My name is Barry Sample. I'll be talking with you today about the HHS Certified Laboratory. First, I'd like to start with the disclosure. Currently, I'm self-employed. I retired recently after 40 plus years in the drug testing industry, and I'm now working as a consultant with a variety of laboratories and IBD companies. Let's talk about the agenda for the HHS Certified Laboratory. I want to give a brief overview and introduction, talk about chain of custody procedures, the testing procedures, the drugs that are included in the testing, specimen validity testing where applicable, and then wrap it all up with a summary. The specimen types that are allowed under the HHS testing program are historically urine, which is approved for both HHS and DOT testing, as well as now oral fluid, which is approved for HHS and DOT as of 2023. However, there are not yet any laboratories that are certified by the National Laboratory Certification Program or the NLCP for performing oral fluid testing. Consequently, that testing is not yet available for either HHS or DOT regulated entities. But we expect that sometime in late 2023, early 2024, that oral fluid testing will be available. Hair testing, another commonly used specimen type in drugs and abuse testing, is not yet permitted for federally regulated testing. HHS most recently proposed guidelines in September 2020, but that specimen type is not yet approved for testing either HHS or DOT testing. How are specimens collected? First and foremost, there's this absolute right to privacy. There are chain of custody procedures that include verifying the integrity of the specimen, security, proper identification of the donor and the specimen, assessing whether the specimen is valid. That would include testing temperature, but that is only applicable to urine testing. What I'd add at this point is while this particular presentation is focusing on urine, the basic tenets of chain of custody requirements, testing requirements are the same whether one is testing oral fluid or urine. Another assessment of validity is done by looking at the appearance, no evidence of tampering, ensuring that there's sufficient volume. The tamper evidence seal is an integral part of that chain of custody process. The various components of the chain of custody include the custody and control form or CCF, the tamper evident bag and a tamper evident specimen container, secure laboratory, and internal laboratory chain of custody on both specimens and outlook ones. In an HHS certified laboratory, and really one of the basic tenets of all forensic drug testing is a two-step, sometimes some of us refer to it as a two-tiered testing process, whereby there's an initial test on one portion of the original specimen in the event that that test is presumptively and I'll emphasize the word presumptively positive on that initial test. A second portion of that original specimen is subjected to confirmatory testing using definitive testing technology. In a little bit, we'll be talking about the drugs and drug metabolites as well as any required specimen validity testing. So once the specimen arrives at the laboratory, it's accessioned into the laboratory computer system, that the area where the specimens are received as well as where all the testing occurs and has limited access, it's a very secure area. There's strict chain of custody, tracking the aliquoting, interlaboratory chain of custody. The specimen is evaluated for any discrepancies in documentation or acceptance criteria, so-called fatal flaws or recoverable flaws, determine whether or not the specimen needs to be rejected and not tested at all, as well as temporary storage which occurs within that accessioning area. So the most common type of initial test or screening test or first test, if you will, in an HHS certified laboratory would be an immunoassay testing technology and there are a variety of immunoassays. Most of them are some type of enzyme immunoassay or EIA where by a drug interacts with an antibody and there's an enzyme that produces measure enzymatic activity is measured to produce a reaction. There's also fluorescent polarization immunoassay or FPIA. In which case the drug frees a marker which modulates a signal. Another technology is chems or kinetic interaction of microparticles and solution where by the drug affects agglutination and thereby signal. And another very specific type of enzyme immunoassay known as plant-cloned enzyme donor immunoassay. Examples of those would be either Cedia or Cephria which is a newer type of this cloned enzyme donor assay technique. But in this case the immunoassay is based on a reconstitution of the enzyme in solution and it affords much greater sensitivity than the traditional enzyme immunoassay or EIA. One of the basic requirements set forth by HHS and SAMHSA is that for group analytes you can think of those as class assays for example amphetamines or opiates. The assay must have at least 80% cross reactivity with the least reactive member of the group. An additional requirement not so much necessarily from an HHS perspective but from an FDA perspective is that for all federally mandated testing those immunoassays must be FDA cleared. HHS now also permits so-called alternate technology. Alternate technology most commonly that would be some type of chromatography mass spectrometry and more recently some types of fast mass spectrometry. And in the case where alternate technology is used for the screening the assay must use the confirmatory cutoff rather than the initial testing cutoff for determining whether or not there's a presumptive positive. And the other thing I would add with respect to the alternate technology