Welcome everyone. I'm Dr. Kent Peterson, and this is our July monthly MRO online faculty discussion and question and answer. In the past, we have done these as Zoom calls where everyone could see everyone else's name and their faces, but starting last month, we began a trial of doing it as a webinar. So who you see are the five key players in the teaching and support team, and the rest of you who are there will need to use the chat in order to ask questions. If somebody wants to have a dialogue with one of us on the faculty, you can request that in the chat, and Daniel Feinberg can actually bring your face up, and we can have a live dialogue with you. But for those of you who have been with us for a while, you're aware that I'm the Occupational Environmental Physician member of the faculty. To my right on my screen is Dr. Michael Peete, who's the Forensic Toxicologist member of our faculty, and down below is Donna Smith, who is both the policy expert as well as the expert on specimen collection and on federal regulations. So you have many hats, including Substance Abuse Professional and EAP. We're also very grateful to have you, Christine Paciak, Executive Director of MROCC, and we have some questions for you tonight. Thank you for being with us. And Daniel Feinberg, you're now the Director Manager of eLearning for ACOM, and none of this would happen without you. So thank you very much for contributing your evening to us. I'd like to start by doing a few announcements, and I'm going to share a screen, and the announcement should come up. Hopefully everyone can see that. The first, as I've already mentioned, is that we have shifted to a webinar format. And so at the end of this evening, we will ask Danielle to give us a poll, and we'll ask you to indicate your preference. Would you rather have this webinar format, where questions are submitted and posted on the chat, unless you want to be unmuted? Or would you like to return to the earlier format of being in Zoom, where everyone can see each other's names, and if you unmask yourself, see your faces? So that'll be a poll at the end of this evening. Last month, I announced that we are going to have another live faculty session at the ACOM Learning Center at the end of October, and Dr. Doug Martin is going to be joining our faculty, and he will be a leader of this MRO course in the future. So the Fast Track will be live outside of Chicago. I said Elk Park, but it's Elk Park, and it'll be a long day on Saturday. We tried to take a two-day course and give you as much material as we could possibly do. So it's going to be a long day on Saturday, and Sunday we will stop at one. Lunch will be provided on-site, and the MRO-CC exam will then be Sunday afternoon from 2 to 5. So that announcement has been posted in the last couple of days, and if you or some of the people you know prefer live learning rather than distant learning, please let them know about that. I have a brand new announcement, and that is that because we released the MRO course in July of 2020, and three years is coming up this month, we needed to completely review the course and have it re-approved for CME credit. So I have spent many, many days going through every slide and every page of the syllabus and have completely updated the online syllabus that has been delivered to Danielle, and within the next few weeks during the month of July, the website will change and it will have updated the updated syllabus in the website. Now only two of the tabs have major changes, and that's the tab that covers the data on the prevalence of substance abuse in the United States and at the workplace. So we have much more updated years for that, and that will be an entirely new presentation of both slides and a faculty presentation. The other one has to do with the one on oral fluids and hair testing, where there again were a number of updates, and we're using the presentation that Dr. Pete and Dr. Smith gave from the American Occupational Health Conference. In addition to the updated syllabus, I'm going to summarize in one document where the major changes were, where the minor changes were, and actually for all the change slides, I'm going to include them in one document so those of you who have bought a syllabus will not need to feel like your syllabus is out of date, but we will give you specific identification of the changes that are made to the syllabus. We're also aware that because of the recent DOT final rule authorizing oral fluid testing, that there will be further changes to the teaching material that we will make during the summer before October, so there'll be some additional updates as we go to the syllabus for this online course. And since we're going to be updating the website, Danielle has offered to work with me to simplify and streamline the user interface on the internet, and we'll be starting that in July and hopefully have that major changes done in July, but our goal is to simplify things and make it easier for you. So we have two questions tonight. One comes from our last discussion, and the other was submitted by Dr. Porter, and let's just go ahead and take it in order. The question is, what is the fallout that has happened? What have been the reactions? What are the implications, particularly for laboratories, from the DOT authorizing of oral fluid testing? So I'm going to stop sharing, and maybe Donna and Mike, you'd like to just briefly comment on what the reaction has been and the implications. Do you want to go first, Donna? Go ahead. Okay. I think from a lab perspective, how am I going to put this? They've been waiting so long for this announcement. They've obviously, the majority of them, been doing oral fluid testing for non-regulated employers in the last five to ten years. So this is all the mechanics of the NLCP, the National Lab Certification Program, authorizing them, certifying them, whatever the word you want to use, to do this testing according to the proposed guidelines. None of them that I've heard from, which isn't a great number, but the big boys, LabCorp, Quest, are not expecting, you know, revolutionary changes, speedy changes. They're expecting this to be something that may be implementable from the labs towards