Hi everybody, welcome back. We are going to now take the art of the interview, that's what I call it, like I said, and get specific, but I'm starting with this slide like I ended with the last section with this slide, just so hopefully you can keep the type of questionings that I'm talking about in mind when we talk about specific drugs. Here we go, arguably the most confusing one that we're dealing with. I know that to those of you that have never done MRO work or taken an MRO course before, you say, what's so confusing about opiates, they're simple. Well, in urine, the detection period for opiates is roughly two to three days. This all depends on dosage, specimen, concentration and things like that, but we're gonna say roughly two to three days. In oral fluids, same thing, roughly 24 to 36 hours. Now that is a consistent oral fluid detection window. There's more variability in urine detection and in oral fluid detection windows, so keep that in mind. The oral fluid detection window is 24 to 36 hours. A question, are you taking any pain or cough medications? Now, we are calling these opiates. In fact, that's what HHS and DOT call them. However, we could say opioids or opiates including opioids or however you wanna phrase it, keep in mind that this is one of those categories of tests that include a lot of different analytes. Codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone and 6-acetylmorphine but not methadone, apoxifene. And I'm very sorry to tell you in July of 2023, not fentanyl yet. I hope that that changes soon. I promise you when that changes, we will update this presentation. Fentanyl arguably should have been on the testing panel long ago. It took till 2018 to get scheduled two opioids, hydrocodone and oxycodone on to the testing program. Again, arguably very late coming to the process. Every specimen is tested for the heroin metabolite 6-acetylmorphine, every specimen. So we're not testing methadone, oxyfene, fentanyl, buprenorphine, naltrexone, any of the medications used to treat opioid addictions but we are testing for the opioids themselves except fentanyl. Cutoffs are confusing and here they are. First we'll talk about urine cutoffs. Codeine and morphine, the cutoff for both is 2,000. Dr. Sample talked to you about this. I'm going to reiterate it. Expect to see it on the exam and there's lots of different cutoffs and it's confusing. That's why I'm repeating it. Codeine and morphine, 2,000. You heard about poppy seeds. We're going to talk more about poppy seeds. 6-acetylmorphine, 10. Oxycodone and oxymorphone is tested at 100 nanograms per ml both screening and confirming. Hydrocodone and hydromorphone have different screens and confirms. 300 nanograms per ml screen, but it's confirmed at 100. In oral fluid, again, there are differences. Codeine and morphine are tested at 30 screening but confirmed at 15 nanograms per ml. 6-acetylmorphine is screened at four and confirmed at two. And remember we said before the labs have to tell you the levels. Hope I helped by putting the slide in this order for you to look at before the exam. All right, what's with poppy seeds? Well, we know that poppy seeds can cause both morphine and codeine confirmed positives. Now, all the rest of those opioids, oxycodone, nah, hydromorphone, forget about it. The only thing that you're going to see from a poppy seed is codeine or morphine. I don't care what you might hear or what the donor might tell you. Codeine, morphine, period, end of story. And because poppy seeds can pop positive for those two things, the burden of proof is on you except when 6-acetylmorphine is positive. You're not going to see the heroin metabolite from a poppy seed. Don't let anybody tell you you will, you won't. The codeine or morphine is reported to be greater than or equal to 15,000 nanograms per milliliter. If either codeine or morphine is higher than that, regardless of this concentration of the specimen, if it's higher than that, the burden of proof is on the donor to show you a prescription. If the codeine or morphine level is less than 15,000 15,000 in urine, the burden of proof is on you. Without any clinical evidence of abuse, you must downgrade that positive to a negative. If there is no admission of use, we'll go over the specifics in a future slide. If you must downgrade that, if it's less than 15,000 and you don't have any legitimate reason to be able to forensically show illicit codeine or morphine use. Okay, levels that are over 15,000, over 150 nanograms per milliliter of fluid. Now, remember that's different than the cutoffs. These are different levels than the cutoffs. This is the burden of proof level, not a cutoff. Then that is considered clinical evidence of unauthorized use. In US, the MRO reported as positive if there is no legitimate medical explanation. Clinical evidence of unauthorized opiate use in addition to the levels may come from a physical exam. If you want to do it, you don't have to. You can cause to be conducted a face-to-face exam when the examining physician will look for evidence of opioid abuse. We don't regularly do this because I don't think I need to tell most of you physicians that sometimes evidence of opioid use is very obvious. Other times it's not so obvious. So sometimes a very difficult exam to do. Logistically complicated, expensive, time-consuming. Those of us that have been in the business for as long as we have, we tend not to do these exams because we do not feel they add to the program. Someone who has a MRO verified positive will be referred to a substance abuse professional for the termination of diagnosis. Is there a substance use disorder present? Admission of unauthorized use is considered clinical evidence if it is recent enough that explains the result. Remember the detection window, three to five days. Admission of unauthorized use of a foreign medication or somebody else's medication. Those are both clinical evidence of unauthorized opiate use. Rules of thumb for figuring this stuff out. Parent compounds, all the opioids, all four parent compounds are less psychoactive than the metabolites. Parent compounds generally are metabolized more quickly. We're talking about codeine, hydrocodone, and oxycodone. The parent compounds are metabolized more quickly than the metabolites, morphine, hydromorphone, and oxymorphone. It is possible to see results that contain both parent and metabolite, only parent or only metabolite. You can see any combination of that. With an opioid prescription, you will see parent oxycodone and you might see a little bit of hydrocodone. You might see only metabolite, oxy, hydromorphone, okay? You may see only parent oxycodone, hydrocodone, only metabolite, oxymorphone, hydromorphone, or both. It's confusing. The codeine prescription can show you parent codeine or metabolite morphine, alone or both. Can be confusing. Do not use, we used to teach these 30 years ago, we do not use parent metabolite ratios to try to determine the time or the amount of the dose. At, remember, the parent compound is metabolized more quickly. At the end of the three to five day urine detection window, you might see more metabolite morphine at a higher quant level than you see the parent codeine. That doesn't mean that the codeine came from morphine. That doesn't mean that you took morphine and not codeine. Okay? So don't use the ratios. They don't work. Unless you see an extreme difference in quantitative level, you have to assume that the metabolite morphine came from the codeine. Now, extreme difference aside, the relationship of the two, even you can't use an exact ratio, but you will use an inexact ratio. It has to be fairly close. In other words, if you see 20,000 nanograms of morphine and 2000s of codeine, that's