Welcome to this segment called Drug Testing and MRO Basics. The reason we put this together was because so many people taking this course are brand new MROs, often who call yourselves green as grass. And before we got into the details for the veteran MROs who are seasoned, we wanted to cover everything over once quickly so that you are fully grounded before we go deeper. In this segment, we're going to have two sections. The first will deal with the historic context of workplace drug use and drug testing and cover certain basic concepts and terminology. In the second segment, we will review the duties and responsibilities of the MRO. We all know that human beings have long been substance-using creatures. And this was true thousands of years ago, both in the home and in the workplace. Archaeologists who have traced the pathways of Roman soldiers found these amphora, which were carrying alcoholic beverages. So clearly this was part of the workplace. Sailors also had a long history of consuming alcoholic beverage. It was customary to issue tots of grog or what was called pusser's rum in the middle of the day after a long morning's work. And I was shocked to realize that this was the middle of the day before the sailors went back out, climbed the rigging, and engaged in clearly very hazardous work. Looking at this picture, you can see that it was not infrequent to hear the call, man overboard, as someone fell off of one of these riggings and into the sea. It was not unusual for military units to carry very highly psychoactive substances as well. For example, during our civil war in the United States, there were morphine kits that were carried in every unit into the battleground. After the Civil War, patent medicines and a wide variety of potions became available to the American public. One particularly popular one that became known as Coca-Cola was invented by an enterprising drugstore owner in Atlanta. And the original Coca-Cola contained cocaine. No wonder it was a quicker picker-upper. Other patent medicines included belladonna, hemlock oil, death cap mushroom powder, mandrake root, tincture of wolf's bane, and essence of devil's apple. Opiates were in prevalent use, especially in the form of a liquid called laudanum that was often used by one's grandmother to help settle her down. Interestingly, Sigmund Freud became addicted to opiates. So if substances have long been used by citizens and by workers, where did the origin of workplace drug testing begin? I think it happened because of a concatenation of two circumstances. The first was that during the Vietnam War, a very large number of military personnel were using addictive substances. And when they came back from the war, employers were encouraged to bring them back into the workplace, just as had been happened after World War II. But in doing so, employers realized that many of these people were addicted. At the same time, a new technology was emerging, which was called immunoassay screening. And it permitted inexpensive and rapid and fairly accurate detection of substances. So the combination of these two factors led to an explosion of drug testing, both in the military and in the federal government and in the private workforce in the 1980s. In 1982, I was working for IBM in their world headquarters in New York, and two incidents occurred in which employees who had been terminated came back to the workplace and committed violent episodes. This, of course, caused a huge stir among corporate management, who assigned a task force to address the issue of people using illegal substances and creating workplace incidents. I served as a member of that task force, and that was really how I first got involved in workplace drug testing. A number of corporations were experimenting with a variety of means of workplace drug testing. Some of the very best technology emerged from the military because there was a worldwide problem of substance use. And so some of the first guidelines were developed in the Department of Defense. But drug testing really became popular because of a presidential executive order that President Reagan issued, in which he called forth for the nation's largest employer to provide leadership in promoting drug-free workplaces, hence the origin of the term drug-free workplace program. And you'll be hearing that a lot throughout this course. There were five key components of a drug-free workplace program. The first was having a written policy regarding substance use. This seemed essential because an employer was, in essence, telling an employee that they could not use a substance during their nights or weekends when they were off duty because it had implications for workplace safety. A second component was the training of supervisors. This was particularly important if supervisors were going to recognize employees who might have a substance abuse problem and be requiring them to have drug testing for what is called for reasonable suspicion or for cause. A third component of the drug-free workplace program was employee education, which took many forms but basically alerted employees that drugs were not simply pleasant recreational substances but that they had very serious implications for workplace health and safety. Many employees had very little information about the use of unauthorized substances and their potential workplace effects. Certainly many people would not have been able to recognize and distinguish catnip from marijuana. The fourth component of the federal drug-free workplace program was some form of employee assistance, and this term can have several different meanings. At the lowest level, employee assistance could simply mean that an employer provided educational information to an employee, including where they might go for counseling or for help. However, many of the federal programs actually paid to have an employee see an employee assistance counselor who would evaluate that person and either