the end of the fourth quarter of this year, or maybe even the first quarter of next year. And I think the smaller labs are still determining whether it is worthy of their budget to pay for the certification, to pay for the kits with potential, you know, lost kits, et cetera, and to pay for, to get the testing up from a quality control point of view in the lab. And I think a lot of them are deciding just to continue with the way they are and waiting to see. Donna? I'll address it to some extent from my experience with DOT regulated employers. Most of you know that I currently serve as the regulatory compliance officer for a fairly large TPA MRO company that has probably close to 3,000 DOT regulated employer clients, many of them in the trucking industry, a large segment of them actually in the aviation industry, few in the rail industry, et cetera. So, over the past two months now, again, with Zoom calls, webinars, and other activities with those clients about the DOT final rule, I have been surprised to see that I would say 75% of our clients, Workforce QA clients at this juncture, intend to stay with primarily a urine drug testing program. They will use, I think, what they intend to use, oral fluid, where it makes a lot of sense to them, shy bladder circumstances, for example, where directly observed urine collections are required or mandated by the existing rules. So, they will move to oral fluid testing there. But other than that, of the other 25% of the clients are basically saying, yes, once there are laboratories approved, and once there are collection devices approved, and once we get to quote unquote, the financial costs that would be associated with moving from moving from urine testing to oral fluid testing, that's when they'll make their decision, largely based, again, which in many, for many companies, especially trucking companies and others in the oil and gas industry, et cetera, the financial cost of testing is a big factor in, you know, what they may ultimately decide. Fallout in terms of whether people were surprised or there were provisions in the final rule that they found not that they did not like, or that they felt were not appropriate, or that they had real questions about, by and large, I did not find that to be true, with the exception of DOT's requirement for the split specimen collection device and not allowing what HHS allowed over two and a half years ago now, which was that you could use an oral fluid collection device and put two devices, one on each side of the mouth, if you will, or you could do them sequentially by collecting first one, and when you had the one mil of oral fluid on that collection device, then you could put a second one into the mouth and collect what would become the B specimen. But since DOT did not permit that, and since there is no currently FDA-approved device, there is currently no device that meets the DOT specifications for how that split specimen will be collected, meaning that it will actually be subdivided, I think what people are envisioning is that a device where it is a pad device, which is what all of the ones on the market now primarily are, but now the pad will have to be construed so that it can be separated or broken in half, or somehow be able to put into a vial A, or a bottle would have been called a vial A and a vial B. So that's really the feedback or the input with regard to the actual rules. I haven't heard a lot of concern about testing for THC rather than for THCA. Most employers, again, on the DOT side, it currently doesn't make any difference about testing for marijuana, but certainly on the non-regulated side, oral fluid testing with THC is probably preferable because with the restrictions that have been put on various state laws, such as Washington, California, et cetera, about marijuana testing, the testing for THC, which is considered the psychoactive component, in many of those restrictions, you could test for the THC, whereas you could not test for the quote non-psychoactive metabolite THCA. So from that standpoint, I think that there are at least a handful plus, if you will, people that feel that the DOT and the HHS move for oral fluid testing for THC is a good move. The only other thing that I have heard in terms of the kind of fallout or the issues surrounding it is that there are some employers that, again, have expressed the concern about the window of detection being so much shorter. But I think a lot of that is kind of misinformation and not understanding what occurs now with urine testing, with dilute specimens and everything else in terms of the variability of the window of detection. And so I think ultimately, once there's enough education concerning that, that that will not be as great a factor in making a decision about whether they use oral fluid drug testing or continue with urine drug testing. Thank you. One last comment. Some of the labs that I talk to are very concerned about this splitting of oral fluid on one pad. As they should be, Mike. Yeah, as they should be. Because what's going to come is, you know, how did you, from an inspection team, more than likely, how did you determine the equivalence of the split So if you imagine a split where you split the pad into two, obviously, when you split that pad into two, you're going to have spray, right? Things going to spray. And then is there an equivalent amount of THC or drug in the A part of that to the B part of that? And some of them who've seen the FDA applications say that that issue has still not been satisfied. So if the FDA doesn't seem to say that A equals B, then when I mentioned fourth quarter this year, early next year, all bets are off the table if FDA is going to go back and say this design doesn't work. Yeah. So, you know, Mike, we may end up with neat oral fluid in terms of spitting into two tubes, may the teens preserve us. But this is just, I mean, it's what happens when you've got regulators who, in my opinion, in this case, you know, took a hard stand of an interpretation of a 30 year old statute, which, I mean, again, I don't necessarily agree with the interpretation, but I, you know, nobody, well, they did ask me and I put it in my comments, but nonetheless, not the decision