Hello, everyone, and welcome to tonight's MRO monthly discussion call with our faculty. We're just going to give everyone just a few more minutes to hop on. Looks like we have about nine attendees that have joined us so far, and they're still coming along in. While we wait for everyone to join us, I'm going to kick it off to Dr. Kent Peterson, who will be able to do a brief welcome intro, and then we'll go ahead and get started. As a reminder, while we are discussing, we're here to answer your questions. So whatever questions you have, feel free to either chat those in the chat box, the Q&A box, and we'll go ahead and facilitate those. If you do have a question and you really want to raise your hand to ask verbally, feel free to do so. I can allow to take you off mute if that's something that you're interested in. So welcome today. My name is Nikki Hoffman. I am ACOM's staff liaison for this evening. So if you have any other questions for me, feel free to reach out. So welcome, Dr. Peterson. I'm going to kick it over to you. All right. All right. And Doug, I'm going to kick it over to you because you're now the head honcho for MRO training. Yeah. So welcome, everybody. I'll take on to what Nikki has just said. We really appreciate your attendance and your commitment to education for medical review officers. And of course, we do this to provide a forum for continuing your training. The faculty that are involved in MRO training, of course, understand that this is a continuous process just because you go to a course doesn't mean your education stops there. Not only do you, but also the faculty continue to learn things as we go forward. So welcome, everybody. I hope everybody's NCAA bracket turned out the way that you originally planned. I was in one pool that I did pick the national champion correctly. And I won a very small amount of money that probably will get me through a car wash and that's about it. But that's okay. At least there was something positive that came out of that. So I'll go ahead and turn this over to Dr. Smith and Dr. Peterson, who have an important follow up to a question that was posed back in February that I think is worth a review of everybody that's on the Zoom tonight. I'm going to share my screen and take away the Buddha. So first of all, I want to announce that the MRO comprehensive live course is going to take place in May, just a few weeks from now in Orlando at the American Occupational Health Conference. And you'll see some of the same faculty there as here, Dr. Martin will be leading that course. And I'm bringing it up because in the past, some of the people who have registered and paid the money to take the online course have asked if they might be allowed to sit in on the comprehensive course. The syllabus is very similar. There will be a few updates to that syllabus. But if there are available seats, and you want to do that, I would encourage you to get a hold of Nikki. And Nikki, you might want to put your email address in the chat as well. So that's one thing. Similarly, the MROCC, which Chris is the executive director of, publishes a periodic newsletter. And she has already posted tonight into the chat, the latest edition. And that's a very worthwhile newsletter. And I recommend that you copy that and make sure that you add that to your reading. Now with regard to tests, we did get a long question, which I divided into two. And the first deals with canceled tests. The question related to tab 6.9, slide 18. And so I have recopied that here. And you see it's about correctable flaws. The MRO must require a signed statement of correction from the individual committing the error. And if they're not corrected, the MRO must cancel the test if the flaw is not corrected. And that pertains to the first five bullets. However, unlike the other five, the MRO must request a statement of correction. That is, they request a statement, but they don't cancel the test if the statement is not available. And that has to do with the specimen temperature. So the person asking the question says, the statements appear to be contradictory. The MRO must cancel the test if it's not corrected. But they don't have to cancel it if the specimen temperature is not checked. So that seems to be contradictory. He has said that he assumes this applies only to the temperature, but asks again, are there other correctable flaws where you don't have to cancel the test if there's no signed statement of correction? And Donna, you can take us through the answer. OK. So what I provided, and I did give the references to the sections in Part 40, Sections 203 and Section 208. And Dr. Schwartz is correct. His assumption that the condition of not having to cancel the test if a corrective statement is not received applies only to the correctable flaw of temperature box not checked and no remark on the CCF. And so if that is the case, then you simply report the result as is. And you do not cancel that test. All the other correctable flaws, as Kent showed you on that