is even if chromatography mass spectrometry is used for the initial test it doesn't matter how definitive that initial test is there's still this absolute requirement for confirmatory testing on a second portion or aliquot of the specimen. So let's go back to the immunoassays for a second. In this chart you can see you know how those immunoassays work. There's an antibody that has been developed against the drug or drug metabolite. That antibody binds with the drugs which can thereby modulate the signal. Either by being directly proportional to concentration or inversely proportional to concentration but the key take-home message here is that there's an antibody that has been developed specifically for that drug or drug metabolite and by binding with that drug or drug metabolite the signal is modulated. One of the most common types of enzyme immunoassays is the what's known as enzyme multiplied immunoassay sometimes also referred to as EMIT but EMIT actually is a trade name and it's long been off patent so there are a number of enzyme immunoassay systems that utilize that technology but probably better to refer to it as EIA more generically than EMIT which is a trade name. But in this technique an antigen is bound to an enzyme typically glucose 6-phosphate dehydrogenase so that the presence of the antibody sterically restricts access of the substrate to the active site of the enzyme and enzyme activity is thereby inhibited so unlabeled endogenous antigen displaces the enzyme labeled antigens from the binding sites on the antibodies and the unbound enzyme-antigen conjugates provide access to the substrate allowing the conversion to product B. This therefore enzyme activity is the measured signal and is directly proportional to the concentration of drug in the specimen. So this provides a graphical overview of that initial testing process. So in the case of urine testing there is initial drug and specimen validity testing. Any specimen that is presumptively positive adulterated or substituted or invalid sends a reflex order to accessioning for the aliquoting of a second specimen for confirmatory testing again that's true whether it's an immunoassay or chromatographic mass spectrometric procedure. If a specimen is negative it would then be reported as negative and no further testing is performed. There is strict quality control that includes calibration of the assay, controls at least 10% open controls, and some degree of linearity around the cutoff so that laboratories can reliably differentiate specimens that are below cutoff from those that are above cutoff. So in the confirmatory test as I mentioned there's a separate aliquot of the specimen. The technology typically involves a chromatographic method which is coupled with mass spectrometry and that can include gas chromatography mass spectrometry or GCMS, gas chromatography mass spectrometry mass spectrometry which is known as gas chromatography tandem mass spectrometry sometimes, LC-MS which is liquid chromatography mass spectrometry, as well as LC tandem mass spectrometry. So today probably the two most common types of methodology techniques that are used in laboratories would either be the more traditional GCMS or a more modern LC-MS technique. Both of those have the same underlying principles, both techniques produce equivalent results, accurate, reliable, forensically defensible. Decision on which technology to use is really driven by laboratory operations and not so much by the, you know, any differences in their ability to accurately identify and quantify drugs or drug metabolites. So looking at the overview of just the confirmatory drug testing piece, again quality control includes calibrators, controls, at least 10 percent above and below the cutoff. Because these are quantitative assays there's an absolute requirement for linearity typically over a wide range and then obviously the criteria for the reporting of a positive specimen. So after testing and on the confirmatory method any specimen that is confirmed positive would then be stored, long-term storage in a freezer, and that's true whether it's oral fluid or urine. And, you know, two possible outcomes from that confirmatory test is that it could be positive or negative. One of the basic things that one should always remember as a medical review officer or really anyone in the drug testing industry is that a negative result doesn't necessarily mean no drug is there. Oftentimes it does, but it may mean that drug is present but it is less than the cutoff. So in theory we could have a specimen that screens positive at or above the cutoff but confirms negative at, sorry, confirms negative below the cutoff. Or in the case of these immunoassay tests which, while they're designed to be as specific as possible, may interact with similar drugs, structurally similar drugs that might be in the specimen, might have specimens that are immunoassay positive that are totally negative on the confirmatory test. So again, a negative specimen while it oftentimes may mean no drug is there, that is not always the case. So let's talk a little bit about the underlying technology for chromatography. So as we look at chromatographic mass spectrometric techniques, the chromatographic procedure is really part of the identification process and is designed to separate in time the various components, drug or drug metabolite, that may be present in the specimen. So after preparing the sample for analysis, that entire sample extract is injected into the chromatographic system. It travels down the length of a chromatographic column which affects that separation in time for the various constituents that may be in that specimen. So while