Welcome to those who are joining us. The numbers are going up, so I'm going to wait just a little longer. But I can go ahead and get us started. I'm Dr. Kent Peterson, the course director for the online MRO course. And I am surrounded by the most wonderful team in the world. This is the 11th faculty meeting of this year. So welcome to the November meeting. I think you know all of us, so we don't need to do introductions. I'm the physician member of the faculty team. Donna Smith is a person who covers so many different subjects and knows them all well. Dr. Pete is our forensic toxicologist. And we've got a number of questions focused on his area of expertise tonight. Chris Paciak is the executive director of MROCC. And I'm sure there will be questions for her because all of our teaching efforts ultimately culminate in our students taking the MRO examination. And we couldn't do any of this without Danielle Feinberg, who's our ACOM support person. Every time I turn around, you have a new title. But I think at this point, you're the manager of not only e-learning, but you're the manager of education. So thank you for being here on an evening. I know you're preparing for a whole three-day symposium later, so you're probably on overwhelm right now. But thank you so much for being here. And tonight, you're going to be running a poll. So our numbers are up to 18. So there's 13 students as well as us. And I am going to share my screen. And I have a few announcements to make. I think this will be a busy night. There's a crowded agenda. And I think we may go for an hour and a half. So let me share my screen, and we will move ahead fairly quickly. So first of all, a few announcements. A week ago, we held a two-day live MRO course at the ACOM Learning Center. It was sold out. I'm sure we would have had more than the 44 who registered if there had been more space. And Chris administered with her assistant. And Chris administered with her assistant a MRCC exam on Sunday afternoon. And I think the course tried to do a lot by taking a two-day course and compressing it into a little over a day and a half. But we had a very appreciative audience. And it was the first time we taught live since April. The second announcement is that there will be another live course at the American Occupational Health Conference next May in Orlando. And at that meeting, our new course director, Douglas Martin, will be leading a faculty. And this may be the transition meeting where we see some of the old faculty and also are trying on new members of the faculty. So that will be coming up in May. Since we last met a month ago, SAMHSA has made a request for public comments. And the topic is the possible addition of fentanyl and norefentanyl to the federal drug panel. Obviously, this is the focus of the overdose death epidemic due to synthetic opioids. But the question is, should it be added as part of the routine federal panel? Comments are due no later than January 4th. And I just want to stop right here and ask Mike and Donna if you have any preliminary thoughts about the pros and cons of adding fentanyl to the federal panel. Well, it's obviously just to the HHS panel. DOT, obviously, will have to come behind when HHS decides to add it. You know, I often tell the tale of the East German sports doctors. And somewhat akin to that, there are all sorts of fentanyls out there. I mean, probably 15 to 20 or more out there. They're very easy to synthesize. So I understand the purpose of deterrent. You know, people will switch to a different fentanyl if they're going to use fentanyl. So that's my two penny worth on it. I'll let Donna chime in. With some discussions with folks in the industry over the past week since this announcement came out, there's some real concern about what impact this will have on the laboratories and, again, the availability of fentanyl assays and for doing the initial screening, whether that is by some form of immunoassay or whether that is through mass spectrometry screening. So I think it is not likely that we would perhaps see this added to the panel as nimbly or quickly as one might think. So it wouldn't surprise me that this will be at least a year in coming. And I think that Mike is right. We are likely to be in the scenario where, yes, we might have some impact with deterrents and perhaps detection with fentanyl. But because of the cumbersome actions that are needed in order to be able to cover all the synthetics or a portion of the synthetics, again, through screening assays that have to go through FDA clearance and then separate validation, it's, I don't think, going to be the panacea that people might think. And I would add that I don't think of fentanyl as a commonly, regularly used drug of abuse. It's not something people take routinely to abuse. It's more often taken unknowingly and in large doses. And often, it's mixed with other drugs. So I don't see that addressing a common workplace drug of abuse. But we will see what comes out of that. A fourth announcement, the DOT has been this year releasing a set of what they call back to basics for MROs and other service agents. And the particular June issue was called back to basics for MROs. One page summary, some of the questions that come to the DOT, some of the practical issues that occur. And because this particular month was focused on MROs, I wanted to give you the link to that. My fifth announcement is that the MROCC has recently