slide, do require a statement of correction from the collector, the laboratory, or the employer or other appropriate third party. And if you, as the medical review officer, did not receive a copy of that statement of correction, then you must cancel the test. I do want to make kind of a practical clarification here. With regard to when a CCF is received at the laboratory where the specimen temperature box was not checked, in other words, it wasn't checked yes or wasn't checked no, the laboratory procedure requires the laboratory to contact the collector and ask them, you forgot to check this, was the temperature within range, yes, or was the temperature not in range for this specimen collection? They must wait five days to see if they get a statement of correction from the collector. And if they do not, then they are going to report it out. They've run the test. They're going to report it out to you, the medical review officer. So in reality, the specimen temperature not checked, there has already been an attempt to get a statement about that fact by the laboratory. And so there's really nothing in Part 40 that would require you as the medical review officer to go and do that again. Is that making sense? That you would not be required to do that. So you could simply report out that test result. Thank you, Donna. Now, the second part of this same person's question, I started on a new page and it relates to creatinine and specific gravity and a table that is found in tab 38, slide 75. I remember Donna and me putting this together with great care because there was a lot of confusion among our students with regard to creatinine and specific gravity. And I think this slide is helpful, but in this case, it's a little confusing. Now, Donna, if you want, you could take us through the whole slide and then we could go to the specific question. Do you want to do that? Well, I don't know whether how helpful that will be other than to show that there are with specimen validity testing and the first of all, the laboratory is all is going to report the creatinine and the specific gravity value on any test where they are reporting it as negative or as substituted or as in balance. So you will always have the actual value of the creatinine or of the specific gravity. Now, the one that is perhaps the most confusing is the third band here. And that, by the way, applies only to Department of Transportation drug testing. It does not apply to Nuclear Regulatory Commission or to HHS federal employee testing. So it's kind of an outlier, if you will, that the Department of Transportation put this particular category, a second category, if you will, of a negative dilute. So if the creatinine, remember now, in order for it to be a dilute, the creatinine had to be less than 1.003, but greater than 1.001. Why is that greater than 1.001? Because that's the demarcation on specific gravity, that it's either going to be substituted or it's going to be invalid because that specific gravity value is not consistent, if you will, with a freshly voided human specimen. So that's what you need to remember, is that if you're getting a negative dilute where the creatinine is identified as 2 to 5, the assumption you need to make is that that specific gravity value is 1.001 up to 1.003. And that's the circumstance. You do not interview the employee. You simply will direct the medical, excuse me, the employer, the designated employer representative, that this test must be recollected under direct observation. So you don't cancel it. The rule doesn't really say what you do with it. It just simply says that you essentially say negative dilute creatinine 2 to 5 must recollect under direct observation. And then the other ones that are there, the invalids, where it has to do with creatinine and specific gravity, are where they are inconsistent. So where you've got the creatinine value that meets the substitution criteria, that is, it's less than 2 milligrams, and you have specific gravity that is greater than the demarcation for substitution at 1.001 and less than 1.020, which would also be a substitution criteria for specific gravity. And then you have an inconsistent one where you've got greater than the substitution cutoff, if you will, for creatinine, that is, it's equal to or greater than 2 milligrams. However, the specific gravity is less than or greater than 1.001, again, the substitution cutoff, if you will, for specific gravity. There's not an easy way to learn this other than to keep this chart there and just refer to it. I mean, MROs that I work with that do hundreds of these literally a week or whatever, and they get one of these, which is, you know, one out of 500 or whatever, they have to look it up also, you know, because it's not intuitive, to be honest with you. Mike, do you want to add anything there? No, I just think I would stress that these are very, very rare. These are not something that you need to worry about this table apart from when you're taking the test. Yeah. You know, they're