provide short-term in-house treatment, for example, three to five sessions, or refer them for outside treatment and rehabilitation, which could take place over a longer period of time. The fifth and final component was some method of identifying drug users, and quite frankly, if this method had been something that involved psychomotor abilities or mental abilities, it probably would not have become a major component of employee health programs. But because urine testing was the mode that was chosen, and because that involved a bodily fluid, that brought occupational and environmental medicine professionals right in the middle of the drug-free workplace program. So remember, we're covering the basics of drug testing in this segment, and one of the key questions is, what's the purpose of doing drug testing? The answers here did not come from any federal statute or written regulations, but were put together by your faculty. The first goal is to reduce the illegal or inappropriate use of drugs among workers. And notice that the term says reduce. It does not say eliminate or completely abolish, and the elements of the programs that were created clearly had in mind the reduction and not the elimination of drug use. A second reason for doing drug testing is that it gets the attention of employees, and it helps educate both managers and employees. I remember when my daughter had graduated from college, and she was applying for a job with an airline, she wanted to know something about her father's work. She asked me one day, Dad, how long do these substances stay in your blood? And I thought that was really wonderful to have a child interested in their father's work. A third purpose is to identify and then remove drug users from what became known as safety or security-sensitive jobs. This was challenged by labor unions, and a case involving Amtrak went all the way to the U.S. Supreme Court, where it was felt that the public safety and security outweighed the individual right to privacy. A fourth purpose is to actually find and treat and rehabilitate drug users. I know some employers' attitude was, let's find them and fire them, but that's going to mean a large number of unemployed people. A far better goal is to rehabilitate people, get them safely back to work. And lastly, drug testing does create a deterrent against drug use and abuse. It gets employees' attention. People know that they're at risk of being called in for a drug test at any time, and as a result, they may decide not to use a recreational drug on the weekend. There are many different types of drug testing, and the first two you see here. The most common form of drug testing is what is called pre-employment or pre-placement drug testing that's done before a person is offered a job in a safety or security-sensitive workplace position. The second type of drug testing occurs after a person has had an accident that caused a certain specified amount of damage, or there was an incident that endangered the worker and others, or they violated a workplace practice, and therefore, there is a requirement that they be tested. There's no question that the use of psychoactive substances or alcohol in relationship to work definitely increases the likelihood of workplace accident and injury. The third type of drug testing has an unusual name. It's called reasonable suspicion or sometimes for-cause testing. This occurs in a situation where a supervisor observes behavior of an employee and is suspicious. For example, they may be missing work on Mondays and Fridays. They may be taking excessive lunch breaks, or they may seem to have a personality change where they're getting into conflict with fellow workers or with the supervisor. So the usual practice is for the supervisor to document the behavior that they're suspicious of and then to discuss it with their second-level supervisor. And if both agree, then the employee can be brought in and required to have drug testing for reasonable suspicion. What was once the most controversial type of drug testing is called random testing. That's where all of the workers in a particular category, for example, with safety-sensitive jobs, all of their names are put into a pool, and periodically, their names are randomly drawn out, and they're subjected to drug testing. Now, of course, if they have a negative drug test, then their names are excluded, and the next time the pool is drawn, there'll be different people, right? Well, actually, that's not right, because even after you've had a negative drug test, your name goes right back into the pool. So the next time drug testing is called for, you have an equal chance of everybody else of being tested again. So of course, some people go for years without being drug tested, and other people may be tested two or three times within a single year. Another type of drug testing is return-to-duty testing. That's where a person has been away from work for a period of time. It may have been due to illness. It may have been due to the fact that they're only working seasonal or summer jobs. But before they can return to their jobs, the employer requires them to produce a clean urine. A similar type of testing is called follow-up-to-treatment, and that's where a person has been tested positive or been diagnosed with a substance abuse disorder. They've had education or treatment, and the employer has decided that they want to allow them to come back to work. But before they do, they have to have a negative drug test to reenter their job, and then there are a series of follow-up tests where a person is, in essence, in a random pool of one, and they will be tested four, six, or even more times per year for up to several years. The last type of drug testing is called periodic or voluntary. And you could very well ask the question, well, does it make any sense to have a scheduled drug test, for example, as part of an annual exam? And all I can say is they don't call