published another version of their newsletter. I put the link in there because it's a wonderful newsletter. And Chris, you may want to comment on that if you wish. I can't hear you, Chris. Okay, finally. Yes, we did just release a newsletter that did include some additional information on the June updates that came out. The previous edition, which you also have access to, has really good summary about those updates as well. We are expecting to have another newsletter released before the end of the year, and hopefully we'll have some information about the SAMHSA proposal in that newsletter when it comes out. Good, thank you. And the last announcement is that we have been having these monthly online discussions since I think August or September of 2020. We've been doing them on Wednesday nights, and there's a possibility of a change of the day of the week. One of the reasons is that Dr. Martin, who's joining our faculty, has another commitment on Wednesday nights. So we wanted to ask you all, I know that you're simply a harbinger of our larger group of 790 MROs who've taken our course, but we wanted to ask you to complete a poll, and Danielle has put that together. And why don't we conduct that right now, Danielle? Okay. So the question is, which of the following weeknights would you be able to attend the monthly faculty discussions? And you can check one, two, or three of these. The current one is Wednesday, and we've added Tuesday and Thursday. So why don't we give you about 30 seconds to answer that question, and let's see where we end up. I have not polled the other faculty. I don't know if there are other blockout dates, but I wanted to ask you, the learners, as well as our faculty, so that we would be able to. Well, I'm a little confused, Kent. If you said that Dr. Martin can't do Wednesdays, why are we putting that as an option? Well, I just want to know what our audience would like. We, it's possible we could continue, but I'm hoping that Tuesday or Thursday will turn out okay. Now, we, the panelists, cannot vote, so. So we should have 14 potential people who can give us their answers, and it's possible that Danielle would conduct a larger poll to our whole audience of students. Okay, I am going to end the poll, and it will capture the information. So Tuesday and Wednesday seem to be, Wednesday is the highest option, Tuesday being the secondary, so I will end the poll. Okay. And then, yes, I can absolutely reach out to our registrants, so if you received this, an email with this information, again, please forgive me for sending it, but I will just send out a quick one-question survey to our MRO attendees to say, if you attend the course or the discussion, what day would be better? If Doug is unable to do Wednesday, and he's gonna become the course director, I don't know why Wednesday's on the choices. I agree. I mean, I just, that doesn't make any sense at all. Do you want me to just list Tuesday and Thursday? Tuesday, Thursday, or any other day of the year. Okay. All right, let that be. So now let us go on to questions that have been submitted, and the first one, I would appreciate comments from both you, Mike, and you, Donna. It's about a positive urine drug screen for codeine. I had a patient with a positive pre-employment urine drug screen. It doesn't say whether it was federal or non-federal. She is very persistent that she did not take anything that had this, that is, that had codeine in it, and I reviewed her medication list to confirm. She states she had no poppy seed use and no other pain meds. She requested a retest, so that would be a split. Her retest shows codeine, but it was not, there was not done at a certain level, so it was present above the limit of detection. The initial test results show as well as you can see that she was positive for amphetamine. There's no mention of that, so I'm assuming she was on Adderall or another drug for which there was a legitimate prescription. You'll see that it was positive for codeine. The reference range is up to 900. I mean, up to 300, and the codeine was listed at 729, so that's not terribly high above the cutoff level. She swears she has not taken anything to have caused this. I don't know what it means to say we use MSGC. I guess we use mass spectrometry GC for our send out request to Quest, and so that's the situation. So Mike, maybe you'd like to comment about codeine and then Donna as well. But well, this is not a DOT test. No. A, there's too many drugs, and B, the cutoffs are not DOT screening cutoffs. So I don't know how, for example, the lab could differentiate a positive codeine from a codeine and morphine because both will cross-react in the screening test. So never minding that, to me, there's some issues here. Unless the lab or the MRO talk to the lab certifying scientists, with a codeine of 730 nanograms per mil by mass spectrometry, somebody should have detected morphine. Morphine is the metabolite of codeine. In normal cases, you can say it's gonna be about a third or so of the codeine concentration, which would put it around, you know, 300. And if they're doing a 300 codeine morphine, they should be able to detect that by GC mass spec. So I don't make any sense of this because it doesn't make any sense to me. So I would have recommended in this, the MRO reach out to the lab, talk to the certifying scientists to see if there's any morphine present in that urine, which there should be. And if that