it might roll three three months in a row you don't know okay um so that that's that and and you can do a lot there's lots of different ways to randomize um and then you have to when you randomize you also have to do with what if the person you selected by whatever your mechanism is isn't available today what happens what's your backup plan like what if they're on vacation so do you get them they come back from work from vacation do you just put them back in the pool and ignore it there's a lot of ways to do it none of them are wrong you have to pick one and write it down so it's in your system in your plan because one of the things you can't do is make it up as you go along that will get you in trouble because you remember you're putting people's employment at risk and sometimes people fight back against that so reasonable suspicion this has to do with the employer acting unusual at the workplace i put a little thing in there it says should bring donor key thing here is if you think somebody's too impaired to work don't tell them to drive to the doctor's office across town that's a huge risk to the employer have have them or a co-worker take drive the the imperative driver the worker across town to get to their test okay um post-accident dot is some very specific standards um for non-dot it's employer policy interestingly osha now recommends you do not test um for near misses in the workplace or or for people you know for incidents are approved in the workplace unless there's suspicion because what they think is osha's logic is that employers employees do not report incidents because they're going to get drug tested and they think it's impacting the the reportables rates um now if you if you if there's suspicion you still test the people under suspicion you don't just say well you were using a machete to cut this thing and you ended up with a cut on your finger therefore we're going to drug test you which a lot of employers were doing that every recordable got drug tested automatically right away and that was a disincentive to report events um so return to duty is a very special thing this has to do means you fail the drug test right before you've gone through whatever your rehab process is, and now you're trying to come back to the workplace, a return to duty test must be negative. It can't be anything else. It can't be a failure to test, and it can't be a test canceled. It has to be an actual negative. A follow-up test is a follow-up after a positive, and that's on some random schedule, usually set up by the SAP that says, when this person comes back, test them after a week, and then skip two weeks, then test them again, then skip a day, test them again. They actually give you the schedule. You don't tell the employee what that schedule is, but that's what follow-up testing is. It's somebody who failed a drug test in the past, has gotten their return to duty, and now they're back in the workplace, but subject to a testing regimen. So this is positivity by reason testing, and the thing I want you to notice is that the big, I think it's dark blue bar, is for-cause testing, which is like third, testing positive. All the other reasons for testing positive stay under 10%, with post-accident being the highest, that dark green bar that's just to the right of the dark blue bar. So keep in mind that for-cause is still the most likely thing. So key thing, if you're gonna use, have any kind of a drug-free workplace effort is train your supervisors to identify people who are impaired at work, and don't let them just be impaired at work, because that's not safe for anybody. Post-accident testing, it's very specific following a motor vehicle accident. They have to test for drugs and alcohol. They want it within eight hours. It might have to be up to 24. There are some parts of the country where this is nearly impossible to set up, and it's especially, it's not too bad if it's your drivers, and you've got your hospital that you go to, and you've worked this out. But this has to be available. If you think about it, they want it within eight hours. There's gotta be an option at 3 a.m. to get this done. And in most hospital emergency departments will, unless it's prearranged, will run away from this like the plague. They want nothing to do with this kind of testing, because they're not used to it. They don't do it all the time. They don't do it ever, and so you have to kind of be clever. Interestingly, respiratory therapists, if you pay them a little bit, because they're already in the hospital, will often do this for you and do it right. So that's actually a trick. I know of two people that have done that in hospitals, because they're already there, and you can train them, and then if a need for a DOT comes in while they're on shift, they go do it. It doesn't mess with it. The nurses don't have to know. The lab doesn't have to get involved. It's all taken care of. Just an option, something to think about, or have people that are on call and will go to the hospitals and do it if you're in a metropolitan area. Like I'm sure in Kansas City, there's at least one place that will send somebody out to whatever hospital they need to go to or meet them at three o'clock in the morning at the office to do a test if that's indicated. OSHA has weird rules for testing people who are dead, and the FAA does too, but as I said, OSHA now discourages routine post-accident testing unless there's suspicion of impairment. And then obviously, if they're a commercial motor vehicle operator, that trumps all of that. So if they're under another regimen, then the other regimen wins. So basic steps. First thing you do is you notify the donor, identify them when they show up. If I have some sort of photo ID or personal knowledge, that's okay. If you're the person at a plant and you know this is George from the