very, very, very rare. Yeah. So have it near you when you're taking the exam and, you know, print it out and keep it in your little reference stuff or whatever once you start doing these results so that when you get one of these, ah, OK, I can pull out the table and do the greater than, less than, et cetera. You know, Donna, one of the things that you said here, I think, is maybe worth reiterating just from a practical standpoint with regards to the negative dilute where you're in that 2 to 5 milligrams creatinine level and you have to do the direct observation. You're exactly right. There really is no specific instructions as to what an MRO is supposed to do with the quote, unquote, result of that first test. And this leads to a problem in those software programs that many of us MROs use that mandate that we come up with a determination. Yes. Yeah. And I don't... Yeah. We try to use not reportable or... Yes. But man, that gets people so upset. It does. And it creates all kinds of consternation and yelling and screaming about software programmers and all kinds of things. But it is something that's worth reiterating. I do not know if there ever will be a clarification on that or not, but it probably would be worth to try to push for that because I know that has come up before. Yes. And my practical advice on that is that substitution requires two criteria to be met. So I raise both of my hands. If one of them is met and the other one is not met, that's inconsistent with substitution. And that is then an invalid. If one but not both are present, that simply is invalid. It is not consistent with substitution. It's darn near substitution and those are the ones that are invalid. But regardless of that, you don't get that far down the chart. If it's two to five and it's a DOT, then you are going to have mandatory recollection. So what I did was to turn that into a question. And Donna, you may have given the answer above, but why don't you see if there's anything else in your written answer that we should cover? So basically, I just tried to get the citation from the Part 40, which talks about both the two to five negative dilute, if you will, and then the invalid that involves a creatinine or specific gravity that is at or below the substitution criteria. So if the creatinine is two to five and the specific gravity is greater than 1.001, less than 1.030, then the MRO must order a recollection of a specimen under direct observation. Whether that's a pre-employment test, whether that's a random test, even if that is a post-accident test, it does not matter. There has to be another test done under direct observation. So if the creatinine is greater than two and the specific gravity is less than or equal to 1.001, again, the specific gravity substitution criteria, then the specimen is going to report that as invalid. In that case, you would interview the donor, which you must do for any invalid test result that is reported to you on a federal specimen, and you would end up canceling the test. Now, if there is a medical explanation for this inconsistency in the creatinine and specific gravity values, then you would not order a recollection under direct observation. I don't think I've ever seen one of those. Dr. Martin, have you? Have you seen a medical condition that has... I have not. I have done, I don't know how many interviews of people in this scenario, and I've never been able to find anything that makes any medical sense. Right. Okay. So then that means that probably close to 100% of these invalids for inconsistent creatinine and specific gravity are going to be determined by the MRO as a canceled test and with a requirement for a recollection under direct observation. So, the last part of what you've written is only for those... That's only for a regular collection, but if you've got a 2 to 5 and a specific gravity, you're going to order a recollection and not go further. Yes. Yes. Yeah. Because I was trying to answer his question, which is, yeah, right. Yeah, right. Right. So, I should have separated those out. Yeah. Well, thank you very much. You can see why I thought these were relevant to our discussion for students who are learning the intricacies of being an MRO. So, that's the only set of questions for tonight, and I'm going to take it back to you, Doug, for whatever comes next. Yeah. So, there's two things in the Q&A. One is just a hi from New Zealand. Hi back. I have no clue what time it is there. It's got to be some ungodly hour. So, what a dedicated person to join us. And then the second one, the second is a question, is an employee with an active CDL has a no driving, loading the truck, not driving the truck accident. Okay. And needs to have a urine drug test requested by his employer. What kind of drug test should he have, DOT or a non-DOT? I want to make sure I'm understanding this correctly. I'm assuming that this is like a back strain kind of a thing where the person is doing manual labor, but are they doing this in the course of their operation