Doug, you're going to kick this off. All right, so welcome everybody to take our question and answer session for medical review officers. I see that people are joining as I speak, so that's good. I understand that we did not have any pre-submitted questions, so that means that I get to invite questions from those of you who are in attendance. And I will tell everybody in advance, I am sitting right now in wonderful Dakota Dunes, South Dakota, in the middle of an old-fashioned Midwestern thunderstorm. So if you lose me, you will know why. So you can type your questions into the chat, you can raise your hand, multiple ways to get a question for the queue. And if we don't get any questions, then I get to start talking about things like Nebraska football and what's going on with the current baseball season, although Donna can probably correct me, because she's much more knowledgeable about that than I am. I see Mary Oberly has her hand up. I don't know how we recognize her or allow her to speak. Nikki should be. All right, you should be able to welcome Mary. Excellent. Thank you so much, Nikki. Of course. Good morning, team. I'm sitting here in New Zealand. It's a cold day, but there's no thunderstorms here. I am an MRO for various industries in New Zealand, and we're really struggling with the medicinal cannabis issues and this idea about fitness for work versus impairment and trying to establish how we can get this assurance of people coming to work fit for work every day. And so a lot of my employers are really, really interested in the technical stuff and apps. And I know that I've asked these kind of questions on the forum before. My employers are asking me questions like, what's happening in the United States? Can we talk to employers who are using apps successfully and who like them? I'm a little bit reluctant to approach the manufacturers of the apps because they'll have a biased opinion. And again, I'm asking kind of the same questions that I did last time I was on the forum of any positive experiences, anything that anyone can help me with in terms of adding technology to the fitness for work toolbox, not as a standalone, but in addition to your own drug testing and all the other things that we have like education and good alcohol and drug policies. That's an excellent question, Mary. And I will bring up one thing that has happened in the US, I think since you asked this question at the last forum, we have had a notice of proposed rulemaking, which what that means is when there's an agency in the federal government that proposes a change in statute or new law or adjustment to the law or what have you, they have to publish a rule in what we call the federal register, which is where that's published and they have to provide for public feedback or responses. And on May 21st, we had a notice of proposed rulemaking that was authored by the Department of Justice that would make marijuana a Schedule III drug under the current DEA Controlled Substance Act process. And I will tell you that this has created quite a bit of discussion, not only within ACOM, but also in other arenas. The notice of proposed rule is only 86 pages long, so it took me a while to read through it and actually understand what it said. ACOM does have a cannabis workgroup that is coddling together and I'm part of that to try to figure out what sort of a response that we're going to make to that. We are obviously focused on the issue of safety sensitive work. How is that going to impact public safety? I think from an MRO perspective, it has an interesting twist because I have and others within the group have raised the question is, okay, if we're going to say that it's now all of a sudden a Schedule III drug, what does that mean for the current state dispensaries that either sell this as a result of recreational marijuana or even medicinal marijuana? Does that now mean that they're under all the rules that traditional pharmacies have to follow under? Does that mean that these dispensaries and the processes are now subject to the inspections that are typically done by FDA on purity and quality of the manufacturing processes? After reading this rule, my first thought went to, oh, we're going to have to hire 3,000 more FDA inspectors to come investigate the marijuana fields in Iowa where a lot of this has grown because it's going to now be under federal oversight. I don't know if that's true. The problem is that the Notice of Proposed Rule doesn't really get into those details that we as occupational physicians, I think, probably want to know. It is very narrow focused on the scheduling issue and, of course, we have advocates on one side that say, well, I think we do need to schedule it something other than a Schedule I so that we can do research. Okay, I get that argument and that's a valid argument because you can't do research with Schedule I drugs as it sits right now. But my problem is, of course, in the federal testing system, if it's going to be Schedule III, that means that it no longer can be tested because the current statute says that only Schedule I and Schedule II drugs can be tested under the federal system. So it brings up a lot of interesting things. I don't have the foggiest idea where this is all going to wind up. I have some people who have told me that they think this is