not all. You use your judgment here, but remember that you can see more metabolite than parent across the board here. To confuse you even more, you can see minor metabolites. When a large amount of morphine is present, hydromorphone may show up. It may be as high as 15% of the total morphine on level. With a large amount of codeine, hydrocodone may be present up to 15%. So if you see those minor metabolites present, less than 15%, you have to give benefit of the doubt to whatever prescription you are verifying, morphine or codeine in either of those cases. Slides are in blue for your review. I know it's confusing. We've given you a graphic here that I hope will also help. Now we are going to make a short interruption to your program that is in progress to do what I told you way back in the introduction, keep you current. This is current again, as of November 1st, because SAMHSA, the Division of Workplace Programs on October the 12th, 23, issued some guideline changes. Guideline changes for urine that take effect on February 1st of next year, and for oral fluid that are effective immediately. Now, remember, this is SAMHSA. This is HHS. It is not the Department of Transportation. The Department of Transportation is required to ultimately come up with conforming regulations that mimic the DHHS levels for testing the specific analytes and the specific cutoffs. So DOT has to get around to that. They should do it as soon as possible. As of November 1st, they haven't. Remember, back in the introduction and during this talk, I've given you two listservs that you should become members of so you will know instantly when DOT issues those conforming regulations. Ultimately, we will also re-update this course, but trust me, DOT will do it first before we get a chance to re-update it, so I really want you to be on those listservs. Remember, though, that what we are gonna talk about for the next two slides are, in effect, only for SAMHSA and SAMHSA-covered, meaning federal employee drug testing, not the Department of Transportation drug testing, but you'll remember that I just probably seriously confused you, especially if you haven't taken this course before, about the bifurcated way that MROs have to handle opiate positives currently in DOT. That has been awkward ever since we first started teaching it back in the 90s. Finally, there has been an agreement to change that for the better by raising the morphine cutoff to 4,000 nanograms per mil, but leaving the codeine cutoff for urine at 2,000 nanograms per milliliter. When that happens, for tests performed and reviews performed under those guidelines and ultimately under those conforming regulations, the whole 15,000 nanogram benefit of the DOT poppy seed issue disappears. It goes away. You don't have to ever think about poppy seeds again as an MRO when you're doing the review because the rule says that you're not gonna see it above 4,000 nanograms per mil of morphine in urine and above 2,000 nanograms per mil of codeine in urine. Current research has shown in real life that just doesn't happen. So the cutoffs are raised for morphine and the poppy seed issue goes away once DOT issues the conforming regs. I know I'm saying that over and over again because I really know some of you are gonna be taking this exam. I don't wanna confuse you. This will not be on the exam until DOT issues those conforming regulations. This is just a heads up for now. More guideline changes. Oral fluid HHS guidelines and DOT guidelines, of course, essentially unchanged, but this makes common sense. Now, if you think about it, when you don't have a poppy seed excuse anymore, then you don't need to look at the requirement for clinical evidence of unauthorized opiate use, do you? When you have a morphine positive above 4,000 nanograms per mil, they either have a prescription or they don't. You can forget about needing to figure out the clinical evidence that I talked about. A very, very good thing. And additionally, the requirement for clinical evidence of illegal use in addition to a drug test result for the MRO to verify either urine or oral fluid, codeine morphine reviews, has been removed. So again, don't worry about the clinical evidence. One more thing that is, I think, a long overdue change is that SAMHSA is now going to reserve the right to annually review by a federal registered notice the existing federal drug testing panel. That means that if they want to, once a year, when they have this annual review, they can change the panel. We are looking at a very possible addition of fentanyl. Again, we mentioned that back in the original opiate talk in this course. We are hoping that fentanyl gets added at least to the federal panel during this annual review, possibly as soon as December of this year. We don't know it yet, but by this guideline change that came out in October, SAMHSA reserves the right to do that for the very first time ever. If that changes, you will see it on the listservs that I gave you. You can also, of course, fire off questions to us like many of you have been from attendees in the course past, which I welcome. I'm glad to see those questions. I'm glad to answer those questions. If there's any doubt in your mind, don't, please don't hesitate to ask. Just go ahead and ask. Okay, now we are going to return to our originally scheduled program. Thanks. Okay, non-opiate positive verification gets a lot easier. Okay, donor always has the burden of proof, period, end of story. And we want them to present that burden of proof and information on the first interview. Although, as we've talked about, we've got this magic five-day period sitting out there. And if you feel you need to for even verification reason, you must extend the verification time up to five days. Okay, that does not mean that you have to add this prescription five days to physician contact five days that we talked about in the last course and get 10 days. That doesn't mean that. Five days is kind of the magic number here for all the MRO wait periods, except for the 10-day non-contact period we talked about before. So if you don't get a prescription, what do you do? Even though you might believe them, you have to verify the result is positive. Now, again, I said before, you can help the donor get their act together and do things. You can make the review more efficient by doing that. Fine. That does not mean you're getting to the wrong answer. You are simply getting to the right answer in a more efficient manner. So if you can help them, help them. That's part of, I think, your role. Cocaine, again, during the detection period, two to three days, maybe a little bit longer, maybe four days, depending on the concentrations. Oral fluids, same thing. Remember, 24 to 36 hours. What is acceptable cocaine use? Well, topical anesthesia, for one thing. Okay, ask about that. Don't put words into the mouth of a donor. Have you been to an emergency room? You had any nasal throat, dental surgery? Has a physician applied any anesthesia to you in the three days before you took this test? Just like you would with a prescription for opiates, you verify any leads. Remember, in the quotations from Ronald Reagan, trust but verify. That's what you do. You trust, but you have to verify everything. Remember about Taq, Taq is still out there. One to 4% is a local anesthetic. It's not a local, it's a topical anesthetic. It's not injected, but cocaine theoretically could be injected like lidocaine is, although I don't think it's ever done. I've certainly never used it. I've never seen it. You, I think, are familiar with the signs of cocaine intoxication, dysrhythmias, agitation, medriasis, diaphoresis, seizures, heart attacks. Primarily a serious agitation and medriasis are