that's part of the identification and the time that it remains on the column, so-called retention time, is an integral part of the identification. It's not the only identification. What happens next is, after those sample components elute out of the chromatograph into the mass spectrometer, they're bombarded with high-energy electrons, which cause the components to fragment. And they fragment in a very reproducible way, producing what we like to think of as a molecular fingerprint. And you can see an example here for a compound where you have the various molecular fragments that result in the mass spectrometer. And the way that those fragments are produced are very reproducible. And the relative abundances of those various components are quite consistent for, or more than quite, they're very consistent for a specific compound. So based on the retention time, as well as the ratios of those various components, a drug or drug metabolite may be definitively identified in the sample that's being analyzed. So switching a little bit to specimen validity testing, and this really only applies to urine testing, required markers for SVT or creatinine, specific gravity when the creatinine is less than 20 milligrams per deciliter, pH, measure how acidic or basic the specimen is, testing for one or more oxidants, such as nitrites or chromium 6. Sometimes other components that may be used for an adulterated specimen, such as soap or bleach. During that specimen validity testing process, there's also a two-tier testing process. So there's an initial test on one portion of the specimen, followed by a confirmatory test on another portion of the specimen if the initial test is presumptively positive. And the testing technologies that are used either be chemical, for example, some sort of colorimetric test for the measurement of creatinine, or screening for pH, or testing for the oxidants, or a physical characteristic, such as measuring the specific gravity using a refractometer. So this slide shows an overview of what we just talked about in the testing process. You have an initial drug test. If that specimen is negative on that initial drug test, results are transferred to the lens. Ultimately, it's going to be reported as negative after review. If it's presumptively positive, there will be confirmatory testing. And again, that result from that could either be positive or negative. So the individuals involved, at least in the testing process, I'm really talking about the accessioning department. There are analysts that are performing the actual laboratory analysis, laboratory supervisors, certifying scientists. And some newer terminology really refers to certifying technicians who are responsible and can only certify the results of specimens that are negative on that initial test, because they're not yet approved by the NLCP for the review and certification of non-negative results. Certifying scientists, who is responsible for reviewing and certifying non-negative test results. Generically, we're still really referring to them all as laboratory certifying scientists, not really making that differentiation or technical differentiation between a certifying technician and a certifying scientist. And of course, medical review officers are still responsible for verifying all laboratory results, whether they're negative or positive in the federal testing program. The quality controls that are run consist of both open and blind quality controls. And a blind control in the federal program is blind in terms of content not only in content to the analyst, but also in position. So the analyst has no idea whether it's a positive or negative blind or where it is within that batch of specimens. Blinds are only required for the initial or screening test, not required for the confirmatory test, although some labs may also include blinds in the confirmatory test. And there's a requirement for a minimum of 10% quality control. So if you're analyzing 100 specimens, at least 10 of them must be quality control materials. So once all the testing is complete and the data has been reviewed by the analyst at the bench level, there is certifying review. So during the certification process, there's a review of all of the chain of custody documentation, external chain of custody, IECCF, internal chain of custody on both specimens and aliquots. So a thorough review of all of the chain of custody. Review of the open quality controls, open QCs, the blind QCs. Review of the initial test data. And as applicable, review of any confirmatory test data. We'll switch a little bit now to talking about the HHS certification program. So the HHS laboratory certification is under the National Laboratory Certification Program, or NLCP. In order to become an HHS or SAMHSA certified laboratory, one must apply to the NLCP for certification. There's an inspection program. There is a PT or performance testing program component. Laboratories need to ensure that they're in compliance with the NLCP checklist and its guidance manual. The NLCP utilizes trained inspectors. And there are two types of HHS certification because there are two types of testing laboratories, testing facilities. One would be full service laboratories that perform both initial testing as well as confirmatory testing at the same location. And this concept of initial instrumented testing facility, or IITF. However, you can think of that IITF really as having everything in place that's required for initial testing of a specimen with confirmatory testing occurring someplace else. However, that process, the utilization of an IITF is not available to the DOT. Because of DOT rules, both all testing, both the initial testing