Preface

ix

List of Figures and Tables

x

Common Acronyms

xii

About the Authors

xiv

1

The Medical Review Officer (MRO)

1

MRO Responsibilities

1

MRO Assistant

2

MRO Coverage While Away

2

MRO Qualifications

3

Other Roles of Physicians Who Serve as MROs

6

Independence Between Laboratories and MROs

7

Risk Management

7

2

Laws, Guidelines, and Policies

13

Military Testing Programs

13

Federal Drug and Alcohol Testing Laws

13

Nonregulated Testing

17

State Drug and Alcohol Testing Laws

18

Canadian Human Rights Act

19

Employer Policies, Collective Bargaining Agreements

20

Americans with Disabilities Act

20

Clinical Laboratory Improvement Amendments

22

Emergency Medical Treatment and Active Labor Act

22

Food and Drug Administration

22

Health Insurance Portability and Accountability Act

23

Student Drug Testing

23

Impaired Professional Follow-Up Testing

24

Nicotine Testing

24

Pain Clinic Testing

24

Effectiveness of Workplace Drug Testing

25

References

26

3

Test Types

27

Pre-Employment

27

Reasonable Suspicion/Cause

28

Post-accident

28

Random

29

Return-to-Duty

31

Follow-Up

31

Periodic

32

Reference

32

4

Employer Responsibilities

33

Employer Policy

33

Employee Training

34

Supervisor Training

34

Designated Employer Representative

34

Employer Actions After Receiving Test Results

35

Background Checks

37

Standing Down

39

Management Information System Reports

40

Blind Samples

40

Employer Recordkeeping

43

5

Service Agents

47

Consortium/Third-Party Administrators

47

Public Interest Exclusion

48

Fees

50

Payment for Tests

55

Service Agents and Noncompliant Employers

55

Finding Work as a Medical Review Officer

55

Reference

56

6

Specimen Collection

57

Collector

57

Collection Site

60

Collection Supplies

62

Custody and Control Form

63

Release and Consent Forms

65

Testing of Minors

67

On-Time Arrival for Testing

67

DOT and Non-DOT Tests at the Same Visit

68

Donor Identification

68

Federal Agency Identification

69

Urine Collection Procedure

69

Directly Observed Urine Collection Procedure

76

Shy Bladder

79

Refusal to Test

84

Collection Site Recordkeeping

85

Collector Errors

86

After Hours Collections

86

Urine Collection Procedures for Alcohol Testing

86

Hair Collection

87

Nail Collection

88

Oral Fluid Collection

88

Blood Collection

89

Point-of-Collection Tests

89

References

94

7

Adulterants, Substitution, and Dilution

95

Adulterants

95

Substitution

98

Dilution

98

Pills and Potions

99

Oral Fluid Test Subversion

99

References

99

8

Laboratory Analysis

101

Laboratory Certification

101

Initial Instrumented Test Facility

102

Accessioning

102

Specimen Validity Testing

107

Drugs and Cutoff Values

109

Immunoassays

111

Confirmatory Assays

114

Hair Analysis

115

Oral Fluid Analysis

116

Laboratory Review

116

Reporting Laboratory Results

116

Storage of Specimens and Records

118

Semi-Annual Laboratory Reports

119

Data Package

119

Reference

120

9

Laboratory Results

121

Negative Result

121

Positive Result

121

Invalid Result

121

Adulterated Specimen

126

Dilute Specimen

126

Substituted Specimen

128

Specimen Rejected for Testing

129

References

129

10

MRO Review of Drug Test Results

131

Documents Required for Review

131

Review of Test Documents

132

Cancelled Drug Test

134

Negative Result Review

135

Dilute Result

135

The Interview

136

Positive Result Review

143

Unapproved Use of Prescription Medication

148

Drugs versus Metabolites

153

Corroboration of Explanations for Positive Results

154

Passive Exposure

156

Illicit Drugs in Food and Beverages

157

Codeine/Morphine/6-AM Result Review

157

Outcome: Positive, Negative, or Cancelled

159

Invalid Result Review

159

Adulterated or Substituted Result Review

162

Safety Risk and Medical Disqualification

165

Drug Tests and Impairment

170

One Test Event, Two Specimens

171

Tell the Donor the Outcome

171

Inform the Donor of the Right to a Split Test or Retest

172

“Can I Take Another Test, Doc?”

173

Reporting MRO Results

173

Data Management Software

182

MRO Recordkeeping

183

Access to MRO Records

184

Changing the Report

186

Drug Tests and DOT Physicals

186

DNA Testing

188

References

189

11

Split Specimen Tests and Retests

191

Reconfirmation Tests

192

Processing Split Specimen Tests and Retests

193

Failed to Reconfirm

195

Payment for Split Specimen Tests and Retests

199

12

Urine and Other Specimens

201

Regulations

201

Detection Times

202

Non-Urine Specimens Compared with Urine Specimens

203

Conducting Multiple Tests at the Same Visit

205

Medical Review of Non-Urine Test Results

205

Urine

206

Hair

207

Oral Fluid

210

Nail

212

Blood

213

References

215

13

Alcohol and Specific Drugs

217

Alcohol

217

Amphetamines

225

Barbiturates

230

Benzodiazepines

231

Cocaine

233

Lysergic Acid Diethylamide

237

Marijuana

238

Methaqualone

244

Nicotine

245

Opioids: Introduction

245

Codeine, Morphine, and Heroin

247

Buprenorphine

250

Fentanyl

252

Hydrocodone

253

Hydromorphone

255

Meperidine

256

Methadone

257

Oxycodone

259

Oxymorphone

261

Propoxyphene

262

Phencyclidine

264

References

265

14

Alcohol Testing

269

Breath Alcohol Technician, Screening Test Technician

269

Alcohol Test Devices

271

Alcohol Testing Form

273

Alcohol Test Site

274

Alcohol Test Procedure

274

Shy Lung

275

Insufficient Saliva Sample

276

Alcohol Test Errors

276

Reporting Results

276

Recordkeeping

278

Fitness-for-Duty Determination

278

References

278

15

Return-to-Duty Process

279

Responsibilities of the Substance Abuse Professional

279

SAP Qualifications

279

Referring the Employee to the SAP

281

Payment for SAP Services, Treatment, and Follow-Up Tests

281

Initial SAP Evaluation

282

Treatment

284

Follow-Up Evaluation

284

Continuing Care Recommendations

286

Return-to-Duty Test

286

Return to Duty Under USCG

286

Follow-Up Tests

287

Return-to-Duty Agreement

287

Changing SAP Recommendations

288

Recordkeeping

288

References

288

16

The Medical Review Officer Certification Council   Brian L. Compney

289

The Council and its Philosophy

289

The MRO Certification Examination

290

Prerequisites for Application

290

The Examination Blueprint and Content Areas

291

MRO Assistant Certification Program

293

CME Activities and Monograph Series

294

Research Funding

294

APPENDICES

A

Information Sources

295

B

MRO Code of Ethics

298

C

Ethical Aspects of Drug Testing

299

D

Controlled Substances Act, Schedules I-V

301

E

Federal Drug Testing Custody and Control Form

302

F

DOT Procedures, 49 CFR Part 40

309

G

DOT Agency Rules

401

Index

409