the things you should look for, possibly diaphoresis. Now we're going to switch to marijuana. And this is one that has changed a little bit more than some of the other drugs of abuse because of the inception of the oral fluid testing that we're updating all of our presentations to account for. But we'll talk to you a little bit initially about the clinical aspects of marijuana, which I probably don't have to tell you about, but I'm going to anyway. Marijuana can cause positive mood, relaxation, increased awareness, increased appetite. We all know the munchies, psychomotor slowness, dry mouth, dependence, a lot of lung problems. That's the major debate going on now about the safety or not so much safety of marijuana. And we also can't forget that marijuana is a hallucinogen, takes higher dosage of it to really get into the hallucinatory experience, but it is a hallucinogen. So it has a very long urine detection period. And we've all heard about that. It's been on the internet. It's stated, overstated frequently on the internet that detection period for marijuana in urine can go on for weeks, possibly months, depending on the history. But a single dose of an edible or a toke on the weekend or something has pretty much an average detection time in urine, which is three to four days, depending on the concentration of the specimen, a little bit, depending on the amount of the dose was ingested. So that single experience, a single ingestion has a short detection period that doesn't fall under what we keep hearing about the very, very long weeks to months detection period, which is caused by chronic use. Chronic use has a two department elimination syndrome as to several of the other drugs that we're doing in the non-federal space now, such as fentanyl and norfentanyl, ketamine and several others. Chronic marijuana use may show detectable and a light in the urine for more than one month, four to six weeks, and sometimes even longer than that, depending on the case. But remember again, when we're talking about oral fluid, the detection period in oral fluid is more relative to the matrix itself than to the drug we're detecting. Oral fluid has a detection period of 24 to 36 hours. You've seen in all the other analytes that we're talking about, that is also true with marijuana. So this prolonged detection period does not happen in oral fluid. Questions for you to ask during the interview. Are you taking any medications that may be given for cancer or AIDS? If you want to be specific, are you taking dronabinol or epidiolex? They're prescriptions, you have to verify them if they say that they are. Remember, trust but verify. So dronabinol, brand name Marinol, epidiolex, which is CBD may cause urine positives for the metabolite carboxy-THC. And if there is a question, remember, these are synthetics. Dronabinol and epidiolex are synthetics. So they are not likely to have naturally occurring contaminants in their dosage. We're gonna talk about THC-V in the next slide, but also remember the federal testing does not authorize any other forms of cannabinoids that may cause this positive. You're not allowed to test for CBD, even though it may cause a carboxy-THC positive, Delta-9, you're not allowed to test for Delta-8 and it doesn't really matter anyway, because Delta-8 is not going to cause a Delta-9 carboxy-THC positive. So this is a just in federal testing. You're not allowed to do any of that. If you verify a prescription in urine, then you can think about making this negative, but you have to verify the prescription first. Now, oral fluid, this is different. Remember, Dr. Sample, in his talk, will talk about the contamination of the oral cavity as the source of drug in oral fluid testing. Oral fluid testing is only for parent THC. It is not for the carboxymetabolite of THC. It's only for the parent. And the parent and metabolites do not diffuse from plasma into the oral fluid. So diffusion doesn't happen because of acid-base issues, PKA. It just is chemically something that doesn't happen. So properly taken dronabinol or epidiolex will not cause an oral fluid positive for parent THC, unless you're doing something goofy with the medications. Now, if you're holding the medications in your mouth and sucking them or having them dissolve or something weirdly, you're not supposed to be doing, although these can be available in solutions. The two medications do come in solutions. So if they swish around in the mouth, then you can get contamination of the oral cavity via that swish and possibly cause a parent marijuana positive, but if the medication is swallowed directly, you do not expect to see an oral fluid parent marijuana positive from dronabinol or epidiolex. Now, studies show that confirmed marijuana in oral fluid is consistent with ingestion unless, the zebra, folks, this hardly ever happens, but there is a simple exception to the rule here, unless a specimen is collected in a smoky atmosphere or within three hours of exposure to a heavy smoky atmosphere. And I've given you the reference for that statement. Last slide mentioned THCV. It's a natural, tetrahydrocannabinobarone is a naturally occurring cannabinoid. It's found in various strains of THC, but it isn't there in the synthetics. So if you want to, you can test for THCV. There are two federally certified laboratories that do it. It's expensive, it takes time, but you can do it. If you feel like you want to, to help to try to distinguish whether the positive in urine that you are looking for now is from dronabinol or from smoked marijuana or possibly from CBD, of course, now that we're dealing with the CBD, the world according to CBD. Presence of THCV is consistent with THC ingestion, not dronabinol or epidiolex. Trouble is that THCV is kind of like 6-acetylmorphine in heroin. It's not always there and its absence does not disprove that the THC came from smoking. But if it's there, it does prove that the positive that you're seeing came from smoked or eaten tetrahydrocannabinol, not from the synthetic medications. There are two certified labs and only two in the country that are DHH certified to do that right now. And to wipe up, to wrap up, I'm sorry, wrap up marijuana, remember, the things that we do not accept as excuses. I just ate a brownie, doesn't work. Laced brownies, sauces, salads, that doesn't work. Just as a little bit of an aside while we're talking about edibles, remember that the ingestion from an edible is significantly slower than it is from smoked marijuana. And because of that, the high that you get from edibles is also delayed considerably from the time of ingestion. Matter of fact, it's possible that the person ingesting that won't feel a high for four to six hours after the ingestion of an edible. That's actually caused the death of some children because they keep eating. They keep eating because especially in children, but even in older teenagers and all, they're not getting a high, they keep eating, they fall asleep, and the dose that they've actually ingested is toxic. There have been fatal incidences of that. You are not allowed to accept a hemp oil excuse. You are not allowed to accept a CBD other than a verified Epidiolex prescription. You are not allowed to accept medical marijuana program participation and or state or district laws that allow recreational use, that does not work. Currently at this recording, it does not work for federal testing. As always, there are discussions going on about downgrading THC from schedule one. If that happens, we'll probably have to redo this recording again. But as it stands right now, the state local district laws do not trump federal laws. So when you're doing federal testing, marijuana is a positive regardless of the state local laws. Moving on amphetamine. During the detection period, two to four days, sometimes again, maybe a little longer. Oral fluid, guess what? 24, 36 hours. Are you on prescription medications? I think it's one study showed about 84% of pure amphetamine laboratory confirmed positives are because of a prescription. These are the things that cause you problems. You have to verify the prescriptions, then you have to decide if you're gonna put a safety concern on it. It's not an easy decision to make. You have to do it on a case-by-case basis. In many cases, the argument is the person would be more of a hazard. The diagnosis of ADHD is correct. Person might be more of a hazard if they weren't taking Adderall. You take medications for depression, diet, narcolepsy, Parkinson's, ask what kind, verify the prescription. Again, there are more amphetamine positives than there are cocaine positives nowadays. 