maintenance department that you deal with all the time, that's fine. You don't have to get George's driver's license out of his locker someplace. You're ready for the donation. So they empty and invert their pockets. The donor does. So that means you have to have a place for them to put all their stuff, like little baskets you can buy at the dollar store are just fine for that. You color the toilet water or turn it off so they can't just dip blue water out of the toilet. Sink handles are turned off or taped. And then they do the donation in the bathroom that you've prepared by themselves. So they go in, close the door and do the donation thing. They hand the specimen back to the collector. They'll verify the temperature on the switch. It's built into the cup. There's a little thermometer there. They do all the processing right in front of the patient, of the donor, where they put it into the little tubes and initial it, put the seals on, initial everything. They can finish the CCF and send everything to the lab. So that's the donation process. Now, special collections, some things are directly observed. For example, if they gave you a cold specimen, I said, the hardest thing to get to fake is temperature if you're not gonna use a biologic specimen. So it could end up hot or cold. Both occur from time to time. Then they do directly observe. So a same gender observer will come to the donor into the bathroom and they directly visualize urination. And this follows, if this is for federal testing, some employers do this for all collections. The military does this for everybody. So return to work or follow-up collections. This is a little bit different. This is scheduled, right? This is super scheduled for a person that already failed the drug test. So these guys, they have the same gender observer. They raise or lower all their clothing from mid thigh to their belly button. They do a pirouette, turn 360, and then they put their clothing back in the usual position and then they go back and do the donation on their own without, it's not directly observed. In an unregulated test, there's no issue with having them put into a gown, correct? Because it's unregulated? In unregulated tests, it's whatever the employer wants you to do. I would be cautious in deviating on the collection process from what DOT asks for. And what you just said is not, it's not a huge deviation, but it's a little bit. It is. And so make sure you've justified why you're doing it and that you understand it. Now, if they're coming in radioactive or covered in blood or something, that's different. But if you're just doing it as a means to thwart cheating, be very careful. Thank you. Because, and the thing is, are you gonna, and the other thing I would say is if you're not taking away their underwear, you've not done anything useful. And this is why. This is the main problem, is the thing called the Wizenator. Now they sell this as a, well, it's on the next thing. This is prosthetic. It is the most realistic thing on the market. And of course this is just for sexual use, but it has no application to anything about drug testing. But so, and it comes in lots of colors. And unless you're gonna take off people's underwear, it's gonna be hard to overcome this with a gown. Going back for, whoops. So you can see this is the kit here in the bottom of the screen. And that, and going into the bag kind of behind the prosthesis is artificial urine that comes in the little bags. And then you put little heater packs in there so they keep it just the right temperature. Okay. That's my joke for this cut through. Okay, so laboratory testing. So when this urine specimen gets to the lab, they're gonna put data from the CCF into their computer system. They're gonna check, they're gonna do a quantitative screen for drugs, kind of like an instant drug test. If that's negative, they're gonna test creatinine, they're gonna test specific gravity. They're gonna screen for these common adulterants. If all of that is negative, they report the test as negative and throw it out and send you a report. They're done. So all that is gonna get you a negative test and they discard it and they don't keep it. Now, if one of those is not negative, then they'll do a GC-MS to look at that specific metabolite and they'll give you way more information, but they only do the GC-MS spec testing if there's a positive on their initial screen. And so some tests get automatic secondary testing. If it's methamphetamines, they'll test chirality to tell legal from dirty. Interestingly, when I first took my MRO class, you could buy Vicks Inhaler, which is the legal version of this. Then it went off the market for a while. Now it's back on the market. So you can buy L-methamphetamine at your favorite gas station. And 6 a.m. is not part of every test, so you don't need to reflex test that. That's part of everybody's tests for, oops, sorry. So we went through this. This is the way we started. We did the NIDA-5. So marijuana, cocaine, amphetamines, opiates, and phencyclidine. Notice the opiates is just cocaine, morphine, and then 6 a.m. as a reflex test. And that started in 1986, then went 1991, went to all the transportation workers. It expanded, 2010, and they added some more amphetamines. They added MDMA and MDA, and all the ecstasy and its friends. And then they added 6 a.m. as part of the test for everybody. Still, opiates is just codeine, morphine, and 6 a.m. Then in 2017, they blew the thing out. Now we've got the rest of the tests. I have been involved in, I'm gonna say, at least half a dozen legal matters where the problem was the employer or the physician or the employer didn't understand the opiate test they were ordering. They would be prescribing hydrocodone, and then they would fire the patient, maybe end up with, you know, and because I'm prescribing