a foregone conclusion that the federal government has made and it's sort of like, okay, we need to pass this and then deal with all the other fallout from the other agencies after the fact. I hope not. I hope that's not what happens. And then we have other people on the other side of the equation that say, well, this is just a first step in maybe a three-year, five-year, I've even heard seven-year process to eventually get this done. So I don't pretend to have any answers, Mary. I know that this NPRM probably makes your question even harder to answer from a United States perspective. We continue in the fitness for duty world and return to work world struggle for that magical thing to tell us whether an employee is fit or not fit. And it's not just marijuana, although it's a legitimate question, but it's all kinds of other things like interactions of prescription medications or interactions with over-the-counter medications, which as you know, can be just as big of an issue as far as people who perform those safety sensitive issues. So I personally don't have any experience with the apps that you're talking about. I don't know if anybody else on the call does, but the other problem with the app is, is does that hold up to any kind of legal challenge? And I think in the United States, given the fact that we are heavily litigation driven, my guess is, is that that is probably not ready for prime time because to prove it in a court of law, you're going to have a bunch of scientific things behind you. We of course have the Daubert standard in the United States. So you can't get up on the stand and say anything unless you've got really good research to prove what it is that you're saying. So anyway, I've talked a lot and I'm going to shut up now and let my colleagues chime in on what their perspectives are. Go ahead, Ken. Well, I can offer one perspective and that is that about a dozen years ago, the ACOM MRO faculty were invited to teach an MRO course in Australia. And in fact, we went there and taught four MRO courses in four very disparate locations and over a hundred Australian physicians took the exam after our course. What was relevant was that they were dealing with the civil aviation industry. The federal government was contemplating instituting a mandatory testing, which would include marijuana. And in their ultimate judgment, they chose not to allow urine testing to be done because the window of detection could be so long after the use of marijuana. And they were really looking for impairment. And so they went as an Australian standard with oral fluid testing. And of course, a lot of us have been waiting for years for oral fluid to become available on a day to day basis because that would make life so much easier in the US. But they chose as a national policy to only allow oral fluid testing because it shortened the window of detection. That does not get into all the impairment issues that Tony may wish to speak about, but it was an international conundrum. And that's how Australia chose to answer it. So I'm done. Australia is going away from the oral testing now. There's so much cheating. It's so easy to cheat an oral test by chucking in a lolly or scrubbing your mouth quickly. It's not illegal to carry a toothbrush. And there's been so many problems with the Australian police. It's not an easy solution. And you don't get the meth hangovers. You don't get the benzodiazepines as well. And we don't really see it as, because in Australia and New Zealand, we don't really see it as a really good answer to the question because it's actually brought up a lot of other issues. Yeah, I'm surprised to hear that a little bit, and I'll defer to Tony, but we've had about six years with regard to experience with a lab-based oral fluid test using a swab application. It's obviously observed. And there's always at least a 10-minute wait period before the test is conducted. And again, the research that I've shown, Tony, you can jump in here, has not shown that any of the mouthwashes or the rinses or that kind of thing have been effective in masking or in some ways subverting the test. Again, maybe my information, Tony, is old or outdated. No, I agree with you, Donna. That's my current knowledge as well. And the fact of the matter is for the industries that have adopted oral fluid testing, the positivity rate remains greater across all the drugs, including marijuana and the opiates and cocaine, amphetamines still. Yeah, because we find much more manipulation, quite frankly, in the urine test through intentional or unintentional dilution through other kinds of things. But Tony, I'll let you make that comparison a little bit. No, that was the point I was getting at. The ability to adulterate or dilute an oral fluid sample seems to be much less. It's still an immunoassay-based screening test. So anything to adulterate or substitute that we know is not available in any fashion, it would be amenable to using in that scenario. It's really interesting because our experience has been that we often get, if you do two at the same time, the oral and the urine, that the urine comes back positive, but the oral doesn't. And it's somebody who's had recent use who's done something to their mouth. And we're doing it the same way, Donna, that you just described with the 10-minute wait