was not the case, I really don't have any explanation why you would have no morphine and a positive codeine. Donna, you want to comment? No, I would agree. And the only, if there is some morphine detected below the cutoff of 300, so their limited detection should be, you know, way down around 50 or less, right, Mike, probably? Yes. Wouldn't you say? So, and if there's nothing at all, then although you did do a re-confirmation at Quest who also found or reconfirmed the presence of codeine, I mean, my thought might be, even though she denies poppy seeds, she denies this or whatever, I would think that perhaps there was some incidental or whatever exposure to codeine, perhaps a 2-2-2 or something, you know, over the counter, maybe through a cough syrup that she doesn't, you know, necessarily know that had codeine in it, that it was taken at such a time before there was an opportunity for the metabolism to morphine. But, you know, I would say it was a lab error, except that you got a confirmation of the codeine at a second lab. So it doesn't appear to be an analytical error in terms of there being codeine present in the specimen. But this is the problem that, I mean, I see all the time with the professional health monitoring programs that do codeine and morphine at a hundred, even, nanogram cutoffs for confirmation. And there's just so much extraneous reason that that could be, even, you know, in terms of contamination of various things that are pretty innocuous that we don't have any answers for them. So Donna, what about the 15,000 cutoff level that if the codeine or the morphine is below 15,000 and there's no explanation, that that's not verified as a positive? Well, that's due for a DOT test, but this isn't a DOT test. It's not a DOT test. Right, so this is in the non-regulated arena, but I would think that that guidance would guide me as an MRO, and I would have verified that as a negative. I'm not impressed that this is likely to be a violation of company drug policy. But again, it depends on what the policy is, and we don't know that from the employer. But this is a problem because codeine is available over the counter in cough medicines, cough syrups, and many other products, particularly things that have multiple ingredients. Now, here's a second question that was submitted during the month. It's a frequently asked question, and I think it's worth considering, and that is the use by MROs of the many different state prescription drug monitoring programs. So the simple question is, can MROs use these monitoring databases? It's a natural instinct. It's a useful resource. The problem is the answer is absolutely and definitively no. The state's licensing boards that put these together, SAMHSA and DOT have all explicitly said that as service agents for an employer in an administrative role, we are not authorized to use this, which is a clinical database intended to be used by prescribing physicians for monitoring their patients. So it's tempting, it's appealing. Every MRO asked the question, but the answer, I think, is very clearly no. And I think to add to that, Kent, that this further under, this is really underpinned by the assertion that DOT and HHS have had from the beginning that as a medical review officer, you are not in any way engaged in a doctor-patient relationship. So if they come off of that for this, you see, then that presents a whole bunch of other issues with regard to what this role is. So it makes sense as to why that would be the position, in my opinion, of the Department of Transportation and HHS, et cetera. Good. Now I want to move into a third question that came up, and this is a fairly long set of communications back and forth between Dr. Charlotte and Dr. Smith. And so we have basically four different episodes, if you want to say. First, let's take the question. Yesterday, his staff did a federal drug screen collection. So this is a federal collection. On a bus driver, it was a post-accident collection. The donor attempted to give a urine sample three attempts in three hours. She never reached the right amount of urine. The donor admits that they don't have any bladder problems, and therefore, according to the regulations, they would have had a shy bladder and it would be a refusal to test. However, now we come to the reality of collectors, which is, as we've said, is the weakest link in the chain. Unfortunately, the urine collector is new, and the same donor came back to our clinic in the afternoon. After a few hours, the urine collector gave the donor another chance and did another urine collection in the afternoon. The donor was successful in providing an adequate amount of urine sample, which was sent to the lab. So there are no further details, as Dr. Smith will get into. Do I just tell the employer the screw-up? Do I disregard the second urine collection? The results are still pending for the second urine collection. So Donna, you deal regularly with all the screw-ups of collectors. You train collectors, you know the things they do wrong. Do you want to run through your answer to this? Sure. I asked for a few more details, first of all, before I responded specifically to the medical review officer in this case. But I asked, was the DER notified when the bus driver was unable to provide the specimen in the three hours of the first collection event? I don't think that they were. There was an assumption made that because she did not give what