of the CDL? I don't know the answer to that. It doesn't matter, Dr. Martin, really. They're operating under a safety-sensitive function, so they qualify. But the criteria for whether you do a DOT post-accident test is what? He had to be operating the vehicle and have an accident in which there was injury or physical damage to a vehicle requiring towing, disabling damage, requiring towing from the scene. And the driver was cited for a moving violation. So, I don't see how here, since the injury was not from a crash, right? It was from unloading. Is that right? Well, that's how I'm interpreting it. Now, maybe I'm not interpreting it correctly, but yes. So, apparently, if I'm understanding this right, the need to have the urine drug test, I think, and maybe I'm not getting this right, I think it's probably because of some other company policy, like just a regular old post-accident, you know, non-federal whatever kind of injury, whatever it might be. Yeah. Yeah. Yeah. I think that's what I'm understanding. So, and Dr. King has followed up with, yes. So, I think we must have that one down correctly. So, the answer is, what kind of a test is it? It's non-DOT. Okay. Next question. I have a non-DOT urine drug screen question. Okay. I am an MRO for a large hospital system. I apologize about that. I used to do that. It's not easy. And we have many corporate accounts. Ah, this sounds familiar. I reviewed a positive non-DOT urine drug screening for amphetamines on a new hire from corporate account. After the MRO review, the donor had a legitimate prescription of Adderall prescribed August 2017, about six years and eight months ago. I told her she should not be taking a medication that old. She said she takes them infrequently. Okay. As her MRO, I determined her urine drug is, I think that means negative. I don't know if there's a question there. Perhaps, oh, there's more to it. Sorry. Urine drug test is negative because she has a legitimate prescription. Am I correct? Is there specific rules for old prescriptions or expired prescriptions and DOT standards? The corporate account prefers I use DOT standards for their non-DOT urine drug screens. Okay. So this is a question about the age old problem of, is there such a thing as a too old of a prescription? And the question- What's that, Ken? Not that question. There are great debates. There are tremendous debates that have been had amongst medical review officers as to what that is. And some people will use DEA, FDA references that suggest that, you know, things got to be within a year. Some people would use other types of things, maybe their state regulations that might say that or not say that. To my knowledge, DOT has never taken an official position on how old is a prescription, even though I think many of us would like to have had DOT take a position on that. The scenario as I read it, I think opens up another question now is, is a legitimate prescription for Adderall correct in the context that this person is taking it? So, I think that we probably need more information. One thing as an MRO that I oftentimes do when I run into this scenario is I try to get a hold of the prescribing physician and try to get an understanding. Is this the way the medication has actually been prescribed for the individual? Is it intended to be used as a PRN type medication? What is the situation here? Now, is that like, you know, it's set in stone someplace? No, it's not set in stone anywhere, but it helps me understand quote-unquote the legitimacy of this. Now, the other part about this, this is interesting, is that we've been told here from Dr. Joseph that this is a non-DOT drug screen. So, I'm going to always tip my hat to the statement that I am famous for saying is you have to understand the rules of the game in order to play. So, if you have a state law or some other statute that might be in play here, you have to understand what that is. And we don't know the information about the jurisdiction or the rules or any of that sort of thing in this situation. So, those things might come into play as well. Other comments, Dr. Peterson? One other comment. I was asked this question so many times that I finally wrote an article in the MROCC newsletter about that very question. And I went into the FDA and the DEA and DOT comments. DOT does have a statement. And what they said is they're not going to take a position on it because they're deferring to FDA. So, an FDA would not or DEA would not take a position either. So, the answer that they came up with from DOT is to say unless you have a, and if it was a prescription in your name, then you will not be found to be positive for that. That is, it is a legitimate explanation. DOT is not happy about it. You know, gentlemen, I think this needs to go back to what Adderall is used for. Right? There is no way PRN use of Adderall is authorized for treating attention deficit syndrome. It's just not a use of amphetamine. So, irrespective of the age of the prescription, if somebody's using Adderall