and all the rest of it. Yeah, we should share our data because we do have those matched samples with several piles and specimens collected exactly at the same time on the same donors. And we have exactly the opposite finding. I'd love to see that data because that would be very helpful to my industries who are talking about their ESG requirements, the environmental social governance requirements that are international, and saying, oh, this is part of our social responsibility to sort this out. And also, they're trying very hard to work with each other to find solutions, but we seem to be going through exactly the same as you are. I'm not political. I just want to make sure that the work is safe. And there doesn't seem to be a really easy answer. We do. And even in the paired data, we do have discrepancies in positivity, positive findings in oral fluid and urine. But that's always been considered to be a timing issue with respect to ingestion or a dilution issue with the urine sample because these were controlled studies. Well, we believe that the substitution of the urine sample was highly unlikely. One thing I could also add is that in recent time, and I will say this, and probably in just the past year or two, we have seen more employers who want to continue to test for cannabis use, for marijuana use. They are in states where there has been great liberalization of the cannabis laws, whether that's for medical purposes, for adult use purposes, et cetera. And many of those employers have opted to go with the lab-based oral fluid testing, as opposed to urine testing that they were doing previously, because the oral fluid testing is testing for the tetrahydrocannabinol, the 9-delta, the psychoactive component, and not the THCA, which is what in the US, the vast majority of urine tests, that's what they are reporting. And of course, the THCA is a non-psychoactive. You have the whole issue of how, whether or not that is recent use, i.e. within a couple of days of being in the workplace. So that is what, I'm not saying that it's a stampede, but it is certainly some things that the employers here in the US are considering. In fact, three or four now of the states, California's one, for example, Washington's another, in their state workplace testing rules, if you will, have limited the testing that you can only test for the psychoactive component of marijuana, which means you can only test for the 9-delta. And again, Tony, I'll defer to you to get more science about that. Yeah, which we're never going to find a TA, no one's testing for THC in urine. It's a good test in hair. It's a good test in oral fluid to show recent ingestion. So I think that's the reason that they want to test for the psychoactive compound. And just to sort of round the conversation off, and I really appreciate the conversation because this is something that I'll bring back to all the employers in New Zealand and Australia as a discussion point, and I really appreciate your input. So there's, in New Zealand and maybe, and in Australia, there's been a lot of advertising for, well, we can test for impairment. Just load this app on your phone and does two things, you do two things at once, like stand on one leg and do a maths test or whatever it is. And then we can test you for your impairment and it's all cause impairment, not just alcohol and drugs. And so it's wonderful and it'll solve all your problems. And all you have to do is pay us some cash and we'll sort it all out for you. And it's cloud-based and the employer owns the data and they can look at departments, they can look at individuals, they can get alerts in real time and all the rest of it. And it's very, very snazzy, very glossy brochures, very amazing advertising. And it's kind of like bypassing all the MRO stuff, all the oral versus urine and all the rest of it. Just, you know, tech is gonna save the day. And I wondered whether anyone in the United States was having similar experiences, because for me, this has been quite a strong push and all the employers are saying to me, well, can we just try it? Yeah, does this type of fitness for duty test try to specify the type of substance that the person- No, no, it's just impairment or not. Right. Yeah. So it establishes, does it establish a baseline for each employee? Yes. Observed baseline, do it three times to make sure you get absolutely, the absolute correct baseline. And they all say, oh, this is based on neuroscience and we've done like millions of tests in the United States in the mining industry and fire and emergency and manufacturing. And so therefore I come to these meetings just kind of doing a sense check. Is that actually true? And you guys are kind of sitting there bamboozled and saying, well, we don't really have that much experience with these apps. And yet the app sellers are saying, everyone's doing it in the United States. It's absolutely wonderful. So that's my sense check, basically. I'm gonna go back and say, I've spoken to some really brainy experts in the United States during this meeting and they're all shaking their heads. So this is a good thing, not a bad thing. Yeah, Mary, I would go back to what I said before that I think the legal environment in the United States would probably have all kinds of fun with that in the court systems. We have a lot of