they considered an adequate, acceptable specimen, which we'll get to in just a little bit, okay, because there's another caveat to that line, that it was an automatic refusal to test because she said that she didn't have any bladder problems or she didn't have whatever. That is not true. You can't make a determination on a shy bladder scenario where they waited three hours and they did not collect a, without going to the shy bladder examination. The fact that if you ask the person, well, do you have any bladder problems? And they say, not that I know of, that's not enough to declare that a refusal to test. So that was number one, okay? And that's why I ask that if there was a shy bladder examination that was completed by a physician, that's the question number two. And I make that point that you can't go to a refusal to test without that examination and that the findings of that examination being provided to the medical review officer, if that physician says, I find no physiological medical condition that would preclude the individual from providing an adequate specimen in three hours, given the opportunity to hydrate with at least 40 ounces of water, then and only then can the medical review officer declare this a refusal to test. And I then asked some questions about the second collection event, although I don't know why I even asked that because it really isn't material. But anyway, and I asked if it was done on a federal form, was there a second CCF done? And was there any mention of the earlier shy bladder event on that CCF in the remarks section? And then I said that if the second collection specimen is reported as positive adulterate or substitute and it is verified as such, it should be reported to the employer. If the second collection specimen is reported as negative, it should not be reported to the employer. The result for the post-accident test will be either refusal to test based on the shy bladder examination, for the inability to provide a sufficient specimen or test canceled if the shy bladder exam findings support a medical explanation. But as it turns out, none of this was true. So now we have to go to the next part. Okay, so then the MRO comes back and says that it turns out that the donor in their three attempts in the three hours did urinate. And presumably, and again, I'm assuming something here, that they did produce 45 mLs of urine. However, they had diarrhea at the same time and the specimen was contaminated with fecal matter apparently. So that's why the collector would not send any of those specimens or a specimen to the laboratory. And so she then said that she allowed the donor to clean up and to come back after the diarrhea resolved, which happened to be in this case on the same day. And then that urine specimen was apparently collected without any problems. And it came back as negative dilute with a creatinine of 11. Now, again, federal test, I'm assuming that negative dilute meant that it obviously had creatinine less than 11 and it must've had specific gravity less than 1.003. And he says, since you need a definitive result for a post-accident, we will ask her to come in again. No, no, no, you don't ask her to come in again. A negative dilute is a definitive result. Okay, it's not a canceled test. It is a negative dilute. So then he goes on to say that the medical director and the senior MRO created a local clinic standing order to allow a donor to come back if having diarrhea and cancel the test and let them come back the same day or after the illness resolves or stabilize. We will not do a shy bladder workup, which is a good thing because there wasn't a shy bladder. And we will not interpret the first test as a refusal to test. So then I set a urine specimen that is provided even if it is quote contaminated with feces or blood should be sent to the laboratory. The laboratory in almost all cases, and I'll defer here to Mike too because he's got a lot of experience on the lab side, will test the specimen. If the biological contaminants make it impossible to get a valid result, it will be reported to the MRO as invalid. The MRO would cancel the test in that case if it's reported as invalid. And the medical explanation for that, I assume, again, after talking with a certifying scientist would be because of the diarrhea or because of menstruation or because of hematuria. And that is the end of it for a post-accident test. The event is a canceled test. You do not recollect a canceled post-accident test when there is a medical explanation for the invalidity. You only have to do another collection when you have a canceled test if it is a pre-employment. Why is that? Because what do you need in order to hire the person under DOT? You have to have a negative pre-employment test, which you don't have. You have a cancel. The other circumstance where you would have the person come back if you have canceled this invalid test because of a medical explanation, you would for a return to duty or for a follow-up test because the same thing is true. You have to have a negative DOT return to duty in order to allow the person to resume performing safety-sensitive duties. And you have to have a negative on any follow-up tests so that they can continue to perform safety-sensitive functions. All right. And I said that there is no provision in the rule to have the donor return hours later or the next day for another collection attempt. And I said that the negative