84% in one study are because of a verifiable prescription. Speed, again, agitation, metriasis, dysrhythmias, elevated blood pressure, things that you have to be aware of. Amphetamine-like, there's a lot of meds out there that are amphetamine-like but are not amphetamines. You will hear about this because it's like the donors are gonna blame their positive lab results. Pseudofeds, the stimulant is not an amphetamine. Phenylpropanolamine, Phentermine, Methylphenidate, they're not amphetamines. PPL, phenylpropanolamine, is sometimes indistinguishable from the pseudofed metabolite, even though phenylpropanolamine cannot be given nowadays. In case you're wondering about all the things you're gonna hear, do a Google search, how to beat a drug test, and remember the difference that Dr. Sample talked about between screening immunoassays and confirmation procedures. All of those how to beat a drug test references are because screening immunoassay nonspecificity. A lot of them are true. They do not, they're not relevant for mass spec to confirm positives. Now, we're gonna be specific about methamphetamine review. Methamphetamine comes in two isomers, L and D, levolegal, D, dextrodum, drug. You as the MRO need to know the presence, the relative presence of each of these isomers. L, legal, is present in Selegiline and levomethamphetamine, which is found, again, next slide, in some dry nasal inhalers. So you need to know if there is L, present, D, dumb, drug, present in Dazoxan or Didrex. I may have seen one or two of those prescriptions in the 30 years I've been doing this. Nobody prescribes Dazoxan or Didrex in this country anymore because it's methamphetamine and it's D-methamphetamine, highly abusable. So if you see D, it's drug. Now, I'm gonna give you a rule of thumb for doing your review and figuring out the difference between L and D. But before I do that, you gotta know what's there. So go ahead, talk to your laboratory and get them to do it automatically before the laboratory reports a methamphetamine positive to you. In other words, you should get the chiral separation at the same time you get the meth positive. The Vicks defense, the brand name inhalers no longer contain L-methamphetamine, they don't. But there's still some on cabinet shelves and generics can contain it. So if you hear about a dry nasal inhaler, that's why you need to know how much L is present. The United States, with the exception of levomethamphetamine, all GC-MS confirmed positives and amphetamine positives require a prescription. Vicks defense, this is gonna be on your test, I guarantee it. The Vicks defense requires there be more than 80% of the L isomer of methamphetamine present. So if you see positive meth that has 79% L and 21%, sorry, and 21% D, guess what? It has to be more than 80% of the L present. In other words, it has to be 81 of the L, not 79 of the L. PCP, very easy to figure out. Very few positives only on quality control programs. Longer detection period in urine, sometimes still seen as a contaminant, especially the way, but now we're in the age of a lot of different contaminants and salicine and things that are just, you don't see PCP nearly as much as you used to. Serious nystagmus agitation. Somebody high on PCP is a very, very dangerous person, call for backup. Okay, checklist seven, inform the donor of what you're gonna do. You've gotta tell the truth. You've gotta tell them what you're gonna do. I have to report it as a positive or I'll call it a negative if you can verify your prescription. And we've talked about verifying prescription. Your staff can help you do it. It's usually smart to get immediate verification. Again, we've got that five-day wait that Part 40 allows you to do. And if you're going to, if you believe from the interview that you have a safety concern, again, you have to inform the donor right there because that mandates that five-day pause we were talking about before. Okay, if you're gonna report it as a positive, you have to give them split specimen, reconfirmation, testing options. You have to request that within 72 hours. Now, does that mean actually 72 hours or three business days? You can interpret that any way you want. In my humble opinion, I'd give them three business days. That's not gonna change that much to give them that extra period of time. It's much more easily defensible if you wind up having to defend it. The donor is not required to pay for the test, but they need to be told that the employer may seek reimbursement after the test is done. So they may not be required to pay for it before you order it, but ultimately it may come down to they get billed for it. After 72 hours or three working days, it's up to you. You can allow split testing that the employer doesn't have to pay for. Donor isn't paying for it. The employer is paying for it within 72 hours. That's why the employer is seeking reimbursement. Okay, but after 72 hours, the employer doesn't have to pay for it. And you don't have to authorize it either. You can if you want to. Sometimes it's probably easier to go ahead and do it, but you don't have to. Okay, if a split is requested during the interview, removal from safety-sensitive duties is not stayed. You have to get them out of the truck, out of the cockpit, out of the engine cab. Then you end with this. Given contact information, be available. As we said before, the laboratory confirms. You are the one that verifies. And again, we're going to review the basis of that non-negative decision. You've got to have copy one before you even start the interview. You've got to have copy two before you start the interview. Before you can do the verification, you've got to have any relevant memoranda for anything else that you're talking about, corrected flaws, other papers, anything that the donor may want to present, prescription medication, things like that, donor interview, you've got to have a donor interview or documentation that the donor refused the interview. If you ask for more information, the donor has to comply. If the donor doesn't comply, that's a refusal to comply and you report the positive. So you need to have all this in hand before you report the positive. For legitimate medical explanations, it is on you and your staff now, happily, to verify the explanation. Verifiable prescriptions, confirmed as positives, can be gotten from internet, samples, over-the-counter opiates. There can be a lot of excuses out of there, but whether you accept them as legitimate is questionable in a lot of cases. If you get it from the internet, is there a doctor-patient relationship from that prescription? Can you verify that the physician actually gave samples or did you get them from a friend? Over-the-counter opiates, in some cases, cough medicines with codeine can be signed out at the pharmacy. Otherwise, over-the-counter medications