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The Medical Review Officer: An Addiction Medicine Perspective. CSAM October 9, 2004 By David E. Smith, M.D. Past President, CSAM Past President, ASAM. Addiction- Scope of the Problem. In 1998 6.6% of employees reported current drug use Absent from the job 100 hours per year

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the medical review officer an addiction medicine perspective

The Medical Review Officer: An Addiction Medicine Perspective

CSAM October 9, 2004

By David E. Smith, M.D.

Past President, CSAM

Past President, ASAM

addiction scope of the problem
Addiction- Scope of the Problem
  • In 1998 6.6% of employees reported current drug use
  • Absent from the job 100 hours per year
  • 3.5 times as likely to be involved in an accident
  • 5 times as likely to file a Workman’s Comp claim
  • 3 times as likely to be fired
  • Alcohol- $ 120 billion
  • Nicotine- $ 60 billion
  • Illicit drugs- $ 60 billion
the drug free workplace act
The Drug Free Workplace Act
  • 1996 Executive Order 12564
  • A comprehensive program prohibiting workplace drug use
  • Employees will be educated about drug use
  • Supervisors will be trained regarding their responsibility
  • EAP helping hand programs will be available
  • Ability to identify drug users including urine testing
the role of the medical review officer
The Role of the Medical Review Officer
  • A positive test does not always identify and illicit drug user
  • Must be a licensed Medical Doctor
  • Knowledgeable of substance abuse disorders
  • Knowledgeable about how to interpret positive tests
  • Verify is there is a legitimate medical explanation
  • Gatekeeper (Narrow) vs. Addiction Medicine Specialist (Expanded) Role
types of tests
Types of Tests
  • Pre-employment
  • For Cause
  • Return to Duty and Follow-up
  • Random- Most controversial
    • Not triggered by workplace impairment
toxicological considerations
Toxicological Considerations
  • Screening and Confirmatory tests
  • Types of Samples- Urine, Hair, etc.
  • Detection Windows
  • Screening levels and cutoffs
  • Drug testing technologies
  • Validity testing- dilution, temperature, contaminants
  • New Regs- Stand downs and PIE’s and NOPE’s
scope of addiction expert witness
Scope of Addiction Expert Witness
  • Criminal and civil cases
  • Family custody disputes
  • Return to work
  • Appeals evaluations
  • Professional re-entry evaluations
  • Complicated workplace situations
    • Following an accident
      • Interpretation of toxicological test results
      • Compliance with governmental regulations
workplace issues
Workplace Issues
  • Case may be criminal followed by civil
    • Employer often becomes the deep pocket
    • Post Accident

- Exxon Valdez Case

criminal issues
Criminal Issues
  • Toxicity
  • Developmental Model Issues
  • Recall
  • Amnesia
  • Non-toxic psychiatric co-morbidities
  • Intent issues
    • New Brain, Old Brain dilemma
validity testing
Validity Testing
  • Verify a urine specimen is consistent with normal human urine
    • Adulterated
    • Diluted
    • Substituted
validity 2
Validity (2)
  • Treated the same as a confirmed positive
    • The adulterant got there by physiologic means
    • Employee can produce the dilute specimen by physiologic means
    • MRO must use best professional judgment
    • Employee may be directed to get a medical evaluation by another MD
americans with disabilities act
Americans with Disabilities Act
  • What is covered
    • Illicit drugs are not covered under ADA
      • A using heroin addict is not covered
      • A heroin addict stabilized on methadone is covered
      • A recovering (abstinent) addict is covered

**Alcohol is covered under ADA

        • However, if there are other federal regulations re: alcohol the employer must comply i.e. B.A. > .02

**A person falsely accused is also covered

hhs certified lab
HHS CERTIFIED LAB
  • Introduction
  • Chain of Custody Procedures
  • Overview of Testing Procedures
  • Drugs Included in the Testing
  • Adulterant Testing
  • Summary
chain of custody
Chain of Custody
  • Custody and Control Form
  • Tamper Evident Bag and Tamper Evident Bottle
  • Secured Laboratory
  • Internal Chain of Custody
introduction
Introduction
  • HHS Certified Lab Procedures
  • Two Step Testing Procedure
    • Screening Test