you hydrocodone and your opiate test is negative. Well, it wasn't testing for hydrocodone. It's a synthetic. It's never gonna test positive. And so they were firing patients or employers were telling people they weren't using their medicine the way they're supposed to. Insurance companies, health insurance companies got weird. And so they now expanded it. Now it includes hydrocodone, hydromorphone, oxymorphone, and oxycodone. They're all part of that test now. So we now have a reasonable coverage of the, now, what's still missing off that list that's kind of a big problem right now? What's killing everybody right now? Is fentanyl. Fentanyl is still not on that list. So fentanyl is not part of routine drug testing. It's just something to be aware of when you're in a clinical setting that might be important, but also when you're looking at this. Now, your hospital may have a different, may use a different screen in the ER from what they use from this drug testing. And you have to find out what exactly, if it's a clinical screen, exactly what does it test for? And my hospital had the bad habit of every time they got a different pack for their lab machine, they would change the screen drugs and wouldn't tell anybody. I mean, you could figure it out if you went, and if you went and looked it up every time you ordered the test, you could find it on their online system, but you couldn't tell in advance. They didn't tell you when they changed it. It just changed. So this is all the things. These are all the semi, these are all the opiates that are currently available in the United States. So we always had that. We've added that sort of, now it's in the panel. Come on, go. It was added in 2017. Still not in the panel. Buprenorphine, not there. Fentanyl, propoxyphene, and methadone are not in the normal panel. Just be aware of that. So we're still back in the laboratory. Confirm we're testing positive. They notified the MRO of the positive test, what they found, and what the levels are. Sometimes that drives decision-making. And if they did special tests, they'll tell you about that too. And sometimes the lab will do special tests for their own purposes, and they'll notify you what those results are. And if there's any problems with your paperwork or collection process, they're on that like white on rice. They will let you know, and you'll get to complete affidavits to say you're sorry you filled the form wrong. So what does the MRO do? So the MRO reviews the collection paperwork, and they get the lab results. So for positives, they're going to contact the donor to ask them for a legitimate medical explanation for why the positive occurred. Then you verify that. And that may be talking to a pharmacy. It may be looking at a current pill bottle. There's lots of different ways to do that. If it's a testing where split specimen is an option like DOT testing, you'll explain that to the driver. I'm still waiting to have a lab positive that was negative on the split specimen. The only time that that's likely is if somebody was right to cut off. Like if the cutoff is 50 and they were 52, maybe when they run it at the alternate lab, it'll be 48. That is a possibility. But other than that, you're super unlikely. The labs are pretty stable at this point. You're super unlikely to see a positive for 30,000 at that lab and zero at that lab. Pretty unlikely. You do have to understand what the rules are for split specimens and who pays for it, which is always a key thing, because the employer may or may not pay for it. It depends. And then when you're finally done with all that, you report the final determination to the employer. Choices. So this is all the things that could get you to an MRO negative. So they had a negative screening test or a positive. It was below the confirmatory level. Legitimate medical explanation. Maybe it's got a legal prescription. Timing varies among MROs. If it's something that really needs a new prescription every month, or if it's throwing amphetamines or something, then that would be one set of cutoffs. The number of people that use an opiate occasionally when their back is really bad, and invariably their back was really bad two days before you took the test, that always works out that way. Timing varies between MROs. And or if there's an abnormal result, like low specific gravity, but it's medically explained, like they have diabetes insipidus, that might be okay. So that would be an MRO negative. It's medically explained lab abnormality. Negative dilute. It's not a negative result, but it is a negative result in some settings. For drivers, it's up to the employer. Now they have to obviously layer this in advance, but it's up to the employer whether they want to retest these people or just take it as negative. It's their choice. They just have to be consistent for all their workers. MRO positive. This is the easiest one. Positive confirmatory test. There's no verified medical explanation, or they don't want to talk to the MRO, which happens sometimes, or they won't provide the verified data. Like you say, I need to just talk to your pharmacy and verify that this is prescribed. Oh, I forget what pharmacy I go to. I don't know. I'm not sure. So that kind of stuff does happen from time to time. If any of those things happen, and there are time cutoffs built into the MRO role. Like I only get so many days for a regulated test. When I get the test result back till I have to result it, even if I contact the employer, and sometimes people are unaccessible for that, for a bit longer than that. I've had two people that were on cruises, and by the time they get back, their days had run out. And so I had to report as a positive. Then the guy gets back from his cruise, calls me, and I can change it to a negative after I've talked to them and verified their reason. I have 60 days to change my result if I choose to. There's no medical explanations except for PCP. Hasn't been used in humans in over 40 years. So unlikely to be prescribed by any medical person. 