dilute results on the collection that in this scenario, which was admittedly pretty messed up, should be accepted as the final result if the employer's policy states that all negative dilutes will be recollected, which the DOT rule allows, that based on the employer's policy, if you get a negative dilute on any kind of test, whether that's a post-accident or pre-employment or random, you can collect another specimen that's not under direct observation. And if that second specimen is also negative dilute, that's the final result. So this is a real dive into the real world of issues and problems that occur at the collection site. None of these are MRO decisions. These are collector decisions, whether this is what they're going to permit. However, if there has been a shy bladder evaluation, that determination would be done by the MRO based on getting a report from the physician that did the shy bladder evaluation. Now, we seem to have had this month a run on shy bladder. So this is a short and sweet question that came from a different MRO. How do you handle a situation where a shy bladder protocol yields a negative dilute? First attempt was insufficient volume. How common is this? So I answered that and said, see Dr. Smith's response above. It's so simple and so clear and straightforward. If the employer's policy states that all negative dilute tests will be recollected, then and only then should this donor have to provide another specimen. But it's a negative dilute. It's not going to be recollected under direct observation. Unfortunately, this happens all too often because if somebody comes in, they could not provide an adequate volume. You load them up with water. You give them several hours to make sure their bladder is full. Very frequently, the second collection will be dilute, but that's the way it happens. And that's why oral fluid testing is really a refreshing alternative to the shy bladder situation. So we've had two questions this month. I'm not sure when we have had ones about shy bladder. So I'd like to shift now to a question that came up from another student, and this is for you, Michael. The student was really very diligent in going through the syllabus and going through the videos and was concerned about the Q&As in the toxicology section. So I have brought up the questions in the toxicology section, the self-assessment questions. I want to put that on the big screen and ask you to go through the four questions. Here, you see the questions, and at the end, the answer will reveal itself. But why don't you take us through that however you wish, Michael. Well, there's only one of those five answers that's correct here. I mean, morphine and 6-AM are both metabolites of heroin. Heroin is diacetylmorphine, and 6-AM is conclusive proof of heroin use. It does not arise in urine from any other drug or any other metabolism pathway. And morphine is then a metabolism of 6-AM, metabolite of 6-AM. So this is clearly B. Okay, good. And we can ask if there's any questions after we've been through all four of those. The next is 46. Well, there's a little trick in here, but heroin is metabolized to the following. We talked about 6-AM or 6-monoacetylmorphine, and morphine just now. Morphine glucuronide is a metabolite of morphine, and codeine is not a metabolite of any of those drugs listed in A through D. And as I said, diacetylmorphine is heroin, and therefore, in the sort of game examination people might play, diacetylmorphine is not applicable because it is the parent drug here. Okay. So those are the three metabolites. Okay. Didraxin, if you're taking the exam, you probably should find the addendum, whatever appendix, or the table in the Bob Glutinsky book, which lists parent drugs and the drugs that they metabolize to in the DOT HHS programs. Didraxin is benzephetamine, and actually is quite widely used, not a lot, but it's certainly used. And benzephetamine will metabolize to methamphetamine and amphetamine, and of course, they will be reported as positive in the DOT test. And norebenzephetamine is another metabolite of benzephetamine and is not detected in the DOT programs. Okay, you've got a morphine of 20,000, hydromorphone at 1,500. Donor denies use of hydromorphone, but presents valid MS cotton prescription, says it only takes it in the evenings of bedtime. 6M is negative. MRO would report this as. Hydromorphone, when there's high concentrations of morphine in a urine specimen, hydromorphone can also be present up to 10 to 15% of the concentration of the morphine. So you can see in here that that 1,500 nanograms per mil is about five or so percent of the morphine concentration. So it could be present in the urine specimen because of morphine use, and therefore given the prescription of morphine, this is a negative report. Okay, so those are the four questions on the toxicology section. They may be challenging to you as students because most of our questions had one right answer. And these are all the more difficult questions which have multiple right answers. But they're difficult because they challenge you to really understand the metabolic pathways of the different drugs. And for that reason, I think these are great questions and they really point you to studying and focusing on this until you really feel confident with it. So if there's any chats or Q&As about that, I'm open to have us talk about it. I'm gonna look and just see what there is. I see some other