for PRN, forget it. I mean, that's not a viable prescription. Yeah. Again, if I could just be the non-physician regulator here. Okay. And I think that DOT did spend a lot of time in the preamble to the final rule, the opiate expansion rule in 2017 discussing this very issue. And now I recognize that they were oftentimes discussing that in the context of the opioid drugs, which are often PRN. Okay. Medications. That's number one. But in talking with Patrice Kelly and others over the years since then, which now we're, what, seven years from now, I guess, or 17. Yeah. Right. The out that ODAPSE feels that is available to the medical review officer is if they really question the legitimacy of them having this medication from seven years and not having to have it refilled or whatever, or if they can are concerned as, as Michael has pointed out that the, it is, it's not really a medically authorized use of the medication and therefore is a misuse or abuse. What deal, what ODAPSE has said is that what you do as the MRO is you put a safety concern. You verify it as negative because it is a prescription in the person's name and was lawfully dispensed according, you know, what, what Kent had mentioned. And however, if you feel that it is not being used appropriately, or there is real concern about it, particularly from a safety perspective, safety, safety, sensitive perspective. And don't forget DOT, that's all they can, they care about because that's the only kind of employees that, you know, they are dealing with. They're not dealing with non-safety sensitive categories. And so what their recommendation would be is to put a safety concern. Now, what good does that do? Well, what that means then is that the employer has to resolve that. And so the person is going to have to get a statement from the prescribing physician, just like Dr. Martin is talking about, or if it's a CDL holder, got to go back to the, the medical examiner in terms of whether or not they should be qualified for driving while taking a seven-year-old prescription once a year or once whatever for, of Adderall. So the safety concern is the valve, if you will, that ODAPC has presented for this dilemma. Is it a great one? No, but I just thought I would throw that out from a regulatory standpoint. If you were, go ahead. No, no, I have a, I have a related question for our toxicology experts, Dr. Pete and Dr. Constantino, which I don't know the answer to without going and looking it up. Does the concentration of amphetamine in an Adderall pill dissipate over six years and eight months? I don't think the, I don't think the drug company would have that data for six years and eight months in environmental conditions that might be natural to, you know, a patient. I think there's certainly, you certainly, you can imagine it might, and you can imagine that it might not. I mean, it's, it's amphetamine hydrochloride, it's pretty stable. Yeah, yeah. Good deal. Okay. Anything else about that? The one other thing to consider is that amphetamine is not a benign drug. And if you are naive and you take a full dose, that's going to have a much bigger effect than somebody taking it for ADD. And that may well affect behavior. So I agree with Donna. I think the safety card is the one I would use in this case. And it puts us back to the employer. And that's where it should be. So we have another one, Doug. Okay. Yeah, this is, this is one that I, I admittedly know nothing about. I'm sure it, I'm not sure if this has been discussed already. Can anyone link with me about experiences using impairment apps as part of a fitness for work toolbox? I'd like to investigate the use of technologies to establish impairment in New Zealand. Happy to speak here. You know, dare I say that I do have myself involved in fitness for duty determinations. And, you know, where, where the fitness for work oftentimes is coming up in my world now is this whole THC issue in states that, you know, have recreational marijuana and all these types of in states that, you know, have recreational marijuana and all these types of things. Everybody's looking for the magic, magic box, the magic cube, the magic formula, the magic wand. I don't know what else you want to call it. That's going to give us the answers to whether somebody can go to work or not go to work. I don't know of anyone that's actually held up under any legal review. Yeah. You know, it's, it's a continuous thing that people are trying to search for an answer. I don't know anything about apps as to what, what they do or what they're intended to do. I assume there are probably some, you know, hand-eye coordination type of things or reaction time or, you know, something along those lines, whether they're statistically valid, scientific valid. I do not know the answer to those questions. If, if, if any of us knew the answer to those questions, we could get a Nobel prize. Well, it's not, you know, alcohol, of course, is an exception, but without alcohol, there have been attempts to link quote