In this final module of MRO practice, we're going to pull together a number of loose ends, starting with the evaluation of a shy bladder. The term shy bladder was an invention of the Department of Transportation, dealing in situations of urine drug collection. As Dr. Smith has pointed out, a shy bladder situation arises when a donor is unable to provide 45 ml of urine within three hours after being offered but not having to consume up to 40 ounces of fluid. The evaluation is a clinical evaluation, so if you're going to do it, you'll take off your MRO hat and put on your clinician hat. And the purpose of the evaluation is to determine if there is a reasonable explanation for why the donor was unable to produce a sample. Here's the definition, clearly written by a group of lawyers, and I'll read it to you. A shy bladder is a medical condition, and it includes an ascertainable physiological condition or a medically documented preexisting psychological disorder, but it does not include unsupported assertions of situational anxiety or dehydration. The medical evaluation, first of all, consists of a history, because if a person has an ascertainable condition, there's probably a history before that. They might have a history of bladder outlet obstruction. They might be taking medication that would cause that. It's worth doing a physical examination, because sometimes people say, I was dehydrated. So by taking a blood pressure sitting and standing, or by looking at skin turgor, you can tell if the person really was dehydrated. And simple tests make sense, such as a urinalysis or a BUN or creatinine, but it does not make sense to go to extraordinary means, such as doing an IVP or a cystoscopy. And at the end of the clinical evaluation, the clinician needs to write a report to the MRO. The MRO reviews that, and in their opinion, makes the determination. Dr. Smith talked about a permanent shy bladder, and I'll just briefly review it here. This only applies to someone who's applying for a job, that is a pre-employment evaluation, or who's been away from the job, for example, after drug treatment. The MRO needs to determine if these individuals are using illegal drugs, but they have a permanent shy bladder. For example, they might have an iliobladder, or have to catheterize themselves every time they urinate. So this evaluation consists of a clinical examination. So again, the MRO takes off their MRO hat, and they either evaluate the report from a clinician, or they can do it themselves. And the purpose is to assess whether this person uses illegal drugs. This is the only situation where an MRO can evaluate the results of hair testing or blood testing, but that's possible because this is such an unusual situation. And at the end, after receiving a report, an MRO examines the findings, and if there's no evidence of illegal drug use, they report it as a negative, and that person can then go to work. However, if there's illegal drug use, it's not reported as a positive because the DOT procedures were not followed, but it's reported as a canceled test. Now that may seem counterintuitive, but if somebody is applying in a pre-employment evaluation, and the test comes back canceled, they're not going to get the job. And if somebody's returning to duty after being absent, or after being treated, and they have a canceled test, again, they're not going to be able to return to the workplace. Now let's turn to a more complicated situation where there were multiple specimens collected at the same time. The collector might have had a suspicious urine that might have been tampered with, and so they collected a second specimen under direct observation. In this case, the collector clearly needs to label the two CCFs, specimen one of two and specimen two of two, but they're treated as a single test event, which means that if either of the specimens comes back positive, adulterated, or substituted, then they are reported together. Now usually they come back sequentially, so if you see a specimen that's called specimen one of two, and it's negative, it makes sense to wait before reporting to the employer. If the first specimen is non-negative, however, you can go ahead and continue your MRO evaluation even before getting the second back. This is not a totally rare situation, because you can imagine, for example, someone who provided a specimen, there might have been some question about whether they put something in the urine, and so they drank some additional fluid, and then they did a second collection under direct observation. Amazingly, the first specimen comes back positive, but the second was negative because of the dilution effect of having drunk the additional fluid. Sometimes an MRO gets multiple results on a single specimen. So let's say that it was positive for a drug, but it also showed evidence of an adulterant. Well, once this has been verified by the MRO, then you would report both of those results to the DER. If the donor requests a split, you should, of course, have reported the results before waiting for the split test results. If the split test confirms one of the two positives, you can go ahead then and reconfirm that as a positive. They don't both have to have the same result. And if the split reverses the initial report, then the MRO can always change the results that they reported earlier. Here are some practical don'ts for an MRO, and I'll just review a few of them. Under federal testing, an MRO cannot consider the results of other tests, such as hair or blood or DNA, although I did say that you could use these for a permanent shy bladder. If the donor says that