questions, but are there any comments about this particular one? I don't see that. So if that's the case, let me move on to the remaining questions that were submitted in advance. We're almost ready to handle then your questions from tonight. This is a case that came up in an oral fluid case study. So it was an oral fluid sample. It came back positive for amphetamine and methamphetamine. There was a verbal history from the donor. And you can see that they gave a long list of medications. That's not unusual that people will name everything that they might possibly think of. In addition, the neighbor gave him a pain fill for a toothache, and that's frequently the case that they take someone else's medication, but she denies use of illicit methamphetamines. So the MRO question is, would I request an enantiomer testing of this oral fluid? So you may ask yourself, what is enantiomer testing? If she had pseudoephedrine in one of her medicines, would that explain the result? So Dr. Pete, I'll again, turn this over to you. Well, an enantiomer, methamphetamine and amphetamine would exist in both a D and an L isomeric form. And there are reports in the literature and the common press and all the TV camera stations, that pseudoephedrine and ephedrine may metabolize to methamphetamine. Pseudoephedrine, after all, has been purchased in quantities in the past simply to prepare methamphetamine. There is a rule in the DOT arena that if you have methamphetamine in the urine, you must also detect amphetamine, the metabolite. So they're both present here, which would tell me that that's methamphetamine because methamphetamine from pseudoephedrine synthesis is not, does not metabolize to amphetamine. That does not happen simply because the methamphetamine in these cases is formed in the analytical mass spec procedure and not in the body. So if you have large amounts of pseudoephedrine, then in the analysis that some of that pseudoephedrine, very small quantities, could be converted to methamphetamine. And the separation of the enantiomers, the DNL form is commonly done because L-methamphetamine or L-desoxyephedrine is Vick's inhaler. And Vick's inhaler is a decongestion, a very good one actually. And certainly use of large amounts of Vick's inhaler could cause a positive methamphetamine. However, that would be present in the urine or in this case, the oral fluid as the L-enantiomer and the drug, the drug of choice from methamphetamine is the D. So DOT says, if it's greater than 80% L, it's a negative result from the MRO because of the possible use of Vick's inhaler. And that would be the case here too. If the predominant amount of the methamphetamine in the oral fluid is the L-isomer, then that would be a negative result. And I certainly would recommend that even in the case of all fluid or urine, that you go ahead and do that separation of D and L. So clearly there's not enough information to resolve this question. And therefore, yes, I would recommend routinely doing a DL separation whenever there's a positive methamphetamine. And that's a recommendation that you Mike made to us early in the teaching of the course. Yeah, it's been around a long time. As we've been around a long time with the course. Okay, I'm going to the chat and I see that a question came up. Can a shy bladder exam be conducted by an APP that is an advanced practice professional, non-MD, non-MO? Donna, do you want to quickly review that? The answer is no. Must be a physician. And by physician, the definition again under DOT rules is someone who has a MD or a DO. Okay. Now that's different than a collection, a recollection for somebody who has a shy bladder. That could clearly be done by a non-MD, non-DO. And it of course has to be someone of the same gender. Now Chris, so the answer is very clear there. Chris, you mentioned in the chat that under exam preparation on your website, you have both a benzodiazepine metabolism chart and an opioid metabolism chart. So those are very, very useful. I think our course material has the opioid metabolism chart. It does not have a benzodiazepine metabolism chart. And so I think that's a very, very useful thing for MROs to be aware of. Warning, benzodiazepine metabolism is far more complex than opiates, opioids, far more. And don't get confused because it's not on the DOT, not including the DOT, and it's not going to be in the MRO certification exam. I presume, Chris, right? Can't answer that. Yeah, I don't think there's any questions on metabolism of benzodiazepines in terms of saying, if the specimen is positive for oxazepam and temazepam, what are the, which of the following drugs could explain that? I don't think there's anything like that, Chris, that I recall. I don't recall anything either, but those charts were put there by the exam committee. After our last meeting, they decided to, but I agree with you. I don't recall anything on the exams. The other point of information, we know there's fentanyl and lots of synthetic fentanyls. We know there's a synthetic methamphetamines and amphetamines all over the place. Benzodiazepines are no exception here. There are a lot of synthetic benzodiazepines out there on the street at this point. So Dr. Pete, you mentioned doing a DNL separation for a positive methamphetamine for urine tests. You just recommended it for oral fluids. A question was asked, would you also recommend it if there's a positive hair test? Yes, I would. Same logic