don't contain opiates. It has to be some type of paper trail for opiate prescriptions, other, of course, than poppy seeds. Do dual verification. If you're talking to the person, you get a photo or a fax or an upload of a prescription label. Make sure it shows you all the information you need. Make sure you get the information that you need from the donor if you're doing it verbally during the interview, which you can do, but then you've got to follow up. You've got to call the physician. You've got to call the pharmacy and verify that what you were given is accurate. There was no label alteration and that this is really the cause or likely to be the cause of a lab-confirmed result. Two types of verifications. Get a copy of the label, document what they're telling you on the phone, but then follow up, call the pharmacy. Most pharmacists now, this has been going on since the 90s, they're kind of used to these calls. You just have to tell them that you're not asking for medical information. All you're doing is verifying a prescription. Give them the prescription number. Is this a prescription number, blah, blah, blah, blah, blah, given to Joe Blow for coding? They can say yes or no. You're not asking even who prescribed sometimes. Some pharmacists still won't do it. If that happens, the burden of proof then has to go back for the second part of the verification. The burden of proof has to go back to the donor. They need to go authorize the pharmacist to speak to you, authorize the physician to speak to you. But in the vast majority of cases, workplace drug testing in general, federal drug testing in particular has been around for a very long time. People are aware that it's out there and MRO calls to the pharmacy are not that unusual. So we're gonna talk about foreign medications, but keep in mind that just because, I can't emphasize this enough. Unless you're doing nuclear regulatory commission testing, a past drug test is not a fitness for duty decision. Somebody passes a drug test, that doesn't mean they can drive a truck. Foreign medications need to be used for what they're supposed to be used for. You have to be able to verify to the extent that you can that the donor obtained the substance legally and that the substance is being used for what it should be used for. Not because you smoke weed in Amsterdam. Substance must be used with consistent and proper purpose. And this does not stay your judgment about safety related medical information that you pass on to the employer. Someone else's prescription doesn't fly. We've had anecdotal data from old positions that I've held that use of someone else's prescription by a person who knows he's in a drug free workplace program is illicit use. And a significant proportion of those that went through SAP evaluations were in fact found to have a substance use disorder. You may also wish to consider company policy. Okay, does the policy appropriately address the use of somebody else's prescription to the donor before the testing begins? Are you allowed to use judgment or do you have to follow the policy? In most cases, if your judgment differs from the policy, it's a very difficult explanation for you because you have accepted the person as a client or the company as a client. And when you do that, you accept their policy. If you had issues with their policy, that's a discussion before the client relationship begins. One of the reasons that we wanna fully Mirandize the people went through those three slides earlier is because of issues like this, okay? I didn't think it was wrong to take my kid's cough medicine. No, we have warned you about this in our Miranda discussion earlier. Prescription age, a very tough and debated topic and I'm not going to swear I have the right answer. I'm just gonna give you a DOT answer. The DOT rule is silent about acceptable age. It's not likely that's gonna be any change. The DOT departmental position has been restated many different places and times. In DOT testing, once a valid prescription is approved, it is always valid prescription. And that's a hard one to swallow for a lot of us, but that's the way it is. There are some no-no's for federal testing. Other than the allowed oral fluid, which is now out there, obviously, you can't use any other alternative specimens like hair or blood. You can't have the urine specimen sent for DNA testing. It's not your job to consider whether the test should have been administered. Okay, if it's a post-accident test that you get says post-accident on the chain of custody, fine. Do the review, report the result. Whether it was, in fact, a post-accident test that should have been done is not up to you to decide. That's between the employer and the employee. You cannot consider assertations that even if the drug, even if true, that would not be an acceptable, legitimate medical explanation. Remember, THC is schedule one. You cannot accept I'm in a medical marijuana program. You cannot accept medical explanation for either PCP, 6-acetylmorphine, any confirmed adulterant or a urine specimen that has undetectable level of creatinine. There is no medical explanation for any of those things. Well, I said before, I don't like asking collection questions. And in most cases, the issues of collection improprieties fall under what Dr. Smith talked to you about earlier as de minimis faults. In other words, they are not fatal flaws. They are not even correctable flaws. They are minor flaws that do not affect the person's ability to have a fair and accurate test. If questions are brought up about something that may or may not have occurred at the collection site that in your opinion does potentially affect the right of the employee to have that fair and accurate test, you need to verify that just like you would verify a prescription. If you do, if you verify that the collector really might've messed things up or that something bad happened at the collection site, if you verify what the donor's telling you, then you can cancel the test. But you have to verify it. You have to be able to defend that cancellation, not simply because, not simply just because the donor said something happened at the collection site. We do follow up these assertions many times. Every once in a while, we find one that's accurate. The vast majority are not accurate. The vast majority are minimal problems that do not affect the test and do not cause the test to be canceled. Just know that you have the right if you want to do it. Okay, reporting. Report everything you found. Negative, if it's negative, negative, dilute, report it. If it's positive and positive and dilute, it's okay to say positive for marijuana and dilute. Nothing wrong with that, just say it. If you cancel a test, you have to tell them why. If you report a refusal to test, which we'll talk about in another talk, you have to tell them why. Negatives, you have to label negative. If it's dilute, you label it dilute. Results that go to the DER or an authorized third-party administrator, remember the third-party administrator cannot be the DER. You're gonna hear that from Dr. Smith and you might hear it on a test. So the designated employer rep can authorize somebody at the third-party administrator to get the result, but the DER cannot make the person at the TPA into a DER. You can't delegate that level of authority, okay? Negative reports can go by writing or electronic. You rubber stamp them like we talked about before, rubber stamp and initial the negatives. You retain them for a year. You know what the written and electronic reports must include, must include the information on the custody and control form. Also the name of the drug. In some cases, we've even been asked, don't tell us the name of the drug. For