states that have so-called right to work laws, which would present a lot of barriers to what you're talking about. And even from a personal standpoint, as a person that's had an Achilles rupture and two plates and nine screws in my left ankle, I'm not sure I can stand on one foot without coffee in the morning and do any math problems. So I think I might fail your test. And I just, again, I would be curious in these brochures, what kind of science are they citing or what kind of references are they citing? Because I- Stanford, Harvard, Duke, you name it, they'll sully the waters with anything. What does the reference actually say? That's the curiosity that I would have. Is it an end of seven study? Is it, and what are they actually studying? Did they have any impact on job performance or job function? Or, and I hate to use this as an example, but I will use it as an example. The clinical studies that I look at in a treatment world, and I know this has nothing to do with Emeril work right now, so bear with me. But so many times I look at the treatments in the literature that are cited as far as success in the workers' compensation world, as far as treating a musculoskeletal disorder, a neurological issue, or what have you. And the outcome measure is pain. It's not function. It's not return to work. It's not whether you're successful in getting somebody back to their job. It's they're looking at pain. That is irrelevant to the end thing that you're looking at. So again, I don't know what this research is that they're citing, but does it really get to the answer that they purport that they're actually trying to solve? My guess is, is it probably doesn't. Wonderful, thank you. Okay, thank you. Sorry to take up so much time, but- No, no, that's fine. Yeah, really appreciate everybody's input. Okay, there's another question from Dr. McMillan. He said he thought he submitted to this question, but here it is. In situations where morphine or codeine are above the lab cutoff, but below 15,000 nanograms per milliliter, is the MRO required to seek clinical evidence of opiate use or may the MRO presume quote unquote poppy seeds, known or unknown, account for the result and verify the test is negative? So I'll let somebody else answer that and maybe you can tie in the new HHS proposed change on that which might be a narrow walk to have, but I think it's probably worth talking about. Well, first of all, I'll take a stab at it and then we can get some backup from some other people. But the answer to the question, if I got the whole thing, is that it's really two parts that you're asking. When there is a codeine or a morphine result, a urine test result that is above the 2000 nanogram confirmation cutoff, can you, as a medical review officer, verify that as negative, either assuming that poppy seeds could have caused the result or that the person has alleged or has claimed that they have ingested poppy seeds? And the answer to that is yes. The second part of this is, conversely, if you wish to verify a morphine and or codeine result greater than 2000 but less than 15,000 under the current Department of Transportation regulations as a positive, you must have clinical evidence of abuse. Now, the definition of clinical evidence, okay, is in the rule is that you would send them for a medical examination to see if there are clinical signs of codeine or morphine abuse, misuse, et cetera, such as obviously like with morphine, it might be track marks, but it could be other kinds of things. The other thing that has been accepted as clinical, quote, evidence is the history. We talk about, at least from this standpoint, that the clinical evidence is both history and physical. And so if the person has said to you that the codeine there is from, you know, a Tylenol with codeine that my spouse had laying around and that's what I have used, okay, then you could verify that as a positive result because that is unauthorized use of codeine. So that's the short answer, or maybe that was long, but I tried to keep it short. And then the second part that Dr. Martin is alluding to is that just a few months ago, actually, the Department of Health and Human Services, after doing a lot of research about this fall, or actually I should say looking at the published research and trying to compile that through a meta-analysis and everything else, tried to see whether there wasn't something better that we could do with regard to the review and interpretation of codeine and morphine-positive urine results. And as a result of their study, they raised the confirmation cutoff level for morphine to 4,000, retaining the cutoff level for codeine at 2,000, and they removed the requirement for any kind of clinical evidence or evaluation for the MRO to verify those laboratory results as positive. So with the HHS rule, now, if you have a morphine positive of 4,001 or greater or whatever, 4,000 or greater, then you must verify that as a positive test unless the person presents you with a prescription or medical reasons that morphine was medically administered. The same thing is true for codeine at 2,000. So if the codeine result is 2,000 or greater, the person must present to you medical records or an acceptable medical explanation for the use of codeine as medication in order for you to reverse or to report it as