So now we are going to do the assessment quiz that we have to have for all CME activities. And what I would like you to do, I mentioned this in the introduction, but what I would really like for you to do is first of all, look at the attachment on the course that is just the assessment quiz itself, just the questions, not the answers. What I'd like for you to do is then go through the questions, make your choices, and then look at the answers. Now, what I'm doing now, I'm going to go over the whole thing and talk about the answers. So hopefully that when you're viewing this presentation, you will have already taken the quiz and this will be just kind of a grading session for you. So question number one, when a collector receives a specimen for a DOT drug test that has an out of range temperature, the proper action is to A, send the specimen to the lab and do not confront the donor because of safety reasons. B, do an immediate observed recollection and send both specimens to the lab. C, call the DER and ask permission to do an observed recollection. D, begin a shy bladder protocol or last choice E, draw blood. So the answer to this of course is B, the collector does an immediate observed recollection and sends both specimens to the lab. Way back in the nineties, it used to be that there had to be a request to the DER to do an observed collection, or at one point even a request from the collector to the collector's boss to do an observed collection. That's no longer the case. It is the responsibility of the collector and the DOT drug testing program to automatically do an observed recollection and send both specimens to the laboratory. Now, we don't think there's any really good reason to send the temperature out of range specimen along with it. That's a legacy type of requirement that just simply hasn't been changed, but do not forget that that still is a requirement. Okay. Question two, which of the following are fatal flaws? There'll be more than one here now, folks. The temperature box is not checked. Is that a fatal flaw? The collector has its printed name on there, but no signature. Is that a fatal flaw? Insufficient specimen volume, so there's not enough specimen to test? Is that a fatal flaw? What if the CCF is submitted to the lab, but no specimen is submitted to the lab? Or conversely, what if two specimen collections are submitted on one custody and control? And the right answers are C, D, and E. Temperature box not checked is a de minimis flaw, as Dr. Smith tells you. We'd like it checked, but if it isn't, it doesn't really matter. The collector printed name, but no signature is a correctable flaw, but not a fatal flaw. Remember, for it to be a fatal flaw, both the collector printed name and the signature have to be missing. That's a fatal flaw. When only one is missing, it's correctable. But obviously, if there's not enough specimens to test, you can't test it, that's fatal. The CCF is submitted to the lab, but no specimen. How do you match them up? Where has the specimen been? How do you say forensically that that chain of custody has not been broken if they come in separately? You can't do it, so it's a fatal flaw. And conversely, if you get two collections on one CCF, that's a no-no too, fatal flaw. So C, D, and E are the proper answers. Which of the following technologies may be used for confirmation of a screening positive in the DOT drug testing program? And you see five of them listed there. I probably should not have to tell you that four of them are different screening techniques, not confirmation. The only one that's a confirmation is GC-MS, letter C. I don't think that's gonna be too tough. Which one of the following will not produce a confirmed positive in the DOT drug testing program? Heroin, Marinol, Dexedrine, Ritalin, Norco? The answer, of course, is Ritalin. Ritalin is a stimulant, but it is not an amphetamine. Methylphenidate is not on the federal testing panel. You will hear this a lot as an MRO, that their positive might have been because they took Ritalin, but you know it's not true. The confirmation techniques used in this program are way better than that. So Ritalin will not produce a positive result in this program. Okay, which of the following most accurately states the MRO's primary role in the drug testing program? Not gonna read them all, but you should have no trouble with this one. Letter C, acting as an impartial gatekeeper and advocate for the accuracy and integrity of the entire process. That is why we're here. Again, I don't think that should have caused anybody any trouble with that question. What do you need to accept the Vicks defense? L-Meth greater than 80, D-Meth less than 30, L-Meth greater than 50, D-Meth greater than 30. The answer is A, L-Meth amphetamine greater than 80%. That one's very likely to be on the test that really counts too. L-Meth has to be greater than 80%. And believe it or not, that will come up in some of your real life MRO experiences. Number seven, urine test positive for hydromorphone. Hydrocodone is negative. Donor denies use of morphine or hydromorphine, morphone, I'm sorry. Donor presents a valid hydrocodone prescription, but says he only takes it in the evenings at bedtime. What are possible reasons hydrocodone is negative? Not the only reason, possible reasons. A, hydrocodone was present, but below the cutoff. B, hydrocodone is metabolized more quickly than its metabolite. C, the donor took Dilaudid or hydromorphone, but submitted a hydrocodone prescription. And D, all of the above. Okay, all of them are possible explanations. Likely or not likely, maybe, but they are all possible explanations for this result. So what are you going to do? What are you going to report it as? If you have a valid hydrocodone prescription? I'm jumping ahead to question number nine, but think about it. Next question is if you test positive for morphine at a pretty high number, and hydromorphone at a relatively low number compared to the quantitative value of the morphine present. Okay, the donor says no use of hydromorphone, but did give you a valid MS content prescription. Only taken again in the evenings at bedtime. 