DOT testing, that doesn't fly. It's a serious discussion for non-DOT testing. Although I don't know why anybody wants to do it. We've been asked, but for DOT testing and HHS testing, you have to tell the employer what the drug was. You have to tell the employer whether it was dilute, the reason for the refusal and the reason you canceled the test. And again, they have to have your name, address and phone number. So there is a, still in effect, a rule, the UTS, you can see this is in black, it's not a new rule, that when you report a negative and dilute, you can tell the employer that they can order a second unobserved test if there is a policy that is consistent among all employees and if that policy has already been announced before the test. Policy can vary on reason for test. Now you can do second unobserved collections after a negative dilute for pre-employment, but not for a random or vice versa. You can vary it for reason for test, but you cannot vary it amongst employees subject to the testing program. So if you're gonna retest somebody, you don't wanna tell them in advance, you just wanna get them down there as soon as you can. The repeat test is the test of record. And the repeat test, if it's dilute, as it frequently is, which is the reason like most people don't do this anymore, but if the follow-up test is also dilute, is still the test of record, you do not get to do a third test. Okay, non-negative reports, get it out to the employer as soon as you can. Remember, this is a safety program. So try not to leave a voicemail, call, talk to a living person who is allowed to accept MRO results. Again, worry about voicemails. You don't know how often that voicemail is gonna be listened to. Try to get to a live person. It's always a good idea to have more than one person at the employer designated as a DER. Always try to do that, have a backup. You can, after you give the phone call, then you have to send a copy to, with your signature on it, or your proprietary report with all the copy-to information, like we said before. As a part of the result, you must give the name of the drug. Again, why wouldn't you? The name of any adulterants, if they ever happen nowadays, which they usually don't. The reasons for the cancellations and the refusals. Only you get to cancel a test, nobody else. Only you can do that. You check the box, you give the reason, you sign, initial, treat it just like it was a positive. Sign, initial, stamp, date. Rejected for testing is a fatal flaw because of a fatal flaw at the laboratory. Laboratories reject, the MRO cancels. So if you get a rejected for testing because of a fatal flaw, then you report that as a test canceled test, and you give the reason as fatal flaw. Rejected for testing because of uncorrected fatal flaws, uncorrected, correctable flaws, same thing. Give the flaw, give the reason. Laboratories reject, MROs cancel. If it's invalid, we'll talk about that. If the specimen failed to reconfirm or was not available for testing, both tests are canceled. We'll report, we'll talk about that in a different lecture. Always report the full event. Canceled test reports can result in an immediate, unannounced observed recollection when you feel that they should. If you get an invalid report from the laboratory and you do your MRO interview, and in your considered opinion, there is no legitimate explanation for that. You demand that the employer send the person back immediately for an unannounced observed collection. If the split specimen failed to confirm because it wasn't available, it leaked, or it just wasn't done by the collector, or if the split produced an invalid result, then you get an immediate observed recollection. So for most of the time, for mostly the things on this slide that you will see most frequently are invalid results that you interview and you believe there's no legitimate reason for. That results in immediate, unannounced observed recollection. The split specimen failed to reconfirm usually because it's not available. Rarely does that happen if the split gets to the lab. So if the split's not available, test canceled, immediate observed recollection. The effect of a canceled test is like it doesn't exist. It's neither negative nor positive. It cannot produce consequences. It doesn't, if it's a required negative, such as pre-employment, return to duty, or follow-up, the three reasons for tests that require a negative, it doesn't substitute from them. It's a canceled test. You have to get it again. Even if you decided that the invalid result was because of a legitimate medical explanation. If the test was for pre-employment, return to duty, or follow-up reasons, you have to get another test. The difference is, if there's a legitimate reason for the cancellation, that follow-up test is not observed. If there is no legitimate reason for the cancellation, for the invalid result from the laboratory, if there's no medical explanation for that, there is always an observed follow-up, regardless of the reason for the test. Little bit confusing there. Recollection is allowed as described. And again, it does not count for compliance. It does not provide basis for a hair test. For example, you can't do that in the DOT testing program. You retain written reports, signed, stamped, dated, a copy of two. You do not use copy two for reporting a copy of the signed report you sent in addition to the signed and dated copy. That's confusing. In other words, you either report on copy two, or you report on your proprietary form. One or the other, pick one. Even if you have a proprietary form that you use for reporting, you still have to keep copy two for audit. You can reopen sometimes cases, okay? You can reopen within 60 days, a non-contact positive. They went through that 10-day wait. If they decided to finally call you up, you can reopen that yourself if it's within 60 days. You can even make it negative if you get a legitimate medical explanation. If you want to, within 60 days. You can reopen any verified positive if you've got credible new evidence, somebody messed up. The doc lost a prescription, something happened. But it has to be credible, it has to be verifiable. You can reopen a verified positive. If the lab tells you they messed up, I know, sorry, Barry, but sometimes it happens, and you can reopen the test. If you made a mistake, you can reopen, and you should reopen the test. Remember, the idea here is to get things right. If you reported a false positive, fix it. You're probably going to have some pain with that. That pain will be significantly lessened if you take care and do the right thing and fix the false positive. After 60 days, though, you can't. You have to talk to ODAPSI before you make any change to any verified positive that's been out for 60 days or longer. There's a change, it's blue. Only you can change a verified non-negative test result on the basis of legitimate medical explanation. We talked about that, only you. Now, but if there has been a canceled result due to a correctable flaw that finally gets corrected within 60 days, same rule. You can reopen it, you can uncancel the test. Okay, they couldn't do that before. Before the 60 day reopening period was only for verified positives. Now they've added cancellations to that. That's the difference, that's the new thing. So now within 60 days, you can reopen it and report it as a negative or a positive. And again, after 60 days, ODAPSI has to give you permission. Sometimes these cases go to arbitration. Arbitrator does what the arbitrator does. What the arbitrator says does not change your verified result. The arbitrator decides to ignore it. That's gonna be between the arbitrator, the employer and DOT. Your verified results