as well as the confirmatory testing must occur in the same site. The utilization of an IITF might only be applicable to other regulated testing, such as the actual testing of federal employees, what we refer to in the industry as HHS testing, or testing required under the Nuclear Regulatory Commission program. So what drugs are included in the HHS program? And this is true whether it's urine or oral food, testing for cannabinoids, cocaine, PCP, opioids, and amphetamines. And in the event that a specimen is confirmed positive for a drug, the laboratory is required to report all quantitative levels to the medical review officer. And that's true whether it's HHS testing or DOT testing, or even NRC testing. So since we're focusing on urine, let's spend the rest of this presentation talking just about urine testing. So urine drug testing is the longest standing, most utilized specimen type for both regulated and non-regulated testing. And still today, because there are no HHS certified laboratories for oral fluid, the only specimen type that is utilized for federally regulated testing. So there is an extensive scientific base, one of the advantages. It's well proven to be accurate and reliable. It's a very mature technology. But what are some of the disadvantages of urine testing? It only has a two to three day window of detection. Specimens are collected in the privacy of the restroom. And while safeguards are taken, emptying and displaying contents of pockets, removing outer garments, making sure that somebody is not carrying anything into the restroom. At the end of the day, that specimen is collected in the privacy of the restroom, which makes it far easier to adulterate than some other specimen types. Another potential disadvantage, although not really applicable under this program, is that there is no dose concentration relationship. So to review, again, let's give that overall process. Specimens are collected at a collection site, sent to the laboratory where they're accessioned. They then undergo initial drug and specimen validity testing for urine. If a specimen's presentably positive, adulterated, substituted, or invalid, there's a reflex order to accessioning for another aliquot for confirmatory testing. If that specimen is positive, be reported as positive, negative as negative. Any specimens that are non-negative, we really think of, particularly for urine testing specimens, is not necessarily being just positive. Think of them as being non-negative, because that means they could either be positive for a drug or broken cavalite, they could be adulterated, they could be substituted, or they could be invalid, or some combination of all four of those. Looking now at the specific drugs in urine testing, there's testing for marijuana metabolite, carboxy-THC. The initial cutoff is 50 nanograms per milliliter in urine. The confirmatory cutoff is 15, 1.5 nanograms per milliliter. Some people may ask, why is there such a big difference between the initial testing cutoff and the confirmatory cutoff? If you recall, when I was talking about immunoassays, while they're designed to be specific, they may react with structurally similar compounds that may be in the specimen. In the case of marijuana or cannabis, which is extensively metabolized, there may be other metabolites in that urine specimen contributing to the response on that immunoassay test. So the initial cutoff is set at 50, and the confirmatory cutoff is set at 15. One of the issues that medical review officers may run across in reviewing positive marijuana results is the issue of CBD. Donors may certainly like to raise that as a potential issue. I can assure you that the laboratory analysis does not confuse carboxy-CBD and carboxy-THC or THCA. They are two very distinct compounds with different chromatographic and mass spectrometric characteristics. However, THC may be a contaminant in CBD products. However, that's not an alternative medical explanation, and you'll be hearing a lot more about that during the MRO lectures. One of the rising potential issues is THC analogs. For example, the delta-8-THC, or when I was talking about THC, I was really talking about delta-9-THC, the main psychoactive ingredient in cannabis. There's also delta-8-THC. Delta-8-THC is not covered in the federal program. In any review that you may perform for non-regulated employers, they may not care about delta-8, but there are a number of issues related to delta-8 and the fact that it may actually be legal in some states. In some states, it may be illegal. So it's far more complicated. Bottom line here is that delta-8 is not a part of the federal program. Moving to cocaine metabolite, laboratories test for benzolecanine, the main metabolite of cocaine. Initial cutoff is 150 nanograms per milliliter. Confirmatory cutoff is 100 nanograms per milliliter. PCP, the initial and confirmatory cutoff are the same at 25 nanograms per ml. In testing for opioids, up until 2019, opioids included only codeine, morphine, and 6-acetylmorphine. Cutoff for codeine and morphine is 2,000 nanograms per ml. And the cutoff for 6-acetylmorphine, the heroin-specific metabolite, is 10 nanograms per ml. I'm sorry, I said 2019. In 2018, when the DOT started testing for the expanded opioids, hydrocodone, hydromorphone, oxycodone, oxymorphone, those were added to the panel. And those have different cutoffs. So as we look at those, codeine, morphine, initial and confirmatory cutoff is 2,000 nanograms per ml. Heroin is metabolized to morphine. Codeine is metabolized to morphine. So morphine may be present in a urine specimen either as a parent drug or as a metabolite. 