unquote, impairing effects of THC to divided attention tasks. And there's been studies to that end in drivers and non-drivers. None of those, as far as I know, have been successful. You don't have that straight division between, you know, 0.08 and impairment that you have in alcohol to a blood concentration of THC or breath concentration of THC. And I think, you know, that I don't see how they're going to do that actually, because that's a very difficult task to achieve. And there was a paper in clinical chemistry not too long ago that looked at saliva, as well as blood and urine cannabinoid concentrations and couldn't find any data to support impairing concentrations, like the 0.08 in alcohol, they couldn't find data to match that. So I don't see anything happening that way, but there are a lot of companies playing here. Because of the issue you raised, which is, you know, legal THC and illegal THC and everything else that's going on. So, but today there's been nothing. And I quite honestly, I just don't believe given the complexities of cannabinoids in the body that that's going to be achieved. And there's too much tolerance and too much everything else that goes on in the opioid field and amphetamine field to even begin that discussion. So Nikki Hoffman, Dr. O'Bailey would like to speak. Can you make it possible for her to be heard live? Yes. Can you please, Dr. O'Bailey, will you please raise your hand and I will go ahead and take you off mute. Give me one moment here. There you are. Welcome, Dr. O'Bailey. You should be able to unmute and ask your question. Hello, I absolutely love these meetings. I think they're fabulous. And I always come out of them very inspired that you can still do ethical and professional medical work and do the right thing at the right time and do a good job and not be influenced by the agendas of other people like employers or workers or regulators or whoever. I find the concept of apps really interesting because I think we've all experienced the bad apps in the mining industry where people could easily cheat. And then we've been put off by them. But I wonder whether because of new technology and AI and all this stuff, they're actually, they might be getting better and there might be the opportunity to use apps not by themselves, but as part of our toolbox for Fitness for Work. And there's a lot of American stuff going on and particularly a company called Druid, D-R-U-I-D, which has been trying to sell this in New Zealand. And so my idea was that I could take 10 of the companies that I deal with and get a bunch of workers and actually test these out alongside our normal alcohol and drug procedures, what we normally do and just put these apps in alongside, like whenever there's a critical event, do the drug test, but also do the app. And after about three months, just collect the data and see, did it align? Was it interesting? Was it useful? What were the problems? And all of those kinds of things. And maybe even, you know, New Zealand could be a trailblazer in terms of all the legal stuff as well. I've been talking to the lawyers and they're saying it sounds really interesting. So that's what I wanted to say. And I wanted to kind of, if there's anybody that's had an experience of this in the United States, I'd love to talk to them. I personally don't know anybody who's doing that sort of work, Dr. Overlie. You know, I'm an editor of a journal and increasingly scientific journals deal with statistical power. You know, when you do anything, you could have enough statistical power to find a true difference that makes a difference, so to put it. Yeah, I hear you. That would be my only caution on doing a study, you know, with an app is that you somehow have to figure out how that is gonna be statistically valid. And in New Zealand, when you want to do some university-based research, you have to come up with $200,000 to pay the university to do your research, which I don't have. And I don't think my employers would really pay that much. So I'm not particularly sure how legitimate this would be. And maybe I'll end up doing something kind of a little bit more cheap and nasty, but still at least provocative. So watch the space. I think it's really interesting to think about the viability of using technology to capture those real intangible and personalized impairment hazards and risks in real time. Yep. As I said, if we could figure out that, holy grail. Well, you know, keep going. Tuesday night. Thank you so much. Thank you. It was probably 10 years ago that I looked into this and there was a group in Texas that was developing what they thought was a valid way to test pilots. So they were specifically looking at pilots and it was a software program with questions and they thought it had great validity. I looked at it and I thought it was very questionable. And at that time, it was clear that a technical solution beyond a laboratory test, you know, would definitely be the holy grail. But I haven't even seen studies or data in the last 10 