6 a.m. even if opiate's negative. I'm not sure that's good science, but that is the rules. Alcohol above the cutoff is automatic. There's no medical explanation for that. If you're doing your thing, right? We do occasionally give ethanol to people medically, like if they've had certain exposures or if they're a heavy drinker and we have to have them in the hospital for a little bit, we'll give them alcohol so they don't start seizing. That's fine, but you can't start driving again until you're done with that, right? So just, and so that's, they need to have recovered from whatever that procedure activity was before they try to drive. So there's no medical explanation for it. It's a positive. I don't care what they tell me their cause is. It doesn't matter. Test canceled. So this is a no harm, no foul. Something was wrong. There's a problem in the collection process. Like they forgot to write your name on the form or the bottles, the numbers on the bottles don't match the number on the form. Something like that has happened. An invalid test in the lab or there's a collection error, or maybe it's, all those things can happen. That's a test canceled. Usually what next happens is you repeat the test. I've had one patient that went through two rounds of medication interference that the lab, it's just like, we know that we can't analyze this. There's something going on. There's a medication there that is interfering with our test. That's the best I got. So the second one we'll call negative, but because it's not something the employer, that the worker did volitionally, it's just the nature of their medical care. Refusal to test. This is, and most employers consider this equivalent to a positive. So you didn't show up. You wouldn't follow the rules when you came to your collection. You won't identify yourself and you don't care. And there, you know, there's, they won't provide your room without a medical explanation. They just substitute, they've either adulterated or substituted the specimen. And most employers treat that as equivalent to a positive. So whatever bad thing happens to you because of a positive happens to you because of a refusal to test. If there's adulterants, they may add things there. There are a million places you can get stuff that will help you pass this. The best place to find them is on the internet. I don't recommend using any of them, but it is an option. Substitution is when you give me something other than your own, the donor's urine. We sometimes get the urine of another human. Yes, there are people that will put a cat, a foley in, instill somebody else's urine into their bladder and then come pee for you really fast. I'm basically impossible to detect as long as they leave it in your bladder long enough to warm up the body temperature, but not add any of their own urine to the bladder while it's there. You can buy urine substitutes, which is really hard to keep safe. And you can buy at your favorite truck stop, you can find this kind of stuff, it's there. And there are less complicated options as well, like just dipping water out. You're pouring water out of the toilet and out of the sink. I've had that a couple of them where I'm like, this isn't human anything. So what happens to the employer? Well, I notify what's called the DER, the Designated Employee Representative. They have to identify somebody whose job is to be the interface with the person doing, with the MRO doing the drug testing. It's for this, it's also if I've total contact in the donor, they'll help me do that, okay? Without any punitive effects. So the employer, if it's DOT, they have to stand down that person till they get to talk to a SAP. They report the results to the database for drivers, and they can only return to driving after they've seen the SAP, been evaluated, done whatever the SAP says they have to do. And then the SAP releases them for return to work and they get their follow-up test that's negative. I'm sorry, they get their return to work test, which is negative. Who pays for SAP services varies quite a bit. Some employers will pay for it once, some employers will pay for it not at all. Sometimes the driver has to pay for it. It's all over the place. Sometimes it's a negotiated thing. Can I ask you a quick question about reporting? Sure. Is it the MROs? No, I don't report anything. No, it's the employer that reports it. It's the employer that reports it. Yeah. The DER has to report it. Correct. And how this... The one thing I will say is, if you're operating a consortium for owner-operators in your area, you may have to report as part of the consortium. Oh, like if you're a TBA? Yes, if you're... Well, TBA is a different way to do... It's a different business arrangement, but a consortium is a way for small employers to come together and act like a large employer for this one thing. And if you're organizing the consortium, you have some reporting responsibilities. Because if you kind of think about it, Joe's trucking, where there's one driver, Joe is unlikely to turn himself in, okay? But the database. So if you're operating a consortium with a lot of small owner-operators, you would have those responsibilities as if you were the employer. But the MRO never does it unless you're operating that separate business as the consortium. I was confused because they make you join whatever that is, that AP, yadda, yadda, yadda. The two organizations that you have to join. I don't know who they are, but sure. No, whatever they are that you have to join. And then, if you change your interpretation, like you were mentioning, I mean, you have to contact those organizations and change your... If