6-acetylmorphine, the heroin-specific metabolite. It's an intermediate that's formed in the metabolism of heroin to morphine. So heroin is diacetylmorphine. 6-acetylmorphine involves removal of one of those acetyl groups. And if the second acetyl group is removed, it becomes morphine. The initial and screening, initial and confirmatory cutoff for 6-acetylmorphine is 10 nanograms per milliliter. And for quite some time now, all specimens are tested for 6-AM in the federal program regardless of the morphine result. So what are some of the issues? Screening confirmatory cutoffs for codeine morphine are 2,000 nanograms per mL. But poppy seeds can cause morphine positives above 2,000 nanograms per mL. Consequently, there's sort of a buffer zone between 2,000 and 15,000. You'll hear more about that during VMworld lectures. But any time the concentration is greater than or equal to 15,000 nanograms per mL, that's considered as a burden of proof level. And the specimen would be verified as positive absent the prescription for an opioid that could result in that morphine level. But again, you'll hear a lot more about that during the EMRL lectures. Hydrocodone hydromorphone, again, testing for that in the DOT testing began in January of 2018. The initial cutoff is 300 nanograms per mL. The confirmatory cutoff is 100 nanograms per mL. Hydrocodone metabolizes to hydromorphone. Think of hydrocodone as a pro-drug. It should be noted that hydrocodone may also be present as a minor metabolite of codeine. And hydromorphone may also be present as a minor metabolite of morphine. So that's important as you're doing your EMRL review and looking at those results in your interview with the donor. Case of oxycodone and oxymorphone, testing began in January of 2018. The initial and confirmatory cutoff is the same at 100 nanograms per mL. And similar to hydromorphone being metabolized, sorry, hydrocodone being metabolized to hydromorphone, oxycodone is metabolized to oxymorphone. So what are some of the implications of this metabolism? Parent compound is typically eliminated more quickly than the metabolites. A person taking oxycodone could have a drug test that's positive only for oxymorphone at or above the cutoff. Similarly, someone taking hydrocodone may have a positive test result only for hydromorphone. Consequently, it's important not to rely on parent metabolite ratios, which can change throughout the metabolic site. Except you need to remember that both codeine and morphine may produce minor metabolites. When a large amount of morphine is present, hydromorphone may be seen in a quantity up to 15% of the total morphine. Smaller amounts of hydrocodone have also been reported with large doses of codeine, but it's not quite as pronounced as in the case of morphine being present during treatment with, sorry, hydromorphone being present during treatment with morphine. Testing for amphetamines, and we'll break that apart first into amphetamine and methamphetamine. Initial and confirmatory cutoffs are 500 on the initial test, 250 on the confirmatory test. In laboratory reporting of positive methamphetamine results, they also apply what's known as the amphetamine rule, whereby in order to report a positive result for methamphetamine at or above the 250 nanogram per ml confirmatory test level, amphetamine must also be present at a 100, at a concentration at or above 100 nanograms per ml. But one of the things that means for you as a medical review officer is that the laboratory may only report the methamphetamine positive. In the case where the methamphetamine is positive, but the amphetamine while present and above 100 nanograms per ml is less than 250 and therefore cannot be reported as positive. If in doubt, you can always contact the laboratory to ask them what the amphetamine result was, but that really isn't necessary as laboratories understand the rules and would only be reporting under the federal program a positive methamphetamine if amphetamine is also present as required. And why is there that amphetamine rule? Because methamphetamine metabolizes to amphetamine. So when somebody takes methamphetamine, you may see both amphetamine and methamphetamine. There is also, there are also two different isomers of methamphetamine, a d-isomer and an l-isomer, and you'll hear more about that during the MRO lectures. While the initial test typically doesn't detect both equally, that is they don't have equal cross-reactivity, those initial immunoassay tests are really targeted at the d-isomer. The confirmatory test does not differentiate, but laboratories have the ability to differentiate d- and l-isomer, and that becomes important during your medical, may become important during your medical review of positive results for methamphetamine. In the case of MDMA and MDA, similar cutoffs as amphetamine and methamphetamine, initial testing is performed at a 500 nanogram per ml cutoff, confirmatory testing at a 250 nanogram per ml cutoff. Similar to the metabolism of methamphetamine, MDMA metabolizes to MDA. MDEA, or methylene dioxide ethyl amphetamine, formerly was included in the federal program, but has not been included since 2017 and 2018. Very, very low incidence of laboratory positives for MDEA. So, both amphetamine, sorry, yes, both amphetamine and methamphetamine have d- and l-isomers. The difference between d- and l-isomers is how they rotate polarized light, but within the body, the d-compounds are significantly more active than the l-compounds. That's why it's important to be able to differentiate d-methamphetamine from l-methamphetamine, and even a number of years ago, there were some over-the-counter products that contained l-methamphetamine. But again, more on that during the MRO