point. But the deal is, I don't think that there was any consideration to, OK, can you practically or scientifically do this? I think that was the issue that I have real concern about. OK, I've got some additional comments, but knowing that Chris Paciak needs to leave, I'm going to go to the question that was submitted and I'll show that to you in writing again. So the question was about the best way to prepare for the MROCC exam and specifically for the online exam. And this is more relevant, I think, to all of you in the audience who are interested in the cutting edge of rule changes, but really want to make sure that you have mastered the basic material and that you're prepared to pass your exam on the first try. So the question was, what's the best way to study for the exam? What's the best way to organize materials for an open book exam? And because there's so much information, there's a lot to organize. So I'm going to ask Chris that you give your answer first and then each of our faculty will comment on that. And after that, you can go and then I will go back and make a few additional comments about the oral fluid. Sure. You know, the one thing I always like to point out for anyone taking the exam is that 50% of the exam is based on the regulations. So it always will serve you well to go through the regulations, make notes on things that you think can be tested on. You know, maybe you're just making notes on where to find it so you can easily get back to that. There is a blueprint on our website under the certification section. There's an exam preparation area and there's a link to the DOT regulations there. There's a link to the blueprint which will give you an idea of what topics are covered on the exam. I would review both of those before you even start the exam. Take your notes. Keep in mind it is not an easy exam and you only have three hours for 110 questions. So don't be fooled by being open book. You're not going to have a lot of time to look things up. Have your materials ready so that you're prepared, know where to find things, have yourself a reference sheet with confirmation levels, etc. that you can use. And don't spend too much time on one question. If you don't know it, move on to the next. You can flag it, you can come back to it at the end, but you just don't have a lot of time. So you do want to keep moving. There are two types of questions on the exam. Most of the questions are single best answer, just multiple choice single best answer. But there are 10 to 15 questions that have possibly more than one correct answer. Those questions are still only worth one point. Don't spend a lot of time on them. It's kind of like having five questions in one. If you don't know the answer, tag it, come back to it at the end. You're not getting any additional points and you only get the point if you get it completely correct. So don't be fooled by those questions, just move past them. And the other really important thing to know right now is that the new updates are not covered in the exam. They probably, probably the first time they will be in the exam is the on-site exam in April, May of 2024 at the AOHC meeting. The committee, you know, for starters, we can't test you until you're being taught that. And then we still have, our exam committee has to get together, putting together new questions and get those in the exam. So we're still a ways off before that'll happen. But we do remove any questions that could be confusing or that the answer would have changed. Good, thank you. And you may want to come back again. Mike, a lot of the exam is on the toxicology, the laboratory testing, and that may be challenging for many of the people. Do you have any specific suggestions for how to dig in and master that, knowing that they don't have to memorize every number, but that they need to have it in front of them and to be able to know how to go to it and use it? What's your advice, Mike? Well, for the exam, with all due respect, they're gonna have to memorize the numbers because they're not gonna have time to try to figure out what the options are on those multi-choice questions. And obviously, if you're going to have tables that you've prepared as an examee, they need to be simple to use. They need to be not buried in two inches of other material, but off to a different side of that material. And it's truly both the drugs, their cutoffs, the specimen validity testing, to some degree, some of what Donna teaches in the collections. Those are fairly simple multi-choice questions, or potentially, with one or two real obvious maybes, or a red herring. So you can't do anything but have some memory of those numbers. You can't be taking the test and looking for them. I mean, that's not gonna help you at all, not in 110 questions in three hours. It's not gonna help you. So although we say, ideally, you shouldn't memorize stuff, you should, you know, and use it, but in the exam, I'm sorry, you know, you have to memorize it. I mean, everybody has been a medical student, and I used to teach medical students, and I always said, take the exam and dump the disc. I mean, the days of CDs, not the days of what we got today. I mean, it's truly a memory question, but keep it close to you if you're doing the testing online, and then you'll probably be able to go through the toxicology questions pretty quickly and move on to something that might be a little bit more contentious, like MRO and some of the DOT rules. Yeah, to back that up, memorizing the things that Mike is just talking about are going to help you with a lot of other questions. So you need to know what are the 14 analytes that are on the federal panel, you know, so that when you get a question then about, you know, interpretation of a particular test result, a DOT test result that is reported positive for fentanyl at whatever, well, guess what? Do we test for fentanyl on a DOT test? No, right? So, I mean, so that kind of thing is very important for you to know. So you need to know those analytes. You need to know screen and confirmation. You got to memorize those values like Mike just said, because again, when you get a question that says it was reported, a DOT test was reported positive, you know, at a given