it dope for nothing. Every year as a medical director of examinatics, I get positive drug test results from people who weren't having their annual exam, which included a urine drug screen. And I asked them, I talked with them, and I said, why did you possibly use marijuana when you knew that you were going to have a drug test as part of your annual exam? So that continues to be a type of drug testing. There are many standards of practice pertaining to workplace drug testing. And some people have a misnomer of talking about regulated versus non-regulated drug testing. What they really mean is, is it regulated by federal agencies? And as you see, many federal agencies do have regulations pertaining to drug testing. We'll talk a lot about the Department of Transportation regulations, but the Nuclear Regulatory Commission has a very different set of drug testing specifications for people working in nuclear power plants. The Department of Defense also has a very different drug testing program. For example, all specimens that are collected are done under direct observation. And contractors to the Department of Defense and other federal agencies also need to have in place drug-free workplace policies. In the non-regulated area, though, there are definitely regulations. Almost every state has one or more laws that pertain to some aspect of drug testing. And Donna Smith put together an elaborate compendium of the state laws, which is in the supplement to your syllabus. Every state has workers' compensation laws. And they often indicate that if an employer does do drug testing after accidents, and if an individual has been tested and they're positive, they may have their medical care paid for, but they may not receive salary replacement. So this is known as contributory negligence, namely the employee contributed to the accident or injury by their negligence in taking an unauthorized substance. And finally, many union contracts relate to drug testing as well. I'll never forget our faculty being asked to teach in Palm Springs, California, to a United Auto Workers medical education program for the doctors working for General Motors. But it was interesting that the back row of our CME session had representatives of the union who regularly participated in any educational activities of doctors because they wanted to know what was being taught. I've already started talking to you in alphabet soup. And this will continue. As you work in government-regulated drug testing, the question is, are you able to recognize these letters? Do you know, for example, what SAMHSA stands for or the NLCP? Here you see the answers. So SAMHSA stands for the Substance Abuse and Mental Health Services Administration, which conducts a very extensive drug-free workplace program. And the National Institute on Drug Abuse, NIDA, is part of the National Institutes for Health. Similarly, the Department of Transportation has a number of different what are called modes. You can see, for example, the FHWA. And one of them actually changed their name. So do you know what they stand for? At one time, drug testing actually fell under the authority of the Federal Highway Administration. However, because health concerns became so important within DOT, the Federal Motor Carrier Safety Administration was established. The one that changed its name used to be called the Research and Special Programs Administration. And now the name has been changed to Pipeline Health Now the name has been changed to Pipeline Hazardous Material Safety Administration, so you can actually figure out what it refers to. Similarly, in the world of drug testing, we have our own acronyms. So you'll be dealing with BATS. You'll be dealing with SAPS. You'll be dealing with DERS and even PIE. And we'll go through those over the coming hours. So a BAT is a breath alcohol technician, someone who does evidentiary breath testing. A SAP is a substance abuse professional who will evaluate people who have a non-negative drug test result. And Dr. Smith will talk about the PIE, the Public Interest Exclusion, for those that have disregarded the federal regulations. So back to basics. Drug testing can be broken down into three separate steps. First, a specimen is collected. Then it is tested either on site or sent to a laboratory where there are two forms of testing, an initial test and then a confirmatory test. And finally, there is some medical review of the results. So let me ask you a question. Which of these three steps do you think is the weakest link? So there's no question that the weakest link is in the area of specimen collection. And that's true for several reasons. First of all, there are a far larger number of specimen collectors than there are laboratories or MROs. Secondly, they have the least amount of training, although training is required. And finally, they are the lowest paid workers. And so there is likely to be a very large job turnover. Finally, it's a very demanding job, not only the collection of the specimen, but especially the correct completion of the custody and control form. Specimen collection has several components. First of all, there is a right to privacy under most of the federal regulations, which means that the providing of urine is done not under direct observation, but in an enclosed stall. So there is privacy, unless one of several other factors requires a witness collection. Secondly, there is a very strict following of what is called chain of custody. That is, I provide my urine, and I give it to you, and I sign that I've given it to you. You sign that you have received it from me. Then you, in turn, sign that you are releasing it to a courier to be sent to a laboratory. The laboratory signs that they have accessioned that. And then there are internal chains of custody within the laboratories. A third component is temperature recording. Today's urine collection vessels contain a built-in temperature reading indicator. If the