--Confirmation Test

  • HHS Drugs or Drug Metabolites
  • HHS Specimen Validity Testing
overview of testing procedures
Overview of Testing Procedures
  • Screening Test or First Test
    • Immunoassay
      • Enzyme Multiple Immunoassay (EMIT)
      • Florescent Polarization Immunoassay (FPIA)
      • Kinetic Immunoassay (KIM)
      • Radio Immunoassay (RIA)
overview of testing procedures19
Overview of Testing Procedures
  • Confirmation Testing
    • Separate aliquot of the Specimen
    • Gas Chromatography Mass Spectrometry (GC/MS)
quality controls
Quality Controls
  • Open Quality Controls
  • B Quality Controls for the Analyst
  • Minimum 10% Quality Controls
overview of testing procedures21
Overview of Testing Procedures
  • Review all the Chain of Custody
  • Review the Quality Controls
  • Review the Blind Controls
  • Review the Screening Test Data
  • Review the Confirmation Test Data
dhhs drugs
DHHS Drugs
  • Cannabinoids
  • Cocaine
  • PCP
  • Opiates
  • Amphetamines
marijuana metabolites
Marijuana metabolites
  • Screening 50 ng/ml
  • Confirmation 15 ng/ml
cocaine metabolites
Cocaine Metabolites
  • Screening 300 ng/ml
  • Confirmation 150 ng/ml
phencyclidine pcp
Phencyclidine (PCP)
  • Screening 25 ng/ml
  • Confirmation 25 ng/ml
opiates
Opiates
  • Screening 2000 ng/ml
opiates codeine
Opiates Codeine
  • Confirmation 2000 ng/ml
  • Quantitation if Concentration ≥ 1500 ng/ml
  • Codeine Metabolites to Morphine
opiates morphine
Opiates Morphine
  • Confirmation 2000 ng/ml
  • Quantitation if Concentation ≥ 15000 ng/ml
  • Heroin Metabolites to Morphine
  • Coedeine Metabolites to Morphine
  • Morphine as a drug
opiates heroin 6 monoacetyl morphine
Opiates – Heroin6- Monoacetyl Morphine
  • An Intermediate Metabolite of Heroin
  • Confirmation 10 ng/ml
  • Heroin Metabolites to 6- Monoacetyl Morphine and also to Morphine
amphetamines amphetamine
Amphetamines Amphetamine
  • Screening 1000 ng/ml
amphetamine
Amphetamine
  • Confirmation 500 ng/ml
  • Methamphetamine Metabolites to Amphetamine
methamphetamine
Methamphetamine
  • Confirmation 500 ng/ml
  • Note: In addition 200 ng/ml Amphetamine present
  • Methamphetamine Metabolites to Amphetamine
  • D- isomer or L-isomer
amphetaimes d l isomers
AmphetaimesD & L Isomers
  • D- Amphetamine
  • L- Amphetamine
  • D- Methamphetamine
  • L- Methamphetamine
adulterant testing
Adulterant Testing
  • Creatinine: Normal- greater than 19.9 mg/dl
  • Specific Gravity: Normal – greater than 1.001 or less than 1.020
  • pH: Normal 4.5-9
  • Nitrite and Other Oxidants
  • Soap
  • Bleach
  • Others
reporting adulterants
Reporting Adulterants
  • Adulterated: Nitrite 500 mcg/ml or greater. pH 3 or less; pH 11 or greater. Chromium VI 20 mcg/ml or greater (Lab has the option for cut off)
  • Substituted: Creatinine 5.0 mg/dl or less Creatine 5.0 mg/dl or less and Specific Gravity 1.020 or greater. Challenge 3.8
invalid result
Invalid Result
  • Creatinine ≤ 5.0 mg/dl; Sp. Gr. Sp. Gr. ≥ 1.003 & < 1.020
  • Specific Gravity ≤ 1.001; Creatinine > 5.0 mg/dl
  • Abnormal pH (outside 4-10)
  • Possible (Characterize as Oxidant, Halogen, Aldehyde, or Surfactant) Activity
  • Immunoassay Interference
  • GC/MS Interference
  • Abnormal Physical Characteristics – (Specify)
  • Bottle A and Bottle B – Different physical Appearance
rejected for testing fatal flaw
Rejected for TestingFatal Flaw
  • Specimen ID number mismatch / missing
  • No collector printed name & no signature
  • Tamper- evident seal broken
  • Insufficient specimen volume
  • Wrong CCF used
  • Collector signature not recovered
conclusion
Conclusion
  • Chain of Custody
  • Two Step Testing Protocol
  • Five HHS Drugs
  • Adulterant Testing
  • Reviewed and Certified Results