quantitation, and you know that that is below the confirmatory cutoff level, then again, you know, you are going to have your response to what you do as an MRO is going to be very different. So memorizing the analytes, memorizing the screen and confirmation values, memorizing the three basic criteria for specimen validity testing. What are those pH numbers that mean it's going to be adulterated or invalid? What are those numbers for creatinine that's going to distinguish between dilute and substituted and requiring a recollection for what Kent and I talk about the hyper dilute. What are those values? Same thing with specific gravity. What are those values? And so again, having those memorized, if you want to have the charts, yes, to be for, oh, did I memorize? You know, did I remember that correctly? You see a question that has a specific gravity value that you think, wait a minute, that wasn't one that I memorized. So where does that fall? But I think those are key because you'll find a lot of questions that deal with one of those three things from a laboratory perspective. And always from a laboratory, the toxicology, you do need to know for, again, for some of the other interpretive questions from Mike's presentation of what drugs metabolize to what other drugs. Does codeine go to morphine or morphine go to codeine? Does it go both ways? Again, those are the kinds of things that you need to memorize. So I'm gonna take a totally different approach and that is talk about it from a test taker's point of view. I learned to take tests in high school and it got me well through college and medical school. So if you've got 110 questions in three hours, you're clearly going to have to be aware of time and patient yourself. What I would do is to have a piece of paper that has the number of the question. And as I go through questions, the ones that I feel that I am totally confident in, I'm gonna cross off those numbers so that as I go through, I know the ones that I feel confident about my answers and I don't need to go back. The ones that I don't know, I'm going to leave them blank and I may write a couple of comments. But if there's five possible answers and I know that there's one right answer, then I know that there are four distractors or detractors. Those are answers that may have some appeal that people will be drawn to initially, but they're clearly the wrong answer. So when I go through a written test, I cross through all the answers that I know are wrong. And if I can take five questions and narrow them down to two, then I'm getting better and better in terms of my odds. So if I've got the sheet in front of me and it's question 13, I may say A or C question mark, meaning I don't know which of those two it is. Then I will keep on going through the other questions. And here's where MROCC is my greatest friend because they don't want to do it. But the truth is that if I look at other questions, those other questions often give me the right answer to a previous question that I didn't know the answer. So I can get a lot of help from reading the other questions. And when something rings a bell, I'll go back to that question of A or C and I can often answer that because I got information from another question. So deliberately excluding the wrong answers helps you boil down the pot and you can often get clues from other questions. When it comes down to that timing and you've answered 90 questions and you've got 30 minutes left, that's when you're gonna have to decide what do I ignore and what do I really think I can get a good answer? And as Chris says, the multiple right answer questions and they're clearly stated, mark all that apply. Those are the ones where if you had to not be able to answer everything, I would agree with her, leave those until last. But the simple way that you go about answering the question is very helpful. Shifting gears, when we put together the course and the syllabus, we faculty had to decide what do we think out of the entire part 40 and out of everything else we've read, what are the most important things to know? And if you really study this syllabus carefully, I don't think Donna or Mike or I have put anything in the syllabus that we did not think was important. At one point, I even say, I'm gonna give you a lot of data, it's interesting, but you don't need to know the answers. And that's for example, the prevalence of the use of different drugs. But we have done our best to distill what we think are the most important elements. So that's another thing. So as an MRO, I'm not gonna go back and forth to the syllabus as often as I am to the regs. It's really important since DOT part 40 is the gold standard to treat it as a friend and get to know it well. Whenever there are internet forums with questions and answers, the person who gives the best answer always goes to DOT part 40. They identify the section of the regulation which contains the specific guidance. And that's what you will be relying on if you get to be a better and a better and a better MRO. So you're gonna go directly to, in this case, what you could call the Bible. You're gonna go to that regulation and it's written in a very readable, understandable fashion. So between the syllabus and really having gotten to know part 40, those are the things that you're gonna use as an MRO. So you're really not just studying for the exam, you're preparing yourself to function effectively as an MRO when you don't know the right answer. And knowing how to go to where to go in part 40, knowing where to go in the syllabus, I have found that to be very, very helpful. So that's a different approach. It's more of a test taking and study habit approach than it is what to memorize. Chris, I know you have short time. What additional guidance would you give? Well, the other thing that I would point out is that on the website, on our website, under exam preparation, there's another section called navigating the exam. I would recommend you look at that. There are actual images of the exam pages that show you where the navigation buttons are because there is, you can flag questions and then it shows you how to figure out which ones you flag. So it would definitely take the five minutes to