it got reported within the 60 days. Okay. I didn't know who actually reported it. Right. So if you're... I think it's still all the employer. I don't think you have to report anything. Okay, thank you. That's my understanding. I will admit I'm not... I do occasional MRO cross-coverage, but I'm not a full-on MRO. I mean, I'm certified, but I'm not doing that work very much right now. And so alcohol testing is said, we test breath or saliva. There's DOT mandated cutoffs. The MRO actually certifies the positive. There's no medical explanation. We already covered that a little bit. So on-site screening, I want to talk about this for just a second. There are literally hundreds of options and different ways that this can work. And these are all different options you might choose to use as a... For the employer, you look at the one in the middle, it's testing one thing. I think that's one. I think the one in the middle is actually testing for adulterants. And then you can... And you can have one test a lot of things. You can have a 15-cup or a three-cup or a five-cup or with marijuana or no marijuana, marijuana only. They're all choices you can buy. So benefit is it's really fast and get your results right away and the people can start working immediately. So like when at near me, when the power plants go into shutdown in the spring and the fall to do their maintenance, they'll bring hundreds and hundreds of contractors who are... They're all craftsmen. They're carpenters and pipe fitters and welders and all those guys. But they hire them from union halls. They come out and they want to drug test them before they let them work on their site. They can do these guys and it's boom, boom, boom. And come in PMI cup, 15 minutes later, you've got a negative result, go to work and you can keep working. So it's super fast. It's good for that. One of the things I mentioned here is it allows you to do pre-employment... To stop pre-employment testing if there's a positive while you wait for that to come back. So you don't waste the retina, the lifting test and the carrying test and all that kind of stuff on somebody who's already failed the drug test. And the one thing I'll say about the onsite tests is they're designed so that negatives are negative. If it's negative, you know they're negative but you will have some positives that are not really true positives. And you have to be... Everybody who's doing it has to understand that. Key thing is that they're designed to have false positives. It's intentional so that you know a negative is solid. Positives must be confirmed in the laboratory. Must, absolute. I've testified in three cases where the employer chose to skip that step and had no MRO process. So if you were on your Adderall for your ADHD, taking the way you're supposed to, they would tell people they can't work there. Or if somebody just tested, they came back with a random opiate positive without any further testing, they would fire you. And so it's key that you follow this up with in-lab testing if they're positives. Think about patient privacy because if you think about it, all the negatives are gonna get their test back in 20 minutes and the positives are gonna take three days or two days anyway. And so make sure that the employer is not discriminating. I've run into one employee that wanted to say, well, they don't pass the negative test, we'll just lay them off. And if we need more people like them, we'll call the union hall and get somebody out in 10, 20 minutes. And if we need them, they'll still be on the call out for later. You really can't do that. That is actually discrimination based on a test that's not known to be positive. So they have to understand that maybe that 10 or 15% of your people that we test in a big group are gonna be positives that are gonna be positive, not gonna be non-negative screening tests, and then they're gonna come back later as a negative. And you have to hire them just like they were really a negative. You have to be prepared to do that. So think about the privacy of that. One clinic I know of randomly would take about 30 or 40% of the people and make them take two days just because. It's a way to do it. It does protect the privacy of that smaller group that had a positive test that was lab negative. You may need to stock different options. We had an entire cabinet of these things of different amounts of tests and what was in them. And the costs tend to be equal or a little higher than in-lab testing, because in-lab testing is pretty cheap right now. Some special topics go. So what about the ADA? Drug testing. So drug addiction is a medical condition. It is covered by, drug addiction is covered by the ADA. Current drug use is not. So if you have a history, like, you know, kind of the, you know, I'm an alcoholic. I'm Ted, I live in, you know, I've been dry for four years. That person who says I'm still an alcoholic, completely covered by the ADA. Ted, I'm sitting here drinking my beer as an alcoholic, not covered. So current use is not covered by the ADA. And it's specifically included in the law. The prior drug users are covered. HIPAA, the CCF includes a release from HIPAA. So you're not covered, but HIPAA does not apply to workplace drug testing. The medical information, however, collected by the MRO to make the determination of whether it's a positive or a negative is covered by HIPAA. So that, so that sheet that I'm gonna send, the notification of a final result I'm gonna send to the employer that says that Bob has a positive drug test, that's not protected by HIPAA. But if I call Bob and Bob says, well, I'm prescribed Adderall, great. What about your marijuana use? Okay, so the fact that I know that he was on Adderall, that's protected. And I can't release that to the employer. But it'll still be, so it would be, that guy was positive