temperature is out of range, that is suspicious. It doesn't necessarily mean that there was tampering, but it certainly indicates that it is likely. And so procedures are followed to follow up on a temperature that's out of range. And finally, when urine is poured into the bottles to be sent to a laboratory, there has to be a temper evidence seal that's put over the top of the bottle. And it should be, but does not absolutely have to be initialed by the donor before it gets off for shipping. Oral fluid testing is really coming into its own. And soon, oral fluid will be added to urine testing as being part of federal drug testing programs. There's obviously a big difference in the collection of the two. You can imagine for yourself the time and ease for collecting an oral specimen versus urine. There's no need for a secure toilet facility with oral fluid. And you will, of course, be collecting oral fluid under direct observation, as opposed to the complexities of collecting urine when directly witnessed. Urine collection offers the potential for adding adulterants, which is much less common with oral fluid collection. And finally, of course, there is going to be differences in the sensitivity and the specificity of the laboratory testing. And we'll go into that in a lot more detail as we go on. The second step is laboratory analysis of a specimen. And this is undoubtedly the strongest link in the chain. Because of very, very strict regulations and monitoring and inspection under the National Laboratory Certification Program, I would say that the accuracy of urine drug tests in these laboratories is 99.99-something percent. The drugs tested under most federal panels consist of five categories. Initially, they were called the NIDA-5, standing for the National Institute on Drug Abuse. The name was later changed to the SAMHSA-5. And you will, of course, hear much more about them in detail. But they include a variety of amphetamines, a number of metabolites of marijuana, cocaine and its metabolites, PCP or phencyclidine, and the opiates, which consisted originally of three substances and more recently a set of semi-synthetic opioids were added to the federal panels. The third step in drug testing is the review of the results by a medical review officer. And as we said earlier, both the Department of Health and Human Services and DOT require what is called qualification training. A medical review officer has to be a licensed physician, that is, have one active unrestricted license in any of the states within the United States or Mexico or Canada. Fortunately, only one license is required. Although early in the game, it was not certain as to whether that was required or not. Actually, early in my career, I got licensed in all states in order to be able to be sure that I was properly credentialed. And a medical review officer has to have a basic knowledge in a number of areas, as you see here. The federal requirements for MRO qualification training include specific education about the areas that you see listed here. And the good news is that this course will include every one of these. After an MRO has gone through their initial qualification training, they have to demonstrate their competence by taking and passing a nationally recognized certification examination. And there are a couple of different organizations that are approved by the Department of Health and Human Services. After that, there used to be a continuing medical education requirement, but that has been changed. And now, MROs must, during each five-year period, redo their qualification training, which covers all the same material as the initial qualification training. In addition to being retrained, they also have to then, again, take and pass a nationally recognized certification exam. And that has to be done every five years. So I've already mentioned oral fluids as an alternative to urine. But let's be clear. Urine has been the basis of private and federal drug testing for many, many decades. You can see that urine will detect drugs between hours to a number of days after the substance has been consumed. The use of blood and breath and oral fluid can collect drugs earlier after their use. And the use of sweat, hair, and nails can have very long detection periods. This chart puts together the three most commonly types of specimens with the different types of drug tests. So you'll see that pre-employment and random tests can be successfully done using hair, oral fluid, or urine. But that's not true for post-accident testing, where you want to make sure that the drug was in the body immediately after the accident, and therefore was likely to have been the cause of the accident. The same is true for reasonable suspicion testing. But again, hair can be used for return to duty testing and for follow-up testing. As we complete this module, I just want to point out some additional resources that are available to you and important for you to be familiar with. First, there's a longer list of acronyms and abbreviations that MROs need to be familiar with in your syllabus. There's also a detailed listing of the different drugs covered under the Drug Enforcement Administration control substance schedules, where the Medical Review Officer Certification Council put together a MRO code of ethics that we should all be familiar with. And finally, the MROCC also has a lot of information about the examination. They carefully outlined in detail the competencies of an MRO upon which the examination has been built. They also summarize the topics that are covered in the MRO. They also summarize the topics that are covered on the exam. They give references to read and study. And your syllabus, I think, is usually the top of the list in every category. And they include some sample exam items. So that completes this module.

Drug Testing

MRO Basics

Workplace Drug Use

Historical Context

Drug-Free Workplace Program

Types of Drug Testing