go through those screenshots. That will save you a lot of time on the exam and help you function better while you're going through the exam. Good, and there are also sample questions. There used to be 12 sample questions. I think there are now 11 on the current webpage. And again, the more practice questions you go through, the better you'll do. That's why Donna and Mike and I spent a lot of time developing multiple choice questions for you to do after you go through the sections of the course. They weren't psychometrically validated. They aren't perfect because we're not the, Mike and I are not writing questions for the exam. But once you can translate the basic information into sort of multiple choice language and you can use your mind to think about multiple choices, then you'll be in the groove to be able to quickly go through and master the exam. Any final comments, Donna or Mike? I don't have any. Good, okay, well, Chris, thank you very much. I'm gonna go back and I'm gonna share my screen for just a minute. Bye, Chris. Bye, Chris. Okay, in the actual syllabus, there was one page and it's in the very first segment about how to prepare for the exam. And it says, review carefully each faculty presentation. So we have given you what we think are the most important things. And occasionally there'll be a last page presentation in the syllabus that's called additional materials. And those are often checklists. For example, in Dr. Pete's presentation, there'll be lists of chemicals and what medications they appear in. And those are things that you really do need to study very, very diligently. I would again suggest you study the syllabus and the additional documents. Pay attention to the self-assessment questions. And if you don't think they're right, if you have a question about the question, write to us or bring those up in our monthly discussions. We haven't had a question about them in over a year, but if you have a question about the self-assessment questions, please feel free to bring them forward. And finally, there is very useful information in the MRO resource manual. And that is not essential information for the exam, but if you've gone through it and you see what's there, I'll give you one example. Every state has different laws that pertain to drug use and drug testing and what employers may and may not do. And Donna has summarized and updated as of 2022, the chart covering each of the states. That's not in the syllabus, it's in the resource manual and that's available online. And that's something I think that's so valuable that you should probably print it out and keep it available to you when you're functioning as an MRO. So those are my final suggestions on how to prepare for the exam. I just wanna go back and make a couple comments about oral fluid testing. I think from the collector's point of view, it means the collector has to now be trained twice, first in urine collection and then in oral fluid collection. But when somebody cannot provide an adequate sample of urine on the first try, it is so much easier to shift to an oral fluid test and not have people sitting around drinking water, watching them, making sure that they're not going outside where they can't be in sight. And I think that from the collector's point of view, it's gonna be a great relief. From an MRO's point of view, you're also gonna have a cheer of relief talking to Dr. Martin and the MRO section of ACOM. The doctors have said they could hardly wait for when oral fluid testing was permitted. And finally, from an employer's point of view, employers know that somebody who regularly uses marijuana could test positive for weeks after having used marijuana. And if the concern is fitness for duty and workplace safety, the oral fluid by testing directly for THC has a shorter window of detection. And for many employers, they may feel like that gives them some comfort, particularly if they're in a state which is allowing recreational marijuana, but they are sticking to their guns and saying we will not tolerate active users of marijuana because we think it's a safety concern. So there's many different points of view, and this will definitely be interesting as it rolls out. When, if ever, Mike, will we see hair testing added as the third legally and commonly practiced part of the federal testing program? Let's just say it's gonna be a long while. I mean, I think hair is by far a more difficult specimen to address than oral fluid because the tendency is to compare new specimens with what you've got. And what you've got is urine. Oral fluid is somewhat similar. It's a fluid. You can collect it fairly easily, et cetera. Hair is a very different specimen. It's not even in the same category. And you can include fingernails and toenails if you want in that too because they're becoming somewhat prevalent. So it's gonna be a while before you see hair testing implemented. I heard rumors that there was some proposed regulations going to be published, but I've not seen that. So apart from what was published almost 10 years ago now. So I just think it's a different specimen gonna have to be addressed differently. So Michael, we have a couple of Q and A's about oral fluid testing, and I just wanna read them to you. The first says, it is so easy to cheat oral tests and they don't reflect body burden of a substance. For example, THC is not well secreted into saliva. Now that sounds like a misunderstanding. Essentially, isn't it true that we are simply measuring THC resin on oral surfaces and oral testing is not good for meth or benzos? So do you wanna help address that question? Well, where do you want me to start? Let me first say that neither urine or fluid or any of the specimens we test today reflect body burden. None of those specimens reflect body burden. I don't know of a specimen you could argue today that you could test today. I mean, certainly if you can get body fat specimens, you might be able to reflect body burden, but that's not practical. So that's first thing. Number two, what you test for in oral fluid, the drugs get into oral fluid two different ways. They get there by being left in oral fluid after use, and they get there by passage from the bloodstream into saliva, which