stands. That's the important thing. Record retention, mirror employer's record retention, five years for non-negatives and follow-ups, one year for negative and cancel. Five years for non-negatives, follow-ups, one year for negatives and cancel. Okay, quickly at the end here, a couple of special situation. We've got a whole new talk on split specimens, the invalid thing. I'm sure I've confused you with a little bit so far. Don't worry, we'll make it all as clear as mud in the next lecture. And we are now gonna talk about insufficient specimen volume. We now have something to add to the shy bladder thing. It's called a dry mouth, not called a shy mouth. I don't know why they call it a shy bladder. That's 35 years old by now. It's not changing. Dry mouth is what happens when you can't put your mucus on a swab. Shy bladder. Botopal begins when the donor is unable to void. And what you have to remember is you may be given up to 40 ounces of fluid for the donor over a time period of up to three hours. Just means not longer than that, not more than 40 ounces of fluid. If you get a specimen within three hours, okay, then the initial attempt to specimen is sealed and sent to the laboratory along with the second specimen. Okay. And you need a separate CCF. Donna talked about this. You need a separate CCF for that process. Okay. You can't combine the specimens. The second collection needs to have bottle A and bottle B, the right quantitative amount in them. Can't combine them, but you have to send two specimens to the lab. Okay. The donor cannot provide an adequate specimen within three hours. Then the collector throws out the original specimen and the DER is contacted and it likely to be a refusal to test. So if you have a shy bladder attempt, the initial specimen is sealed and sent to the laboratory along with the adequate specimen. Dry mouth. Protocol begins when the volume indicator on the device does not indicate there's a sufficient specimen after 15 minutes. Donor is offered up to eight ounces of water and one hour instead of three. The 10 minute observed deprivation period, Dr. Smith talked to you about, happens with each collection attempt. And again, after an hour, the collection is discontinued and the DER is contacted just like for a shy bladder. But what's the obvious thing here, folks? Why do we have more than one allowable specimen matrix? Just switch them. So the donor can't be in to look up. Collect an oral fluid. What the heck? That's one of the reasons. They're not the only reason, of course, but that's one of the major reasons. It's there to avoid shy bladders are everybody's problem. Nobody likes shy bladders. The simplest thing to do is switch. But there needs to be employer permission. It's okay to switch from urine to oral fluid or vice versa. There needs to be on record that permission is there regardless of what happens, regardless of what happens. This is an issue between collectors and employer reps. You're not involved yet. You might become involved after a refusal to test from the employer goes out in terms of follow-up and medical evaluation. But at this point, you are not involved. These are between collectors and DER. So the refusal to test is not your decision. It's a DER decision, and you do not issue an MRO report. Now, if third-party administrator, the TPA, may database it, but you as the MRO do not issue a report. And you are not involved until the DER consults with you after that's been issued, after the refusal to test has been issued. Okay, there can be a medical evaluation within five days if the donor is willing to do that. And the physician that does that medical evaluation has to be you or acceptable to you, okay? Now, remember we talked about before, the donor has to agree to do this if you require it, and in this case, if DER requires it. Both of you require it. The donor declines, that's the refusal to test. The donor agrees, then the physician to perform the exam must be acceptable to you, and you wanna do that evaluation as soon as possible. You as the MRO are now involved, and you must inform the referral physician a couple of things. What happened at the collection site? What happens if the final MRO verification is a refusal to test, or the employer verification is refusal to test in this case? You have to tell the referral physician what you expect of them, and because this is federal and forensic, everything needs to be done in writing. So have a form, and there are examples of forms out there in the MRO manuals. Have a form, do everything in writing, and expect that back from the referral physician. Referral physician sends you its recommendation in writing. Regardless of what that physician says, the final decision is yours. Now, we've said before that as a part of the DOT testing program, you cannot do alternative specimens other than oral fluid, but the exception to that rule doesn't come from you. It becomes from a case like this where there is a referral physician doing a consult. As a part of that consult, the referral physician can do anything they want. If they want to do a hair test, they can do a hair test, blood test, anything. That's up to the referral physician. The referral physician will include that in the written report to you. It is your final decision to accept it or not accept it as you make your final verification decision. So the referral physician will make one of the following determinations. No adequate explanation, okay? That's a no-brainer. Then you just verify it as a refusal to test, period. But the referral doc may tell you there's a medical condition with a high probability of explaining the situation. If you agree with that, things change. The written statement, however, must include an estimation of the time disability will persist and the reasoning for that, and it's up to you, again, to make a decision about whether you agree with it or not, okay? If you agree with it, you can cancel the test. And to do that, you need a physiological condition, documented pre-existing symptoms. You can have pre-existing, medically documented, relevant psychological symptoms, such as paruresis, but they have to be pre-documented and relevant to this test. Situation anxiety or a little bit of dehydration does not work, especially with the shy bladder protocol. And then your actions are, again, report in writing, just like you would for anything else. No justification, refusal to test because. But if you get a medical justification that you agree with, even if the result from the referral physician is negative, if a negative result is not needed, it's not those three things that we talked about where you need a negative. If it's not needed, you report the test as canceled, no repeat test allowed. If you need a negative, now, by the way, a canceled test works here, even though it's not a positive. A canceled test worked because remember we said a canceled test cannot be used in place of a negative. Bottom line is this person doesn't get hired or doesn't get put into a truck, I guess is a better way to put it. If a negative is needed, ADA procedures are that you need documentation that the justified condition is permanent and long-term, and that there is no clinical evidence of drug abuse. You are allowed then to report it as negative with a written notification of results of both the evaluation and the medical exam. Now, if clinical evidence of abuse is found by the referral physician, you still don't report it as positive, you report it as canceled. And like I just said, in this case, the canceled test has pretty much the same effect as a negative test in those three circumstances where you need a negative. In other words, nothing further happens. Okay, release of information. Again, to the