years that people have been pursuing this. Have you Mike or Tony? Well, yeah, there's people pursuing it. And I mean, because it's funded by a lot of small companies trying to find the holy grail. But I have seen no papers or publications or presentations have solved that issue. I just, it's, you know, I wouldn't want to experiment, you know, traveling 100,000 miles a year, I wouldn't want to experiment with airlines. I would think that's not a good thing to do. The other problem with even designing a study like that is, you know, I can tell you from a medical perspective, people probably wouldn't pass the darn thing if they're taking too much cold medicine or other over the counter combinations that they shouldn't be taking. Yeah. So what, I mean, where are we going? Are we going to draw the line in the sand here, here, someplace else? I, you know, that becomes difficult for sure. Yes, yes. Thank you very much for your comments. Even if I, even if I prove that it's just rubbish. The U.S., several jurisdictions in the U.S. have what they call drug recognition experts. And you probably have heard that term and may have read some literature on it. Now, when somebody, and Tony can pipe in here too, when somebody gets charged with a driving under offense under THC, for example, the court hears evidence from the lab that there's presence, of course, of THC in the system, not THCA necessarily, but the metabolite, but THC, the parent compound, that the driver was impaired as observed by the patrol officers prior to the stop. And then thirdly, that the drug recognition expert that interviews that driver once he's been arrested, he or she has been arrested for various signs of cannabinoid use or other drug use. And generally when cases go to court, they have all three of those parameters available to the court. Yeah, exactly. Fascinating. And it starts with the field sobriety test. Yeah. Right. So if there's a standardized field sobriety test in the breathalyzer, does it indicate impairment from alcohol? Then the drug recognition expert will be brought to the arrested individual and they'll take certain measurements. They'll do additional field sobriety type tests. They'll measure pupil size, heart rate, blood pressure, reaction time, things like that. None of which will be really useful in a employment setting. And we don't do blood tests. Okay. Very good. Thank you. Thank you so much for all of that. That was really useful. Thank you. Oh, you're welcome. Thank you. All right. I don't see anything else in the chat or the Q&A bubble. So Nikki, I think we might be okay. Yeah, it looks like that's all the questions that we have for this evening. If anybody does have another question, I did put my email or educationinfo.acom.org email in the chat box. So feel free to connect with me and I can get your questions passed along to our faculty and either we can get a response in email or maybe we'll address it on our next monthly call. With AOHC, this is just a friendly reminder with AOHC being so close to the next call in May, we will not have a monthly discussion, but we will reconvene in June. So thank you to all of our faculty for being here this evening. Again, if anybody has questions, feel free to reach out. My name is Nikki Hoffman. And does anybody have any other final words? Dr. Martin, if I could take just maybe two minutes to kind of my role has been here to keep everybody up to date on what's happening with the whole marijuana state, you know, legislation. Please do. If you don't mind, there are four states that in late 2003 and becoming effective in 2003 or early 2024, 2003 and 2024 that have legalized for adult use cannabis. And those are Ohio, Minnesota, Delaware, and what am I missing? Let's see here. There's one other one. Jeez, I don't have my notes. Well, California and Washington. And so if I can quickly mention what they, what the impact they will have. It doesn't affect DOT testing, but it does affect employers who are testing for marijuana in those states for non-DOT employees. So Minnesota, as you might expect has the most protection so that anyone who is using cannabis, whether it's for medical purposes or for recreational purposes or just for the heck of it. Okay. In Minnesota now you cannot do a pre-employment or other drug tests for cannabis or cannabis metabolites unless the individual is in a safety sensitive position. And they identify a number of things that they consider safety sensitive to include positions in healthcare, direct patient care, direct care of children, as well as the obvious firefighters, police officers, first responders and driving vehicles and operating machinery. So that's something to be aware of for Minnesota. Ohio, also on a, Ohio got tired of the legislature not approving. Recreational marijuana or adult use cannabis. So they went with a, an amendment or an action on the state's ballot was approved. 