depends upon a number of factors, including plasma protein binding. Now for THC, it is very, very heavily plasma protein bound. So if you looked at that as being a representation of what you see in oral fluid, it's a very low concentration, but THC is also incredibly lipid soluble. I mean, just incredibly lipid soluble. I mean, it has a volume distribution that is immense compared to other drugs. And what you are testing for, therefore, is THC in the buccal cavity lipid cells in which it is stored. And it's stored probably not as THC, more correctly as fatty acids bound to THC. So although we can certainly say the detection window may be shorter, the cutoffs we use today in urine, detection windows are not what people think they are. They're not, they're just not weeks, they're days. So, you know, I don't think there's too much difference between the two. And we have very little data on long-term use and detection of THC in oral fluid. And the only data we have, I think, is one paper by Marilyn Hustis and coworkers who's, Marilyn is heavily relied upon in the tea, in the marijuana testing field. And they get some, you know, interesting results. They don't get, you know, 14 hours or whatever, they get interesting results. So I think we've got a lot of data together and I wouldn't come to the conclusion that oral fluid is not a good specimen for THC. I just wouldn't come to that conclusion. But I remember, Michael, one of your slides in the oral fluid section of the syllabus that shows that comparing oral fluid to urine testing, the percent is higher for oral fluids than it is for urine. Yeah, but in that slide, the percentage of THC positives, you're comparing THC in oral fluid with THC acid in urine, and you do get similar detection windows, but they're not as long as THC acid in urine. But you've got to remember, you know, at 50 nanograms per mil screen and 15 confirmation, you're artificially restricting that window in urine for THC acid. Now, methamphetamine, on the other hand, all all the basic drugs, the weekly basic drugs in particular, cross well from serum blood into all fluid. I mean, you know, there are, it's just because because of the Henderson-Haspelbach equation, they cross well because they go into the ionized form at those pHs and cross back. So they are routinely detected in all fluid and they have been for a number of years. Benzodiazepines are very much a neutral compound that they're somewhat lipid soluble too. But you know, when people use benzodiazepines, the dose is pretty, pretty high. So the blood concentrations and plasma concentrations are pretty high compared to some other drugs we deal with. And they move back fairly quickly into all fluid. All fluid is a specimen that's used in drug impairment monitoring programs. And benzodiazepines are important in those programs. And most of the labs that do that work do it well and can detect most of the common benzodiazepines. So Donna, I want to ask you to comment as well. But there's an additional component. The question was asked, is there information about potential infection of testers? For example, when doing oral testing, is there an infection risk? Any knowledge or thoughts about that? Or any comments on what Dr. Peet was talking about? Well, I think in response to the first thing, one of the beauties of how workplace oral fluid testing and oral fluid testing under the DOT, the new DOT rules and collection procedures, is that the collector is essentially an observer of the process, does not handle the swab, does not handle in any way. So the exposure is certainly minimal. So, you know, the collection devices is unwrapped. The donor takes a stick, puts it in their mouth, waits for the volume indicator to, you know, to show that there's sufficient oral fluid, then the donor puts that into the vial with the buffer solution, and caps the tube. So I would say that there's, you know, very minimal risk of infection transfer. Mike, do you want to add to that at all? Well, no, there is not a risk, given the processes we use. And I think we need to remember that what is in saliva from an infectious disease point of view, are antibodies. They're not antigens, they're antibodies. And, you know, I know of no bacterial transmission from oral fluid. And you got to also remember that clinical labs have tested oral fluid for decades. And they take the appropriate precautions, obviously, as we all would, and should. But I know of no reports of transmission of disease through contact with oral fluid at all. Now, I'm sure somebody's going to come up with one somewhere back when, but I, you know, it's not a routine problem. It might have been a bigger concern during the active phase of COVID than now. Mike, I've got a question from the Danielle said, submitted, she said, I'm getting a lot of questions about fentanyl, and whether or not we should be adding that to the drug testing panel. Does anyone within the federal regulation body think we should be doing it? What's the best way to What's the best way to respond to that particular concern? Well, I'm going to let Donna answer from a regulatory point of view. But which fentanyl are you talking about? There's 70 out there today. And they're very difficult to detect. Low dose, the structures change quickly. And can be, you know, even the labs that synthesize it in Mexico can change those structures. And, you know, it's not that easy to detect in urine or fluid because they differ so quickly. And secondly, there's such low dose. And certainly, that's what the Department of Transportation and the Department of Health and Human Services found out approximately, it's been almost two years ago when they were really taking a look at adding fentanyl, you know, to the federal panel. And, you know, as quickly as they were determined and work with the labs in terms of methods by mass spec to identify the fentanyl that was out there, there were then seven more that were very different and that would require. And so it became, quite frankly, the cat and mouse game that Mike and I are very familiar with from sports testing. I mean, in the Olympic laboratories that Mike and I have worked with in those kinds of sports testing laboratories over the years, over