lectures. While laboratories do have the ability to differentiate d- and l-methamphetamine and do so routinely, they don't typically test for d- and l-amphetamine, and it's a rarity that a laboratory would have the ability to do a d-l-amphetamine differentiation. So, to summarize all of those cutoffs, this slide just shows the screening for initial testing cutoffs, as well as the confirmatory cutoffs for urine drug testing under the federal program. In the case of specimen validity testing, and we'll be talking more about that later as we talk about SVT testing, an adulterated specimen is one that has nitrite of 500 micrograms per milliliter or greater, a pH less than 4, or a pH greater than or equal to 11, a chromium 6. It's not the chromium that you buy over the counter as a supplement. This is a very toxic compound, but chromium 6, greater than or equal to 50 micrograms per milliliter on the initial test, and greater than or equal to the LOD in the confirmatory test. A substituted specimen is one that has a creatinine less than 2 milligrams per deciliter, and a specific gravity less than or equal to 1.0010. Notice I'm using four decimal places here for the definition of a substituted specimen. Or, a creatinine less than 2 milligrams per deciliter, excuse me, less than 2 milligrams per deciliter, and a specific gravity greater than or equal to 1.0200. A dilute specimen is one with a creatinine that's greater than or equal to 2, but less than 20 milligrams per deciliter, and a specific gravity that is less than 1.0030 and greater than 1.0010. If the specific gravity was any lower, it would then be in the substituted range. You should note that DOT has special requirements for creatinines, that dilute specimens for creatinines that are greater than or equal to 2, but less than or equal to 5, and that's sometimes called a tapered dilute. It's not an official term, but you may hear that term from time to time. An invalid result, there are a variety of reasons where a specimen may be reported as invalid. You think of, you know, those first two cases as meeting half the two legs of reporting a substituted specimen, so a creatinine less than 2, but a specific gravity acceptable, meaning it's greater than 1.0010 and less than 1.0200, or a creatinine that is greater than or equal to 2 with a specific gravity less than 1.0010. So again, half the criteria of a substituted specimen doesn't fully meet it, but not consistent with normal human urine and would be reported as an invalid specimen. An abnormal pH, one that is greater than or equal to 4, but less than 4.5, or greater than or equal to 9, but less than 11. In the case of the oxidants, a nitrite that is greater than or equal to 200 micrograms per milliliter, but less than the cutoff of 500 on that initial test. It's also possible to have abnormal oxidant activity due to other oxidants or halogens, aldehyde, surfactant activity. There may be certain prescription drugs or over-the-counter products that can cause an immunoassay interference. An immunoassay interference should not be interpreted as an attempt to subvert the testing process. It may have resulted from that attempt, but it could also occur very legitimately. Again, you'll hear more about that during the MRO sessions. An interference with the mass spectrometric or confirmatory assay, and that could either be a GC or a gas chromatography or liquid chromatography. A specimen that has abnormal physical characteristics, which then needs to be specified in usual color or odor, for example, or different physical appearances between bottle A and bottle B. There are eight fatal flaws that the laboratory is looking at. No printed collector name and collector signature. If only one of those is missing, it's a recoverable flaw. If it can't be recovered, then it turns into a fatal flaw. But in terms of outright initial fatal flaws rejected by the laboratory, no printed collector's name and no collector's signature. If the specimen ID number on the bottle and the custody control form don't match, if the specimen seal is broken or shows evidence of some sort of tampering and it's not possible for the laboratory to redesignate bottle E, bottle B, as the A specimen, there's an insufficient quantity of specimen for testing. And the laboratory, in the case of urine testing, uses 30 mls as the minimum required volume. There's no CCF submitted with the specimen, obviously. Similarly, no specimen submitted with the CCF. If the laboratory accessioner failed to document the primary A specimen seal condition on the federal CCF and bottle B cannot be redesignated, that would be a fatal flaw. And an eCCF or electronic CCF one only is that there's no authoritative copy received. There's also the flexibility that if the certified laboratory or IITF identifies a flaw other than the ones enumerated above, that in their opinion prevents testing or affects the forensic defensibility of the drug testing cannot be corrected, then they're allowed to stop testing and reject the specimen. So we've talked about chain of custody, the two-step testing protocol, the five drugs and classes, and I would emphasize again, those first three items that we talked about are applicable whether it's urine drug testing or oral fluid drug testing, the specimen validity testing, which is specific to oral fluid, and then the review and certification of results in the same process, whether it's oral fluid testing or urine testing. Thank you very much.

drug testing

HHS certified laboratories

specimen collection

chain of custody

immunoassays

chromatography mass spectrometry

National Laboratory Certification Program

specimen validity testing

federal requirements