Case number one, specimen test result is positive for a marijuana metabolite. Now, each one of these has laboratory information, a little bit of discussion. I'm going to read it for the first couple of ones, then you'll get the hang of it and I won't need to repeat all of this. But you as the MRO are getting the laboratory report. Remember, laboratory reports only go to the MRO. They're sending an electronic report and you get a copy of the federal CCF. One, a laboratory copy of the custody and control form. The information and all the information on the form match. The collector used the term express carrier in step four of the federal CCF rather than stating a specific name of the delivery service. Otherwise, there are no problems with the federal CCF. You're going to be thinking now, what kind of error was that? How important was it? The collector is required to provide the specific name of the delivery service. However, it's pretty de minimis discrepancy if the correct name is not provided. We're really not going to pay attention to that. No action is needed to correct that discrepancy. Before a final determination is made, you are going to discuss the positive result with the donor. During that interview, the donor claims that he was positive because of passive inhalation. He was at a party on Saturday night in which several individuals were smoking marijuana, but he didn't smoke a joint. He certainly didn't inhale. The MRO contacts the lab. He told the concentration of the marijuana metabolite was 30 nanograms per milliliter. What's wrong with that sentence? Anybody know? The answer to that, of course, is that the laboratory is going to provide you with the data of the quantitative value when you get the report. Be it electronic or be it on paper, you're going to know the quant level of the positive result. The federal CCF documents, the donor specimens collected two days after the claimed passive exposure occurred. What is your report? What is your verification report? Well, we have talked about it in the lectures that it is highly unlikely a non-smoking individual would unknowingly inhale sufficient smoke by passive inhalation to result in a high enough drug concentration in urine. The cutoffs in the federal agency program and in most workplace drug testing across the country are high enough to avoid that possibility. The donor's circumstances don't make any sense in this case. Your verification is positive marijuana. Case number 2, positive for morphine. Again, laboratory sent you an electronic report. You have a copy of the CCF, and this time there's no issues with the CCF. The quantitative results reported by the laboratory were 5,200 nanograms per mil of morphine. Six acetylmorphine was reported as negative. Remember, you see things in italics in these cases, they might be important, so I encourage you to remember that. Laboratory is required to test for 6M in all federal specimens. During the interview with the donor, donor doesn't remember a thing. Doesn't recall using prescription medications, does not recall eating poppy seeds. In other words, no idea. Where 5,200 nanograms per mil of morphine might possibly have come from. Additionally, by whatever questions you ask, by whatever methods you employ, you don't find any clinical evidence of the abuse of opiates. What is your MRO report? When there's no clinical evidence of abuse and the concentration of morphine is less than 15,000 nanograms per mil, you are required to report the result as negative. It is your decision when you are making that report, whether you want to add a safety warning as required by paragraph 327. Case 3, this time the results positive for codeine and morphine. The laboratory sent an electronic report and faxed a copy of the federal CCF. Once again, everything's good. Concentrations reported by the lab are 2,500 nanograms per mil of morphine, 4,800 nanograms per mil of codeine with a negative 6M. Don't forget, laboratory tests for 6M on everything. During the interview with the donor, the donor denies using any medication. Again, you don't find any clinical evidence of opiate abuse. Now here, what do you see? It's highly likely, I believe, that this person actually took codeine because morphine, as we've learned, is a metabolite of codeine and it's also positive. Codeine is the parent compound potentially and it's significantly higher than the morphine levels. The odds are this didn't come from poppy seeds. Doesn't matter, does it? Because you remember what we talked about. 