the decades, as soon as we would develop methods and validate them for detecting a particular type of anabolic steroid, for example, or precursor to an anabolic steroid or erythropoietin for blood doping or whatever it was, then the chemists who were getting paid a lot more than Mike Peet was getting paid, right, would develop another version. And so it was just, you know, we were always totally behind the eight ball. And I think that's what the feds came to with regard to fentanyl. You might not know, is that being too... No, I think it's an appropriate comment. And I think, you know, there are very, not complicated, but there are high resolution mass spec procedures that can take a drop of urine and develop fentanyl panel for 25 to 30 drugs, fentanyls. And, you know, 10 of those will change probably within the next year or so, some will remain the same. But every time you make a change to a method like that, just to add another drug, take a drug off, the strict certification requirements of the NLCP say you have to go back and revalidate that method. And that's a complicated procedure. And that brings expense to the program, and probably for very little benefit, because when you look at the DEA data, for fentanyl seizures on the street, it's still primarily fentanyl, you know, 70% of it's fentanyl. And then there's a whole load of others. And these others are the ones that are probably more potent than fentanyl, if you can believe that, and therefore more deadly. So it, the labs in this business shouldn't be coming should not become a DEA lab, quote unquote, doing urine specimens, it needs to be focused on urine, and the drugs that people routinely detect. And I'm going to say this in the workplace, because fentanyls are a street population problem today. And sometimes it's an impaired physician, but they're probably not a problem in the transportation sector. In the in the non federally regulated, private sector testing, Donna, is anyone including fentanyl in their drug panels? Very, very few, at least at Workforce QA, very, very few. The last question that I've gotten that was typed in, into chat has to do with marijuana testing. And the question was, who's teaching this course? And are we really drilling down into the nuances of marijuana reporting, and particularly in states where it's legal, and with regard to CBD? I guess I guess I have some mixed comments about that. But I think we should all close tonight by talking about that. I think where this course is very clear, and very strong is the federal regulations and the federal interpretation of a positive test for THC. And there's no murkiness about that. There's not a lot of nuances. And it's very important for every MRO to recognize that, and to be willing to report something as verified as a positive, if it's under federal regulations. What I say in the MRO section, is that if you're dealing with non federally regulated testing, you really have to rely heavily on your employer, your service, you're a servant agent of the employer, and you have to rely on the server on the employer's policies, their procedures and their regulations. But as an MRO, I am strongly inclined to report a positive test as a positive, and let the employer deal with the issue of whether they're going to accept that or not. I know some are some MROs try to evaluate whether the positive test represented a potentially reasonable use of CBD or marijuana for the condition that the individual reported. I think that is not something that we should as MROs be doing. So I don't think we want to get into the nuances. Dr. Martin has had a lot of experience with this. And he may talk more about that as he joins our faculty. But I think we're strong in the federal regulations. And we rely heavily on what employers want their service agent to report in the non federally regulated area. What else would you add to that, Mike, you teach a lot about CD CBD oil. And again, you say, CBD oil may not under federal guidance, be allowable as a legitimate explanation, right? Right. Right. Well, they're not allowable. It's not may not they're not. Yeah. I mean, I think that the work that's being done with THC, CBD, and the other cannabinoids forget the cannabinoid mimetics, but the other cannabinoids, I think is some important stuff going on there in terms of therapy, and use and pharmacodynamics, etc. But do t and the federal government have been very clear that if you have a positive marijuana metabolite finding reported from the lab, and there's no medical explanation of which is only a limited number. It's a positive, you know, just move on, get on with your life and your day. Yeah, I think it is important to stress that under dot, or the other federal regulations, Nuclear Regulatory Commission, or the HHS guidelines for the testing of federal employees. The only acceptable medical explanation that a medical review officer can use to, to, to downgrade, if you will, a laboratory confirmed positive for THC, or THCA, depending on the specimen, is a prescription, a validated prescription for Marinol, or Dronabinol, or for Sativex. Nothing else at this point, nothing else can be an acceptable medical explanation, not a medical marijuana card, not a prescription written for marijuana, or a recommendation or whatever. So, and I'd also like to point out because I do get a lot of questions from medical review officers that, well, if the state allows medical marijuana, and if the state where the test was done, this is again, a non-regulated test, allows adult cannabis use, isn't the MRO duty bound to report those as negative? And the answer is no. I have done more than I care to remember okay, in terms of looking at at the language in, in the 37 states that have some form of marijuana use provisions and nowhere, nowhere is the medical review officer mentioned as the person who is making a decision. It's all on the employer. And when you look at the 22 states that have some restrictions on either testing for marijuana, or what an employer can do with a marijuana positive test, again, as Kent said, it is on the employer. Now, each medical review officer practice or can make their own decision about what they want to report to the employers. We at