57% to something like 43 or whatever percent no. And so Ohio now also has adult use cannabis and as does, as does Delaware. However, neither of those states have the kind of employment or marijuana testing prohibitions or restrictions that I just mentioned for Minnesota. California and Washington effective January 1st of this year in the state of Washington, you cannot test for a non-psychoactive metabolite of marijuana or cannabis, which would be THCA. Certainly you can, however, continue to test for the psychoactive metabolite or the psychoactive component of cannabis, which is THC. And that applies only to pre-employment testing in the state of Washington. And there are exemptions again for safety sensitive and other, other positions. California, the ban on testing for a non-psychoactive metabolite applies to all forms of drug testing in California. There are no exceptions for, there are very few exceptions I should say. One of them, interestingly enough though is the, is the building and construction trades which I think is interesting. You can still test for marijuana metabolites the non-psychoactive metabolites. What this means realistically for California and for Washington is that you could do an oral fluid test for cannabis because the oral fluid metabolite that is identified and confirmed is THC, the psychoactive component. You could not do a urine test for cannabis because every urine test I know of is THCA. I don't know, Tony, are there any labs that are doing THC confirmation on urine and not THCA? Yeah, they're doing both. They have to gear up for the, for the federal reg. So they are, they're still screening for THCA but they are adding THC to the confirmation. Most are putting both in their confirmation tests. And so when it's reported out though aren't they still reporting it out as THCA? I haven't seen anything come through as reporting it out for THC. If they're testing for THC and they find it they'll report it. Tony, you sure? Boy, that's news to me. Yeah, that's not that big news to me actually. You're talking about oral fluid, correct? No, we're talking, we're talking, well, Donna was talking about urine, but even oral- Oh, urine, I'm sorry. I thought you were talking about oral fluid. No, urine I was talking about. No, no, and urine, no, no one's testing, right? I get it now. So no one's testing for THC in urine. Okay, so, so oral fluid and likewise with hair and nail the analyte that is reported is THCA. Am I correct, Tony and Mike? Yeah, yeah, you're correct. Yes. Okay, so what that means- Some labs, some labs, of course, let's step it up here. Hair is not approved by DOT or HHS for testing. So this is totally non- But this only applies to non-DOT testing anyway in terms of the prohibitions in California and Washington. Yeah, some labs who do hair will report more, they'll report other metabolites of THC, but it's, they're all non-psychoactive metabolites. So basically for your, for non-DOT testing in California and Washington now, beginning in January of 2004, if you want to test for marijuana on an employment test in Washington for pre-employment, in California for any type, you would need to use oral fluid testing rather than urine or hair testing. Yeah, but- That's the simplest way to put that. And I think people need to be a little cautious because of the ability of labs to detect THC at one or two nanograms per mil, it's certainly varied. It's not an easy test to do. Agreed. On oral fluid, you're talking about? Yeah, on oral fluid, on oral fluid. Okay, maybe that was more confusing than it was helpful, Doug, but I wanted to at least put it out there. It's a measure of how complicated the non-regulated testing of marijuana specimens, non-regulated employees, et cetera, for marijuana, it's a measure of how complicated it has become and will become until the federal government approves. Yeah, well, and Kent will probably echo what I'm about ready to say. So many employers that I interact with that do non-DOT drug testing simply have quit testing for it. Yeah. And when I told- They put their hands up and say, we're done, it's not worth our time, our effort, our money, our legal fees, and all this other kind of stuff to try to fight it, so let's just not even test it anymore. Yeah, if you look at the Quest Drug Testing Index for oil fluid, with the speed of approval of marijuana use in the States, that the use of THC, detection of THC acid in oil fluid, and the number of people testing oil fluid for marijuana has dropped precipitously. Yeah. The employees aren't testing for it. Yeah. They're not testing for it. Okay. And are we finding more safety issues? No. I think you're probably too early to say there, because we know this is the last year to two years. Safety issues in the workplace will probably take five years to show up. Right. I don't know what the statistical power that's needed there, Dr. Overlie, but I'll try to find it for you. Thank you. Thank you. All right, very good. Thanks, everybody. Thanks, Nikki. Take care, everybody. Take care. Have a wonderful evening. Bye. Bye, guys.

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