for amphetamine and marijuana. He would go out as positive for marijuana, but the MRO, I wouldn't mention the amphetamine because that's medically explained, right? And if I find something that's a safety issue, this is a tap dance. What I have to do is let the employer know that there's a safety issue, but I can't tell them what it is. So if I call up and say, I have a question about medications you're using. And they tell me about their, I don't know, seizure medicine. And I say, oh, what's that for? Because remember we use seizure medicine for a lot of things now. And they say, oh, that's for my epilepsy. You can't drive when epilepsy, that's a no. That's a hard no. And so that's, I've now identified a safety sensitive to problem that is not compatible with their work. But I can't, because that information is HIPAA protected, I can't tell the employer. But I can say, when I interviewed your employee, George, I identified a health condition that could be an impact safety sensitive work. And then send that letter to the employer, which will make them mad. They will call you and cuss at you because you won't tell them what's wrong. And then they have to send the person to their doctor to figure out what was wrong. A problem with a bad solution. But that's what we got in the US right now. Relationship with employers, I, unless they're only a hundred percent DOT and nothing else, I insist on a written drug policy. And they can scrape the DOT policy off, on repeat on into a Word document, make it their own and that's fine. But if they don't have a policy, they're gonna get in trouble or I'm gonna get in trouble when they do something about, when they make it up as they're going along about results that I gave them. And that just, if they write down, at least we were starting with something on paper. I don't tell them what it has to be, but it has to be written down. So they do the same thing for every employer, employee. If they're gonna offer rehab, who pays for it? If they're gonna, if a SAP assistment is required, who pays for that? Who does all that stuff? And what triggers for-cause testing? Those are things that should be in their plan. Any questions? Any questions from the online people? And you can turn your mic on and ask your questions live if you have questions from the people who are participating remotely. I have a question. There is an online question, okay. Ketamine is detected by the tests. So ketamine is not an opiate, it's not gonna be detected. It's a different kind of a thing. It's certainly bad, but it would certainly interfere with your ability to drive safely, but it would not be detected. Okay, thank you very much. I have a quick question. On the marijuana use, what about the use of PPIs and other substances that may show positive? Okay, so the question, yeah, well, I guess you guys heard. The question was the use of PPIs and other things that could theoretically cause a positive. Today, and this is 2022, not 2010, the tests are pretty solid for avoiding those cross-reactivities. If you're really concerned, and the only time I've ever, I've had to call once or twice and ask the scientists, and they will actually talk to you on the phone. They're happy to do that. The scientists at the drug testing company, and usually the ones I've run into were some of the more esoteric chemotherapy agents that I had somebody that tested positive, and I couldn't find anything about it, because I called and asked, and he looked up and said, no, no, that doesn't, we've tested, that doesn't show up on our test. So, but as far, we used to talk about naproxen and the PPIs, and I forgot, there's a third thing that would show up sometimes on the, as a marijuana positive, and those are mostly not true any longer. They've made the tests enough better that that's not, that cross-reactivity is not really a problem anymore. Any other questions? Just quick clarifying question. In your example where you said that a patient or someone is on like medically prescribed Adderall, and then they also happen to test positive by marijuana, of marijuana, then you said you can report the marijuana being positive to the employer, but then there would be MRO negative for the Adderall. Is that correct? Or can you not even say marijuana? You can only say that there's a safe, there's a positive drug test. No, you would actually, for the positives, you tell them what the substance is. Oh, okay. So that would be a positive for marijuana. You wouldn't even mention the Adderall. You wouldn't, you wouldn't, it wouldn't even be on your report. So it'd just be a positive for marijuana, and then the other thing would be, and the safety concern. I see. No, it wouldn't be anything. The Adderall, and for drivers, drivers are different from pilots. For drivers, their Adderall is actually compliance. The DOT requirements, DOT rules for people with ADHD is if they're on their treatment, they're fine. If they're not taking their ADHD medicine, then they're not safe to drive. Yeah, for DOT, it's actually, it's the other way around from pilots, where if they have ADHD, they're like doomed. But for drivers, because they realize it's a boring job where 13 hours or 11 hours a day, you're just heading down the interstate. And if you don't take your ADHD medicine, you're not gonna be able to pay attention. So they actually, it's required that you, if you're prescribed medicine, that you're on it and taking it. So that, so it's kind of, it's a different way of thinking about this. Two different departments, the Department of Transportation have very different answers for the same medicine. Any other questions? Okay, thank you very much.

drug testing

occupational medicine

employer motivations

positive testing rates

Quest Diagnostics

legal ramifications

MRO involvement

marijuana legalization

workplace policies