there was all kinds of problems at the collection site and that the collector did not follow the correct procedures, you're not in a position to adjudicate in that situation, even if you have concerns. It's not your role to decide whether the donor should or should not have been tested. And if there's an explanation for medical use that is not documented, you really are on shaky ground. So you need to have a documentation from the pharmacist, the treating physician, or at least a picture of the bottle of the prescription drug. You're not going to accept CBD products as a reasonable explanation for the presence of marijuana, certainly not under federal regulations. And finally, you're not going to accept a medical condition where there's no creatinine. Sometimes people do substitute their urine for Mountain Dew, and it may fit the electrolyte criteria, but it is not going to have any creatinine in it. Beyond your narrowly prescribed duties as an MRO, you are able to play other roles. That is, you can put your clinician's hat on and do clinical medical evaluations, such as looking for needle track signs on a physical exam of a positive opiate donor, doing a shy bladder or a shy lung evaluation. MROs can also function as substance abuse professionals, and they will require similar qualification training and examination. You can review the results of oral fluids, hair, or blood, as well as the more narrow urine tests that are still currently in place. And you can also do a commercial motor vehicle driver. So there's nothing that limits you as an MRO from playing any of these other roles. It's important to distinguish the two different kinds of drug tests that a commercial driver can have. During their CDME medical exam, the medical examiner can choose at their discretion to have a drug test done that's based entirely on their own way of doing it or their suspicion. So it does not have to follow the narrow bounds of the official DOT drug test. The panel can be broader. It could include benzodiazepines and barbiturates. The test could be on hair or blood. And the laboratory can be a local lab. It does not have to be an NLCP-certified laboratory. This is quite different than the official DOT drug test, which are mandatory tests. We know that the panel is a fixed five-drug panel, and all of the DOT protocols have to be followed specifically. This brings up the difference between the narrow federal panels of drug testing and non-regulated drug testing, which actually consists of a much larger volume than the federal tests. If you ask Dr. Peet and Dr. Smith and I, do we really believe that a split specimen is required, I think all three of us would say no, because it is so rare to find a failure to reconfirm. So many non-federal drug collections only involve a single specimen. If the donor is concerned about the result and they want to have a specimen retested, you can still have the laboratory take an aliquot from the one bottle and send that to a separate laboratory. Another big difference is the drug panels. Non-federal panels often do include a much larger range of drugs. In the case of testing of impaired professionals, the panels may include up to 30 or 40 or 50 different drugs. In non-federal situations, oral fluid has been collected for many years, as has hair testing, which has been heavily promoted commercially. And there are good reasons to do a hair test, for example, if a employer wants to have a longer window of detection. As far as witness collection, the federal laws specify certain situations, but some industries routinely do a witness collection. The Department of Defense military collections are all done under direct observation. Under the federal program, a donor cannot write on the custody and control form the recent medication. They, however, can be encouraged to turn it over and write on the back of their copy only any medication or over-the-counter drugs that they had as a, quote, memory jogger, unquote. But in non-federal situations, it's not unusual for a collector to ask the donor at the time of collection if they've been on any medication that could cause a positive drug test. Sometimes the cutoff levels are different in non-federal testing. And finally, there's something called on-site collection or point-of-collection testing. This is where a urine is collected, and it is tested right there at the point of collection. If it is negative, the person goes to work. However, if it's positive, for example, in a situation where someone is about to enter a control room of a nuclear power plant, then that person is kept out to work. But the drug specimen is then sent off to a laboratory for confirmatory testing. As an MRO in non-federally regulated testing, you're going to have a wider set of functions. For example, you'll be interpreting an expanded drug test panel, or you may be interpreting the results of a hair test or an oral fluid test or a blood test. You'll need to follow the employer guidelines with regard to what their policy is with regard to medical marijuana or taking medications while traveling in another country or the use of a spouse or friend's medication. As I've said earlier, you can also serve as an SAP, and you can put on your clinical hat and be an examining physician. You'll also have the opportunity to do fitness for duty and return to work determinations. So if there's a safety concern, you can go ahead and do a more detailed evaluation. Sometimes MROs are asked to advise employers about alcohol test results, even though there's no formal role under the federal regulations. And finally, you can do monitoring of post-rehab