donor, you can give them anything they want pretty much. You may charge, there's administrative costs, that's all you can charge for. You get, you can release it to anyone if you have a written request from the worker that is a specific request. In other words, give result of my test on this date to this person only, so that you cannot get permission from a blanket request. No, blanket requests do not work. They have to be specific about the specific test to a specific person or entity. You do have to release it to a substance abuse professional who is following up your confirmed or your verified positive with the donor. You have to release it to a DOT agency. Remember, we talked earlier about DOT owning these tests, they can get anything they want out of that. The NTSB is involved in an accident, you can release it to them. And if there are legal proceedings going on, of course, the employer can get it. The employer or the healthcare provider responsible for determining medical qualifications under DOT can obtain records from you. If that issue of whether this person is safe to perform functions is relevant to your medical review, then you can release the documents that you have based your decision on to the relevant people. In other words, we're back to the Miranda again, if there's a need to know, you can release the information. DOT owns it, you can give them anything you want. The exception to this is if somebody wants the results and you're not releasing it to them because they don't fit the criteria that we're talking about and they get a court order, you have to fight it. I know that's what DOT says, it's not easy sometimes, but if somebody gives a court orders, it convinces the court to give you a subpoena for something that you don't think they need, you have to fight that subpoena. You need to have legal representation in cases. Okay, you need to report to third parties the stuff we talked about in 327. Anybody who is responsible for the person's function in a safe safety environment, you must report to that person or that entity medical information gathered in your process without employee consent. If it disqualifies the person under DOT reg or in your opinion, it causes a significant safety risk. There is such a thing as a public interest exclusion. It's for people that really mess up and entities that really mess up. It's called the nuclear option that comes from the Department of Transportation. Any program service agent who by serious noncompliance has shown not currently acting in a responsible manner, causing a danger to public safety, the DOT is allowed to give what is called a public interest exclusion, which prohibits that person or that entity from participating in DOT testing in any way for a period of time. If the service agent has failed or refused to provide drug or alcohol testing services consistent with requirements, if the person has failed, person or entity has failed to cooperate in any way, DOT can issue PI. And PIs can go on for up to five years. They are not done without certain, they're not done without a lot of preliminary attempts to correct the problem. We're not going into all the specific things that happen, but DOT does attempt over time to correct the problem. These are pretty onerous things that happen. I think there have only been about five of these things issued since the department was allowed to do that in the past 20 years. So you can imagine that violations have to be pretty bad and no attempt to correct the violations have occurred. Okay, how do you make a living doing this? Well, we've got a couple of links here for you that may help you along with that. Do outreach. You're gonna have to learn to sell yourself to some degree, but that's what most good docs do. You wanna teach people. You wanna train people. You want to give lectures. You want to maybe get involved with people doing occupational physicals and become a certified medical examiner for CDLs. You want to get your name known among substance abuse professionals and people who do compliance monitoring because people coming out of treatment centers need jobs. And they, in many cases, need MROs. There are many different ways to start making a living in this program. One of the easiest is by use of some of those links. Right now, in our world, we have a shortage of MROs. We need MROs. Almost every big TPA is looking for MROs. MROC has jobs available on the website. ACOM has jobs available on the website. So make use of those opportunities for you and to help you make a living. If you are doing this on your own and not with the help of the TPA, there's a couple of really possibly obvious things, but maybe not so much when you set up account. And we've talked about that throughout the lectures when the relevant issues have come up in the lectures. Basically, you want to have pretty much everything figured out before it happens. The last thing you want to do is have a non-DOT program that's got a medical marijuana positive and not know what the employer thinks about medical marijuana programs in his employee. So figure out the questions. There are examples of this in the MRO manuals. Have a discussion with your potential clients before you establish that relationship and establish a contractual relationship. Write everything down. Again, we do a lot of writing down in this business. Review your employer's policy. Make sure you understand it. Even if there are pieces in it you don't agree with, make sure you can agree with it enough to do your reviews in accordance with it. You don't have to agree with everything, but you have to work with it. And establish the ground rules. Who's going to be the DER? How many, who's the backup DER? Who do you call if you can't get the regular DER? Because you're going to have to call somebody to report the positives. How, when you're doing a review, how often do you update the status of that review? We've given you the ground rules for waiting for prescriptions or something. We have given you the things that you can tell employers and the things that you can't, but there's nothing wrong with telling an employer that things are under review and leaving it at that. So they may want status updates. It's okay to do that. How are you going to report? Do you call? Do you text? Yes, you can text. I'd rather have a call. I'd rather talk to somebody. How do you know they're getting a text? Some phones tell you, not all. Do you believe that? Calling is the best way to do it for serious positive results, call. What is the employer's thought about familial foreign policy prescriptions? Does the employer agree with the DOT protocol of once a valid prescription, always a valid prescription? What does the employer think about that? Who pays for the split in non-DOT testing? Remember, this whole list of bullet points here is for non-DOT. Who's going to pay for that for non-DOT testing? I'm going to tell you, in most cases, it's going to be the donor. If there's a SAP involved, who pays? The donor. Even for DOT testing, the employer does not have to pay for the SAP evaluation. Donna will tell you that in a later talk. Okay, there's a lot to know. Please feel free to review this. I hope I made it easier for you with the color of the fonts. Again, you have my contact information. Don't hesitate to send questions, comments to my email address or my voicemail. Please, I appreciate your time and it's been a long talk, and there's a lot to know. And the more you do, the more comfortable you'll get. So thank you very much. Possibly diaphoresis.

drug testing

detection processes

verification

opiates

Medical Review Officers

false positives

prescriptions

workplace safety

regulatory compliance

federal guidelines

synthetic drugs