6M is negative. What, again, same as the question before, what are possible reasons hydromorphone was positive? Lab error, minor metabolite of morphine, donor took Dilaudid in spite of what he told you. Yep, again, possible reasons, folks, not likely reasons, possible reasons. B and C, both are possible reasons. I put these two questions in here just for that express purpose, to keep your minds open to the possibilities in this program. Sometimes it's not just as cut and dried as we'd like it to be, but even with both the possibilities for question seven and question eight, what's your verified decision going to be? The answer to that is going to be negative. The answer to that is going to be negative. The benefit of the doubt goes to the donor in a deterrent program. So we don't think it's lab error. We do think that the possible reasons are accounted for by the submission to you and the verification by you of the prescriptions. And when that happens, you downgrade the report to negative. Okay, number 10, when the split specimen from a post-accident drug test is a valid specimen, but does not reconfirm the positive finding in bottle A, you make what recommendation to the employer? What are the important things in this question? It's a split specimen. That's one thing that's important. It's a post-accident drug test. Do you need to have a negative in the DOT program, the federal programs? Are you required to have a negative result from a post-accident drug test? That's the key to the answer. So which recommendation do you make? Immediate observed recollection, both tests canceled, no recollection, both tests canceled, immediate recollection, not observed. The answer is B, both tests canceled, no recollection. As much as we may not like it, you do not need to have a negative in a post-accident drug test in the federal program. So if you have a valid specimen that does not reconfirm on the split specimen reconfirmation process, you cancel both tests and there is no recollection. It's a done deal at that point. Number 11, which of the following most accurately defines the regulatory obligations of the DER after either a verified positive or a verified refusal to test? And after the donor is removed from safety sensitive duties. So verified positive donors are referred to SAPs, the verified refusal donors are referred to SAPs, both must be given SAP information. Donors with verified adulterated specimens are considered as having refused to test and are not eligible for SAP. Both are removed from safety sensitive duties only until they begin the SAP process. Well, you know that's not right because they have to finish the SAP process before they can begin the return to duty process. So you know that E is wrong. The answer is C, both verified positive and refusal donors must be given SAP information. It's not the duty of the employer, the TPA, the MRO or anybody to make sure these folks enter the SAP treatment and protocol, but the employer has to give them the information about how to contact SAPs in their area. That's a requirement. In which of the following functions are TPAs not allowed to perform in the DOT drug testing program? This one should be easy. See TPAs, they can receive verified positive results. They can receive that. They may act, can they act as a DER when the employer wants them to? And the answer to that, of course, is no. So the answer is C, that TPAs under no conditions can act as the designated employer representative. They can do everything else in that list of items, but they can't be the DER. Okay, 13, you are told by an employee with a confirmed marijuana positive on a DOT test that he has a prescription for cannabis from an oncologist in San Francisco. You receive a letter from the oncology service at a major university medical school verifying this. Your proper action is to report it as positive. This is a real case, this happened to me. Remember, we're in the federal program, regardless of the quality of the treatment program this donor is undergoing. Unless the donor presents to you a verifiable prescription for dronabinol, they're not allowed to take marijuana in any other way and test in this program. So you have to report this as positive. 14, the decision to return a DOT-covered employee to work after that employee's failed a drug test is made by who? SAP, MRO, SAP and MRO, SAP and the employer. Who makes that decision? The answer is the employer. Which of the following would not be expected to cause an oral fluid confirmed positive laboratory result? Remember now, oral fluid. When we talk about marijuana in oral fluid. So the options are hydrocodone, dronabinol, Adderall, THC brownies. Which one of that four, and there's only one of them, would not be expected to cause a positive in oral fluid? Hint, hint, may cause a positive in urine, not in oral fluid. The answer is dronabinol, because parent THC and carboxy THC do not diffuse into oral fluid. Now, as I said in the talk, if they're sucking on the dronabinol or swishing it around in their mouth, yeah, that could cause it. Otherwise, no, it does not cause it. Which of the following is the correct procedure when a donor cannot provide a specimen? Now, there can be more than one answer here, hint. In urine, allow 40 ounces of fluid over a period of up to three hours. For oral fluid, same thing, 40 ounces of fluid over a period of three hours. For both, they can't do it, you report a refusal to test if they refuse to take supplemental fluid after the fact. Oral fluid allowing up to eight ounces of fluid over a period of up to one hour. This is here so you can see the differences in the shy bladder and dry mouth protocols that we are talking about. And the answers, of course, are A and B. Remember, if somebody is in a shy bladder or a dry mouth protocol and they refuse fluid, that's not a wise thing for them to do, but it's not a refusal to test. Don't forget that. Last question is a true or false question. All HHS and DOT drug testing requires validity testing for all specimens. Okay, it might be a little tricky here. Apologies. What are the words here? All testing requires validity testing. Not for oral fluid. Urine, yeah, always requires validity testing for urine. There can be in SAMHSA guidelines, there can be validity testing dependent on the MRO ordering it from the lab for oral fluid. It is not required for oral fluid because there is no validity testing for oral fluid that everybody agrees on is really, validity testing is really worth it. So that question might've been a little tricky, but remember, it's not required for oral fluid testing. Okay, we are now done. I hope you enjoyed the course and I thank you all for taking it.

CME drug testing

DOT procedures

Medical Review Officer

specimen temperature

federal guidelines