applies. Yeah, and I mean, it's been my experience sometimes in dealing with various hair testing laboratories which shall be unnamed to protect the guilty or the innocent, that they'll say, oh, well, our stuff is only reactive to D-methamphetamine. Let me tell you, you need to get the DNL chiral. And most drug testing laboratories, it's an extremely expensive process to do. So just so you're aware, you've got to stand your ground. Okay, I see a chat question. It has to do with a drug test that is canceled because of an invalid test. And of course, an invalid test means that the laboratory was unable to do a valid test. An invalid test will come to the MRO and the MRO will always cancel the test. The only question is, is it with a explanation in which case a recollection under direct observation is not needed or it will be a cancellation without a valid explanation in which case a recollection under direct observation is required. So the question says the recollection depends on if a negative test result is required. Now, do you want to go into that, Donna? That's not the direction I was thinking of. You know, when a negative test result is required for employment or return to work, then clearly a canceled test is not going to allow them to be hired or return to work. That's correct. So if you have an invalid result and the invalid result is medically or physiologically explained, then the test is canceled. Right. If it is for a random test or for a post-accident test or whatever, that's the end of the road. If it is for a pre-employment or for a return to duty or a follow-up test, then another specimen must be collected but not under direct observation. When there is no medical or physiological explanation for an invalid result, again, the MRO cancels it, but it is always a recollection necessary under direct observation regardless of whether it is a pre-employment, a random, a post-accident, et cetera. So the question is asked, who will determine if the test result is required? It sounds like that is a decision that the employer is responsible for. They'll know if a negative is required for return to work or for employment. Well, you would know. Under DOT, you'll know because it will be on the CCF, whether this is a random test, a post-accident test, or a return to duty test. Right, so we'll know that, but that's ultimately the authority of the employer, right? Or should the MRO be telling the employer what they need to do, when they need a negative test or not? What we do is that we, we mark it as canceled, no recollection necessary unless it is a pre-employment return to duty or follow-up. That's what our standard comment says. So you give guidance, a little guidance to the employer, that makes perfect sense. It's just also easier for us to put that comment on, rather than to make sure that our MRO correctly identifies whether it was a random or whatever test, so we just put that on. Okay, now, Donna, the question asker said, this is for a school bus driver recertification. So that means they need to have a negative test in order to be recertified to drive a school bus. But wait a minute, folks. I think that you're talking about either an Illinois or perhaps another state law that I'm not familiar with, but that's not a federal test. So if the Illinois statute, again, non-federal tests on the school bus driver says that they must have a negative, then yes, you would have to recollect it. And it is in Illinois. It is Illinois? I can't, I'm not reading the chat. Yes, it is. Okay. Yes, it is. Okay. Okay, well, we have gotten through the questions that were submitted during the last month. We did get through your four toxicology questions, Mike, and I think we have covered the questions in the chat and the Q&A. So let's just take a moment, see if there's anything else, any of our panelists want to cover, and a last chance for any of our students to pose a question. And if not, we may actually end before the hour. I just have one other update that wasn't on your list, Kemp, that I think we should put out there. And that is that the Department of Health and Human Services has published a final rule to adjust the confirmation cutoff levels for morphine and codeine. Since we did a couple of morphine and codeine cases today. Oh, yes, yes, yes. Yeah, this is probably pretty germane. So effective February 1st of 2024, for the federal panel, the confirmation cutoff level for morphine will move from 2,000 nanograms per milliliter to 4,000 nanograms per milliliter. The confirmation cutoff for codeine will remain at 2,000 nanograms per milliliter. So again, that is the amending, if you will, or the revision of the HHS mandatory guidelines for urine drug testing in terms of the panel. Now, it will require that the, in order for this to take effect for medical, for DOT testing, it will require a rulemaking. However, because the OTDA Act says that DOT must follow the technical and scientific guidelines, the urine mandatory guidelines for its testing, for its laboratory urine testing, that's a pro forma conforming amendment. It's not gonna be a comment. Now, that in and of itself may not be that striking for you as a medical review officer, but what the HHS revision also does is it does away with that pesky bifurcated paradigm for MRO interpretation of morphine and codeine confirmed positive results. You heard Kent mention about the 15,000, which meant that, which exists now for both HHS testing