negative. So it's kind of flip-flopped that, and it has done away with what I always refer to as that bifurcated system. There's a cutoff at 2,000, but there's an MRO cutoff, if you will, of 15,000. So that's gone. Here's the hitch. There's always a hitch with the federal rules, it seems, that everyone would have assumed, and they would have been right, but, well, they would have been wrong, but everybody assumed that this would, as all other changes to the HHS or mandatory guidelines, would be adopted by DOT. DOT has not yet adopted this. I will not speak to why that is, and I'll turn it back over to Doug or to Tony. The research is pretty clear, Tony, that, at least to me, that it was pretty comprehensive that they did not believe that codeine or morphine positives above these now-established cutoffs of 2,000 and 4,000 was reasonably associated with poppy seed ingestion, correct? I agree with that. They did a pretty extensive review of the lab-positive MRO-negative opiates, and that's the conclusion that they arrived at. Personally, and I think in different parts of the world, there still are poppy seed-filled pastries that can maybe tip the scale above that 4,000. But that doesn't... So I would say do a thorough investigation. I don't think that's out of the question with that 4,000 cutoff. I think it's unlikely, and it's not going to happen in the United States with the way we wash the poppy seeds now, because that was all from the... Morphine was all from the exudating of the opium poppy, and the poppy seeds not properly washed. But if you have, and that comes into play, I think, more in the military these days, probably, if you deal with somebody who's operating overseas. So, yeah. So I think it's well-established that for our purposes in the States, those cutoffs are useful, appropriate. I think the only thing I'd add to that is just from an MRO perspective, as far as feasibility of trying to get these evaluations done when you have a, whatever, 5,000 milligram or nanogram response, or what have you, there are many parts of the country where that's really hard to arrange. Rural America, in particular, to try to find somebody that even will pick up the phone and talk to me about that evaluation is a chore in and of itself. And then if I'm lucky enough to actually get somebody on the phone and explain what I'm looking for, their response is, is why would I ever wanna do that? And then there's all kinds of other barriers, like paying for the exam, and getting the information quickly, and then maybe not actually giving me the information that we'd talked about before that I wanted to have. And so it creates a certain hassle factor, I guess, for lack of a better term, from an MRO's perspective. So, somebody like me who's challenged with that sort of thing, I kind of wish HHS would get adopted by DOT really quick. I think that would make my life a lot easier, but as Donna said, who knows? We'll just sit our hands and wait and see what happens. All righty. We have, looks like a two part from, if I mispronounce your name, I apologize, Dr. Charleau. He says, I had a DOT driver who had a refusal to test, and I reported her to the clearing house and she will need a SAP evaluation to return to driving. I received an email from a transportation official of the Drug and Alcohol Programs Division, USDOT FMCSA, saying they received a petition to remove the above listed violation from the clearing house. Can you please provide a copy of the CCF, chain of custody forms, MRO notes, and other documentation related to this collection? And the question is, is what is the criteria for petition? And then the second posting, specifically when a driver do a petition to be removed from the clearing house, does any other MRO on the Zoom call experience this and any other advice? I have not had that scenario develop. That doesn't mean I haven't been audited where people have asked to see that information, but not in the context that Dr. Charleau is describing. We've had one or two at Workforce QA, but I guess the question is, you said that you reported a refusal to test. Was it an adulterated or a substituted specimen? I'm assuming, again, or was this a shy bladder where there was no medical explanation? Because it does make a difference. The two that we have had that have been challenged and they're always a difficult circumstance, those who are shy bladders where there was no medical, no medical explanation, and the driver was successful in convincing, now remember, the people he's going to with this petition right, which is one of the rights, it's in the subpart of part 382, which I can look up. I think it's subpart, no, geez, now I don't remember the letter, but at any rate, and it goes through what the driver has to provide in petitioning that a violation be removed from the clearinghouse. And so he has had to provide some documentation as to why he believes that this should not be a violation. And then whoever looked at that at the clearinghouse saw that it was the MRO who made the determination. And so now they are coming back to you, the medical review, the clearinghouse, coming back to you to obtain the information as to why you said it did meet the part 40 requirements for a refusal to test. So in that case, you would need to provide to the clearinghouse all of your