15,000 is the magic opiate number. Both of these values are under 15,000. You're going to have to make this negative again. Now, compare this with case number 2, the last case, and you may be more inclined to put a Part 327 safety warning on this one because of our opinion. Hoping that you share my opinion. Our opinion that this is much more highly likely to have come from some type of opiate medication than the previous value of morphine in case 2. Conclusion is what we just said. Quantitative results are consistent with medication. You still have to report the result as negative. Case 4 is also a codeine morphine case. Again, all the information in the laboratory download in the federal CCF is properly completed. But the concentrations are 6350 nanograms per mil of morphine, but 17,340 nanograms of codeine with the negative 6M. During the interview with the donor, this time the donor states he was taking a prescription medication that contained codeine. Well, that's no surprise to us, is it? The donor gives you a copy of medical record and proves that the medication was properly prescribed to treat back pain at the time of the drug test. What is your MRO verification now? Given that you have verified a prescription and you have results over 15,000, for sure, but a verified prescription. You are going to downgrade this result to a negative. Are you going to include a safety warning? Report 327 safety warning mating. That is your MRO judgment. You're not required to do it, but it's your judgment about whether you want to do that or not. I would suggest you avoid counseling the donor when you're talking to them on the telephone about taking this medication at work. Remember that we are doing forensic medicine here. As you cross from forensic medicine into offering clinical advice, there's a very fine line between those two practices. Advising the donor not to take this at work is much more on the clinical side of that fine line than the forensic side. We might be tempted to do it, but I would advise you not to. Your MRO report is negative with a possible safety warning depending on what you decide. Remember, when you have a prescription to verify, you verify the prescription, as we've talked about in the course, and you are not required to determine if there is any other clinical evidence of abuse. Case number 5 is getting off of the opiates now, it's positive for methamphetamine. Again, the electronic report and the CCF properly completed by the lab. During the interview with the donor, the donor states that he was not taking any prescription medication, but he'd used over-the-counter decongestants and, surprise, surprise, a generic dry nasal inhaler at the time of the drug test. You contact the laboratory, you verify amphetamine was present in the specimen below the cutoff, so it wasn't reported, as you do. Confirmation was 245 nanograms per milliliter. Because the concentration of meth is significantly higher than the amphetamine, it appears the amphetamine, remember, may be present as a metabolite. Don't forget that requirement. We have a history of a dry nasal inhaler, so you're going to want DNL separation. You request that from the laboratory, and you know why you're doing it because L-methamphetamine is a legitimate component of some generic dry nasal inhalers today. You want to be certain that the meth didn't come from one of those. The laboratory tells you that 90 percent of the meth is the D-enantiomer or isomer. Ninety percent is D. Since the inhaler is containing primarily L, the D-meth didn't come. Ninety percent of the D-meth for sure did not come from the inhaler. What is your MRO report for this case? Give you a moment. You're going to report this as a positive methamphetamine. Everybody agrees with that, I hope. So either use a prescription medication illegally or use an illegal source of methamphetamine. Remember, there are two prescription medications that are D-methamphetamine. You hardly ever see them in the real world nowadays. You can't forget they're out there. Either case, no valid medical explanation for the positive result. All right. Case number 6 is positive for cocaine. Again, laboratory report and CCF all in order. During the interview, the donor denies using cocaine, but claims that cocaine was used as a topical anesthetic prior to an endoscopic procedure. The donor submits a copy of the medical record, and the medical record documents the use of the cocaine for the procedure. You also do a secondary verification with the physician because honestly, cocaine for most endoscopic procedures is not the anesthesia of choice. So you're going to do a second verification with the physician who performed the procedure. The medical record supports the use of cocaine. Let's see, we're not going to make it that easy for you. So procedure was 10 days before the specimen was collected. What does that make you think about? What is your report now? What is the detection period, the window of detection for cocaine in urine? In this case, your report is going to be positive cocaine. The documented use of cocaine was 10 days before the drug test. The positive result could not have resulted from the medical use of cocaine. That's true regardless of the concentration of the specimen, which you're not taking into account anyway in federal drug testing. Regardless of whether the person is a slow metabolizer, yada, yada, yada, 10 days is way too long. So this case is positive cocaine. Case number 7 is a positive for morphine at 3150 nanograms per milliliter with a negative 6-acetylmorphine. During the interview with the donor, the donor states that he was