testing programs. As an MRO, you're in a direct relationship with an employer, and you're technically called a service agent. So it's very important for each of your clients to get to know them, to read and review the company policies, and understand what their policies are with regard to, for example, medical marijuana or what they have advised their employees about the use of opiates for pain during work and what their policy is in performing fitness for duty evaluations. How are they going to handle the report that you give them of safety concerns? This is critically important to talk about in advance. And do they have someone lined up to do a fitness for duty evaluation? With regard to dilutes, are they going to routinely test everyone with a dilute specimen with a second collection? This can be done, but everyone in a particular job category has to be treated the same way. How's the company going to deal with the payment for split specimens? Will the company pay for that? Or are they going to require the donor to pay, for example, $100 if they request a split? Is the company going to have, as we've advised, a routine DL separation for positive methamphetamines? Does the company have a policy with regard to the use of special medication? And if so, have they communicated that to their employees? When you do report a positive, it's important to make sure that the company does have a list of SAPs and that they're following the protocol of giving a donor a list of the SAPs, even if they're not going to be paying for it. But it's important to know the company's treatment policies, what they will and will not pay for. And finally, if a donor is having a breath alcohol collection and they're above .02, is the employer going to allow them to drive off? Are they going to advise you to pay for a cab to take that person home? Or is someone from the company going to come and pick that person up? So these are the kinds of issues that it's important to clarify with your employer, and it will bond you much more closely to them and help strengthen your relationship. There's a very wide variation in the many different state laws that affect workplace drug testing. We know that the federal testing always supersedes the state law, but in the absence of federal law or non-federal drug testing, state laws become very critically important. For example, 14 states have mandatory drug testing laws that govern some aspect of non-federal testing. They might restrict, for example, the types of testing, not allow random drug testing. Some do not allow oral fluid collection. Some have provisions related to testing of opioids. And some do not allow direct observation of urine collection. Ten states have provisions that deal with workers' compensation insurance programs. So if an employer does do drug testing, they will be able to pay a lower premium for their workers' compensation insurance. Now that we're seeing marijuana widespread throughout states, the laws fall into basically three categories. Thirty-three states in the District of Columbia now have some provision for medical marijuana, and they vary quite significantly from one to the other. Eleven states in the District of Columbia allow recreational marijuana, and 13 states allow low THC-containing CBD products, for example, for the treatment of childhood epilepsy. At this point, only four states absolutely prohibit marijuana use in any form. And finally, four states require MROs to report the drug test results to a state DMV or commercial driver's registry. After many years of being in the works, the federal oral fluid mandatory guidelines were finally released in 2019. And although they're effective in January of 2020, it's going to require at least 12 to 18 months for laboratories to be fully ready to process them and for the DOT procedures and forms to be completed. From an MRO perspective, oral fluid testing is going to very closely parallel what we do with urine. We'll receive reports, we'll provide an MRO review, we'll have an interview with a donor, and the main difference is that the cutoff levels for oral fluids are considerably lower, so we're going to need to learn a new set of cutoff levels. A couple of key differences in terms of what's tested for. The test for tetrahydrocannabinol actually tests for THC in the oral fluid, not the THC acid. And in the case of cocaine, we're testing not only for the benzoyl econine that we do in urine, but also the parent cocaine itself. In order to do oral fluid testing, MROs must complete a minimum amount of training on the oral fluid mandatory guidelines. And we consider that this course and the segments on oral fluid testing will meet those requirements. So we're at the end of these five modules of dealing with effective MRO practice. I want to close by recommending a couple of additional resources that you will find valuable. Let's start with the summary charts that Dr. Smith has prepared that summarize all of the many different provisions of state laws pertaining to workplace drug testing, and these can be found in the supplement to your syllabus. Dr. Smith also wrote a summary set of MRO procedures and reporting details, and they're at the end of this tab. And finally, you're going to want to be aware of a detailed MRO manual produced by the Department of Health and Human Services. It specifically focuses on the testing of federal employees. And as we pointed out, there are some differences in terms of reporting safety concerns, but it's a very useful and practical manual.

shy bladder

urine drug collection

clinical evaluation

MRO

illegal drug use

canceled test