information that there was a shy bladder evaluation. I won't go into that, because if it's not a shy bladder, I'm wasting everybody's time. So is that enough answer or, and I will look up where it is in part 40, it is subpart H, no, maybe that's not right, but just a minute, I'll do that. But those are the only two that we've had in the MRO practice that I work with. Very good. The answer is that a donor may petition to have their positive removed or their failure refusal to test removed. And that if that's the case, the MRO will be asked to provide detailed documentation to the clearinghouse. So that's a good question. And it's not one that we've had ever raised before. I'm not sure I understood what you were talking about, Kent. Just simplifying what you said. Oh, okay, okay. Yeah, let me. But this question was, yeah. Yes, it can happen. Yes, it's authorized under part 40. Yes, it must provide. It's actually in part 382. And that's why I am trying to look up the part of it. And of course, as I'm trying to get work with half a screen here, I'm not too facile. So I will do that. Let's see here. What is it? I think it's subpart H of part 382. I'm sorry for some reason I must be having the thing I've got a bad thunderstorm here too but I'm not able to open my documents right now but I will keep trying. If you're like me when you try to open these things up in a different window it's like almost five point type and I can't I know it's like crazy right I mean yeah right which is crazy but anyway I will keep trying but it is in part it's 49 CFR part 382 and I believe that it is sub part H it's the final sub part of the FMCSA drug testing regulation that talks about the petitioning process etc right okay very good okay thank you dr. Charlo a good question we have a post from dr. Souters and again I apologize if I'm not pronouncing your name right the question is is there any context in which oral fluid is useful for impairment ie post accident or is the window of detection still too large not asking specific to 2hc but anything on the full panel well again here we are what's the purpose of the drug tests it's not to determine impairment I can guarantee you that drug testing you know is is does not have a very good correlation to impairment of course it can but it doesn't necessarily translate into that so you have people that have positive tests and it really is irrelevant whether it's oral fluid urine testing air testing or what-have-you that are not necessarily impaired but will have positive tests and we run into this all the time I run into it quite frequently obviously because there some of our state laws are kind of wonky to be honest with you and there's a way for individuals who are dismissed from their jobs because of positive drug tests in the state of Iowa in particular who can petition in front of the Unemployment Board which is a whole nother government agencies to try to get that disciplinary action overturned and frequently they will use the argument that it's not an impairment type of evaluation which is true in some cases the administrative law judges who in some cases don't understand really what MROs do or what drug testing is all about will overturn those types of things so there is there is some relevance to that particular point any other comments yeah so when you talk about impairment and oral fluid there are a handful of states now that are using oral fluid in their drugs and driving testing but it's really they they assume impairment just like they do in blood they're really per se rules you know the limit of detection of the laboratory but it is true that a positive that oral fluid will will be positive closer to the time of ingestion then will then will a urine sample but in a post-accident situation by the time the samples the samples collected probably either either one gives an idea at least of the behavior of the individual but dr. Martin's right there's no correlation in any of the samples that that we test for post-accident that are correlated with impairment and really you know the only good correlation for impairment for any body fluid or tissue is with is with alcohol you know the AMA says 0.04% is where everyone has some impairment the federal statute is 0.08% is the level which everyone is impaired and all the states carry that for for blood but there's no and other states have come up with their own per se rules for other drugs and blood such as marijuana but that's just a a best guess and not as well characterized as it is for alcohol many of many of those THC state-specific driving laws borrowed from Europe which had a cutoff of five nanograms per milliliter without really any science saying that there was any magic to five so you know it's like okay we need a number so let's pull out a number right and that was all based on on smoking marijuana not oral marijuana where THC levels are much lower so and it could also be argued that those who are in most cases a per se level for driving under the influence and that they did not have as as both have mentioned both doctors have mentioned that they had no they had no basis for a poor impairment per se so going recent use correct so this is the second time tonight where impairment has come up that is the Holy Grail if we could measure impairment by any other means we would