taking Percodan. I know that's a brand name. Percodan is oxycodone and aspirin at the time he submitted a urine specimen. The donor also states that he routinely eats poppy seed bagels. The MRO requests the donor to provide him a copy of his medical record. The medical record shows oxycodone and aspirin use during that time. What's your report going to be? That's a little bit of a tricky question. Because you're looking at morphine, the only thing you're really reviewing in this case is morphine. You're not reviewing oxycodone. Oxycodone, as you know, nowadays is on the federal panel. It has positive for oxycodone, so you're not reviewing it. You could argue that as the MRO review of this case, you should not have even asked for the medical record. I probably would have, because I would like to know if there was maybe some hidden morphine on there that the donor wasn't telling me about. But it doesn't matter because we're not reviewing oxycodone. Morphine concentration is consistent with eating poppy seeds. You're satisfied, especially now with the medical record, that there's no clinical evidence of opiate abuse. Oxycodone does not metabolize to morphine, it just doesn't. Codeine does, but it didn't take codeine. Looks like the oxycodone was used according to the physician's instruction and had stopped the use three days before the drug test. No reason to contact the prescribing physician. You can inform the donor that taking any remaining oxycodone tablets after it's intended use may be considered illegal, and caution him about the side effects of that at work. Again, remember that line we talked about on the previous specimen. That's really close to the clinical line. You should limit what you say to this person, to what effect taking that medication may have on the drug test. You can also emphasize that if the oxycodone did show up, even with the prescription, it may create a safety issue in your mind as the MRO. Case number 8 is another methamphetamine case. All the forms are intact. Again, you got the amphetamine concentration once more from the laboratory. Everybody knows where the amphetamine came from, I hope. Amphetamine is present as a metabolite, we assume with methamphetamine. During the interview with the donor, the MRO asked the donors to list the drugs, it was taken, diazepam, and a nasal inhaler. Donor volunteered the information because it cut the value. The diazepam may have caused the positive drug test. The MRO, you asked for the chiral separation again. 95 percent of the meth present in this urine was the L isomer. What does that tell you? And what is your report based on what that tells you? You're going to report the result as negative because that is consistent with the Vicks defense that we've talked about in the lectures. Now, what do you do about a Part 327 warning though? Okay. Reasonable medical judgment about issuing a safety warning based on the admission of the diazepam for anxiety. Case number 9 is another methamphetamine case. This time, we have amphetamine reported at 250 nanograms per milliliter and an interview with the donor. He takes Phentermine, brand name Atopex, for weight control. Has a free sample given to him by his physician, but he can't remember the name of the sample. Frequently uses a nasal inhaler for a stuffy nose. Number of nutritional supplements, energy drinks, if you will, from a health food store. So the MRO contacts the donor's physician, indicating the free samples of diethylpropion was given before the prescription for Phentermine. The MRO contacts the laboratory, told that neither diethylpropion nor Phentermine metabolized methamphetamine or amphetamine. Of course, you all don't have to do that because you've listened to this course and you already do diethylpropion nor Phentermine metabolized. You know that. So you are going to determine whether the inhaler caused the positive results. You again ask for the chiral restoration and you get 37% D and 63% L. What is your report? Okay. Well, the report, does that meet the 80% L threshold? And the answer is no. And the answer is no. So this person is taking some kind of mixture and may in fact be taking illicit methamphetamine with a lot of a generic nasal inhaler to get that much L. No question about it. But that does not still meet the 80% threshold. So your report is going to be positive methamphetamine. You know that Tenuate, Natapex, the brand name medicines were not involved in this at all. Okay. And the nasal inhaler does not go over 80% threshold. It's positive methamphetamine because of the de-isomer. All right, case number 10, adulterated nitrite. Again, paperwork is all in order. During the interview with the donor, the donor claims he eats a whole lot of bacon, salami, sausages. What do you think? Is that going to cause nitrites to be present at 850 micrograms per mil? What is your MRO report? Refusal to test specimen adulterated with nitrite. No legitimate explanation for the presence of nitrite.

Medical Review Officer

drug testing

enantiomer analysis

substance exposure

methamphetamine sources