of federal employees and for DOT testing, that if a confirmed positive result for morphine or for codeine is greater than the current cutoff, but less than 15,000 nanograms, then the medical review officer must have additional information clinical evidence, it's called, that the person has misused or abused either codeine or morphine. We've often called this that 15,000 bifurcated whatever paradigm that this is the poppy seed defense goes all the way up to essentially to 15,000 nanograms. Well, effective with the February 1st rule, that goes away. So now a confirmed positive codeine, 2000 nanograms or more is going to be verified by a medical review officer as positive unless the person has a medical explanation, a prescription for coding medication, some documentation of, for example, coding cough syrup or coding containing a cold and flu medications, et cetera. Or if the person asserts that they use medication, codeine containing medications obtained in Mexico or Canada, then the MRO's responsibility is to be able to validate that that is the case and can make, again, use his or her personal judgment, professional judgment about that. Likewise, the same is true for 4,000 nanograms or greater of morphine. No longer is there any allowance for a poppy seed defense. So if the person does not have a script, for example, for MS content or some other morphine containing medication, then it will be verified as a positive. I'm so sorry. I did not turn off my hand line. It's just my son. So basically you're saying that the poppy seed defense will be eliminated and any level above 4,000 will not be allowed as a poppy seed defense. No, you will have to have a script. I mean, this is just going back in essence to the early 1990s. Yes. Where poppy seed was a big issue at much lower concentrations than 2,000 or 4,000. Yeah, right. If it came back positive. Now, when I talked to the people at Odapsy about this decision about the MRO's interpretation of a positive result, at least preliminarily, the people there told me that they do not feel that OTDA, the Ominous Transmission Employee Testing Act binds them to what HHS has determined about the interpretation of the result. It may bind them to the confirmatory levels so that that will involve a rulemaking to say whether or not DOT is also going to go along with a positive is a positive unless there is a prescribed or medical authorization for it. So I don't know what that means to be honest with you. I will, I expect that there may be a circumstance, although I just can't imagine that they would let that go on where there'll be a difference between what the MRO does for federal employees and for nuclear regulatory testing versus what DOT will do, but we'll have to stay tuned for that. Yeah. So Mike, you've indicated that there are a number of experiments done where people were using poppy seed streusel and they could get up to levels of eight, nine, 10,000. I know those would be extreme. How do you view this is gonna be impacting laboratories once that 4,000 level is put into place? It's gonna be akin to marijuana brownies. The people ingested marijuana in the brownies and didn't know anything about it and triggered the cutoffs. Akin to coca tea where the cocaine positive is from the ingestion of coca tea. In essence, DOT won't care wherever that morphine came from. It is the responsibility of the donor not to go out and have a piece of poppy seed cake or even eat poppy seed bagels for breakfast every day of the month. So it will be interesting to see. I expect that type of claim to come back. Yeah, I would expect this will be a conundrum. Okay. So am I missing any additional chats? If not, I think it's time for us to bring this to a close. I will say that in December, I may be having radiation for my vocal cord cancer, which hopefully will begin very soon. So I will be with you. I hope I will be verbal, but I may not. And in that case, I'll ask Mike or Donna to lead the discussion, and I may be texting or typing instead of talking. So if you've had too much of me tonight, you'll get a chance to have very little of me in December. But thank you all very much. Thank you, Chris, for coming here and for the wonderful newsletter you publish. Danielle, thank you for your steadiness in both live courses and online courses. And I know we'll be making our final update to the online course in the next week or two. Thank you, Mike. Thank you, Donna. You did great jobs teaching in Chicago, and I really am grateful to all of you. Well, Kent, you know that Mike's and mine, especially prayers and our thoughts, our positive vibes and all that are with you, and we are confident that you will, as always, beat the snot out of it, okay, and come out on the other side. Well, I understand for radiation oncologists that x-rays were successful in the early days for two conditions. One was vocal cord cancer, where there's over a 90% cure, and the other was cervical cancer. So this is not new technology. So I'm confident. I'm just not sure what it'll be like to have a sore throat during the Christmas season or a leather neck. I'll understand what that expression means, but this is curable, and I'm looking forward to a long and mean life. Okay, be well. Be well. Thank you all, everyone. Good night.

November faculty meeting

Dr. Kent Peterson

live MRO course

upcoming symposium

fentanyl

urine drug screen

codeine

canceled drug test

toxicology

MRO training