be able to potentially eliminate drug testing but no one for decades of research has been able to come up with a valid measure of impairment except possibly in New Zealand where advertising rules but I followed this for 10 years with a variety of research and nobody was coming close so we're using a second best attempt to infer impairment and oral fluid is often better than urine because of detection but we are never able to really document impairment Doug I was able finally to put on my other glasses and I did find that it is subpart G of 49 CFR part 382 and the specific paragraph about a driver's right to petition to have a violation removed is paragraph 717 so it's 382 point 717 it is noted in here that the the clearinghouse folks are kind of under the gun in this section because once the driver files a petition and they believe that the petition contains all the information that's outlined in this section of the rule they have to come up with a decision in 45 days okay and no time to waste right right I never knew the federal government to do anything in 45 days so true so true all right very good thank you for that Donna okay let's see what else we have here any other questions you don't see any other questions Nikki you have any questions in your queue that I'm not seeing no I do not I think that now there's all of our questions for this evening very good okay well everybody be safe my storm is still going on I have not lost power so thank goodness which is all good thing so talking about this marijuana rescheduling thing I did want to draw your attention that I know that you said Doug but you're currently on a task force there was a task force that put out a statement about marijuana as medicine a calm right after a the HHS secretary said oh this is a great idea for it to be medicine right and then directed the Department of Justice to go through the rescheduling process so yeah I don't know what yeah I was on that work group that cannabis work group is that it basically just been continued on throughout the course of time the other interesting thing Donna that you'll and you probably already know this but having just come back from the AMA meeting AMA has the very same policy they have a policy that says marijuana has no known medicinal use for any known condition a period end of story so I don't know if the AMA is going to come out and say anything about this or not you know they oftentimes have much bigger fish to fry than this so it's I think a matter of you know prioritization for them probably but well and again just and I'm sure that it's a soapbox but I would encourage all of you that are on this call and your colleagues or whatever I think that it's worth sending some comments into the public docket the docket is open until July 22nd right and and to I mean if for nothing else then it just infuriates me that one of the tenants that the Department of Health and Human Services gave to the Department of Justice as justification was that no medical group no academic medical no whatever opposed marijuana as medicine I mean and they made a big big deal about how 30,000 well qualified and licensed health care practitioners including physicians prescribed marijuana all the time for everything from toenails to I don't know what else well just you know make it up as you go along at least in some of my states yeah right so I mean I really I just really want to encourage and Chris I'm putting an article together for you to to get out number one and number two maybe in that we can also reference the 2023 document for that a come already has I'm on a crusade I do not want to let them get away with just junk science again no I get it but Donna one correction physicians cannot prescribe marijuana they can only authorize it well but if you look at what they're talking about yes they're using the word recommend okay so I command all not prescribe that's been pretty definitively but again 30,000 health care practitioners recommend marijuana for you know over 19 or 27 medical conditions and it's which when you think about it now you know I'm sometimes I wax poetic about statistics just like Mark Twain did but I think let's see 30,000 the denominator of total licensed physicians in the United States at least according to the AMA is somewhere around 950,000 greater but go ahead okay yeah well licensed physicians who actually have prescribing authority let's put it that way yes there's a bunch of licensed physicians that have nothing to do with prescribing medicine or not in a clinical environment or whatever but the point is is that 30,000 over 950,000 is not much and dare I say let's let's talk about how many physicians prescribe things that are off-label for many medical conditions that number is going to be much higher than 30,000 that's the point that I would make so anyway I'm with you Donna okay okay folks thanks everybody thanks faculty thanks for attending a group and if you have more questions for next time make sure you submit them to Nikki she'll she'll put them in the queue and we'll get to them so take care everybody thank you everyone have a wonderful evening bye-bye

medical review officers

medicinal cannabis

workplace

proposed rulemaking

reschedule marijuana

Schedule III drug

drug test results

clearinghouse violation

oral fluid testing