Workforce QA have taken the approach for non-regulated testing, that we are not going to attempt to validate a medical marijuana card, we will report to the employer that the individual claims that they have medical marijuana status in Oklahoma, or that they have a medical marijuana card from Virginia, or that they purchased marijuana legally in the District of Columbia, and that they're over the age of 21. But we report that as a positive test. And then any validation or any decision about whether they accept that for purposes of continued employment or for hiring a person is up to the employer. One comment, and then I'm going to suggest that we do the poll. So don't go until Danielle has given you the two poll questions. But our addiction, our addiction medicine specialist, Dr. Jennifer Souders made the comment that in forensic work, she sees a lot of positive fentanyl tests. But it's true that many users of illicit fentanyl combine the fentanyl with stimulants. So even though the fentanyl is not tested for, hopefully the other substances, the stimulant substances are detected, and will raise the proper concerns. Or benzodiazepines, we find a lot of that in our, you know, and or xylosine. Yes, correct. Correct. I mean, yeah, forensic toxicology lab is probably testing for a lot of those stimulants, and a lot of the benzodiazepines. But a drug testing lab, I would question whether they would have as broad a menu as that. Yeah. Good. So Danielle, tell us about the poll, how you're going to do it, and what we all need to know and how to do it. Okay. So I will post, there's going to be two poll questions. The first poll question is to determine, do we like this webinar format for the MRO monthly discussions? Or do you prefer the meeting format where everybody can be actively seen and ask their questions live? And it's just, I'll leave the poll open for probably about a minute or so. Please place your vote, and then we'll gauge our next meeting based on the responses to that. So let me launch the poll. Everyone should see it on their screen. Is that where they get to vote? I don't believe that it allows faculty to vote. Sometimes it does, and sometimes it doesn't. I was actually going to do the Chicago system. I pressed one of them contestedly for the next minute. Well, we have 15 participants and the vote may be 100 to 4. That's the Chicago method. All right. As of right now, it looks like the preferred method, even before I end the poll, is the webinar format that we're currently using. So thank you, everybody, for your feedback. We will take that into consideration and we'll follow up. I'll follow up with Drs. Peterson, Peete, and Smith. So let me end that poll. So what's your second question? Our second poll question for this evening is our monthly discussions. So we do record these monthly discussions, and they're posted to the MRO course itself. And what we are asking our learners tonight is, how long do you want these to remain there? Should we go six months back? I'm sorry, should they remain there for six months, 12 months, 18 months, or two years? So when should we archive stuff? And when should we kind of move things forward? So it's just picking which one, how long do you think things should remain in there? So that's active on the website? Correct. Correct. Because right now we have 32 months worth of MRO discussions on there. So we just don't want to, we want in in the interest of streamlining things, what is a good time frame? I'm just curious, Danielle, while people are voting, is there any way that those are indexed or searchable? So if I wanted to look and find out if in an MRO discussion, there was a discussion of fentanyl, for example, or there was a discussion of, I don't know, contamination and external contamination in hair testing, would I be able to do that? Or would I have to go through all 32? So they are in chronological order, what and that might be an outstanding suggestion moving forward, Dr. Smith is, it does not list what the topics are that are covered in there. So that may be something moving forward that we could include in there. This MRO discussion covered a, b, c, and d. I can, I can see it now. AECOM is going to buy GBT for chat. Chat GBT, it's going to apply AI to analyze our previous discussions, and to search for whatever keywords are asked in the question. So, okay, so I will end our poll and 50% said 18 months is a good time frame. That was the number one answer. So I can share the results with everyone. Excellent. It's popping up. Good. Well, I think this is all for answering that. This is probably enough for tonight. Thank you, Danielle, for stepping in so wonderfully, in the place of Heather Hodge. Thank you, Michael, for surviving the heat and being here with us. Thank you, Donna, for not mentioning baseball once this whole evening. How are the Rays doing, Donna? Well, they've had, they're still on top, but they didn't do well toward the last five games, if you will. But both of our But both of our players did very well in the All-Star game. So okay. And I guess they were kind of like Fox, whatever, who probably who broadcast the All-Star game must have been related to Kent Peterson, because of all 32 teams, the one team that the announcers forgot to announce on the the runway coming out was the Tampa Bay Rays. They went right from the Seattle Mariners to the Texas Rangers. No, I think you called it in, Kent. Dr. Smith. Dr. Saunders said to tell you she was at the All-Star game yesterday. Oh, I'm so jealous. Really? So did she see Yandy hit the home run? Yes. She hasn't responded just yet. Yes, she did. Yes. They there's more than one baseball fan in MRO land, Kent. All right, there you go. Well, there's at least two. I will end with a bad pun next month when we gather together. It will be an august occasion. Oh, my God. All right. Bye, y'all. Thanks. Bye, everybody, everyone.

MRO online faculty discussion

occupational and environmental medicine

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ACOM Learning Center

MRO course syllabus

DOT oral fluid testing

MROCC exam preparation

fentanyl in drug testing panel

compliance with federal regulations

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