You might want to hold off recording until everybody's in the room or they already in. As soon as I open the room, they instantly come in. So we've got seven people so far. Then we will begin. Welcome, everyone, to Wednesday, October 11. This is our monthly faculty meeting of the MRO online course. We're going to go ahead and begin, but we will probably have some additional people arrive. I think you know all of us. We don't need to introduce ourselves. But this is an unusual event, because for the first time in two years, we do not have any submitted questions. And that is very unusual. We like to ask people to submit questions in advance so we can pull up appropriate slides or references and hone our answers. But this will literally be a live and unprepared evening. And what I think I'm going to begin is offer each of the five resources that you see to speak briefly about anything that they think you might be interested in. I'm going to start with you, Danielle. I know we're doing a live MRO course in Chicago at the ACOM headquarters in October. You told us a moment ago that it is sold out, but that it might be possible, if somebody still wants to register, that there might be one or two spots at the most. Is that right? That is correct, yes. It's October 28th and 29th, which is a Saturday and a Sunday. Registration on Saturday is at 7 AM. And then the course will begin promptly at 7 30, and it goes until about 5 30 or so. Sunday, the course begins, I believe, at 7 30 or 8. And then it goes until 1. And if you complete the course there, you do also have the opportunity to take the MRO exam on site, which will be nice because everything will be fresh in your mind. So like I said, or Dr. Peterson said, excuse me, we do have one or two spots. If you are interested in, please reach out and I'll type in the email below. It'll be my direct contact. And let me know, and we can work to get you to find out if there is space. Good, thank you very much. And thank you for your support in the evenings. We couldn't do this without you. And speaking of the exam, that brings you up, Chris. So why don't you tell us anything people need to know about taking the exam right after the live course? And more importantly, when somebody completes this online course, what do they need to do to then apply for and take the online certification exam? So one thing I would point out is that Danielle does keep us informed of who's registered for on-site courses and who's completed the online course. We will send you information. So do watch for that when you complete the course. For initial certification, both the on-site and online exams are three-hour exams. The on-site is an open book. I mean, the online is an open book. The on-site is not. They are two different exams. They are not the same exam. But both are scored psychometrically. And the level of difficulty is accounted for in the scoring. So although you may hear that it's easier to do the on-site, the pass rate is right around 80% for people that are taking the exam. For the on-site people who are taking the exam, the online percentage varies constantly because there's people taking the exam all the time. And the numbers aren't that huge. So it's easy to kind of skew those numbers. But it's somewhere between 70% and 80% on their first-time attempts. Everyone who does take the exam does get a free retest. Whether you take it on-site or online, you get a free online retest. So your first attempt can almost be a study tool if you don't pass on your first try. You will get information on how you do in the different subject areas so that you can kind of focus on where you want to study. And almost all of the time, where you want to study is the DOT regulations. 50% of the exam is the DOT regulations. The questions are coming out of information that's in those regulations. It's a good habit to kind of just breeze through some of the big sections of that before you take the exam, whether you do it on-site or online. With the course, you really don't have time, but they go over a lot of the regulations during the course. The other thing that I always like to point out is that there are two different types of questions on the exam. If you take the on-site paper exam, the first approximately 100 questions are single best answer. They're all multiple choice. They're single best answer. There's only one correct answer. At the end of the booklet, there are 10 to 15 questions that can have multiple correct answers. Each question is worth one point. There is no partial given for the multiple correct answer questions. So if you're doing the online where they're mingled in and you don't know the answer, move on to the next, flag it, come back to it at the end. Don't waste a lot of time on the question because it's not worth any more than any other question. And those can be difficult because sometimes it's almost like you're answering five questions at one time. Wonderful. Thank you, Chris. So again, let me make brief rounds, starting with you, Donna. In the world of federal regulations and evolving policy within health and human services and DOT, is there anything that we should know and any sense of the timetable for actual implementation of oral fluid testing? I feel like every month I have to go back and say, well, now it's going to be a month or two months longer than we had originally projected. I think Mike, Pete and I went on record pretty early saying that we didn't think for sure it would be before 2024. I'm not even convinced we'll make it by the end of first quarter of 2024 at this point. There is still no approved oral fluid split specimen collection device, which obviously is holding up the process for laboratory certification. I don't see any indication for oral fluid testing. I don't see any indication that the process will be compressed in that laboratory certification would happen in a month or two. So I think we're still very much in a holding pattern there. There's a continuing pressure from many transportation groups and there may be additions to various parts of legislation for HHS to get its final hair testing regulations, or excuse me, hair testing mandatory guidelines out there. We're still now waiting. I mean, we've had the proposed guidelines, which by the way, were in my opinion, nowhere near to being a final document. So a lot of questions and a lot of problems. I don't know how successful that there's lobbying efforts by various groups, particularly in the transportation sector are going to be in speeding up that process. Probably on the federal regulatory, it's not really regulatory, but federal policy standpoint is that there was a few weeks ago, maybe about three weeks ago, a statement by the Health and Human Services Secretary that the Health and Human Services Secretary believed that marijuana should be reclassified as a schedule three substance. That was kind of a shock to a lot of people. I think particularly on like the DOT side and the nuclear regulatory side saying, what the heck is the secretary doing this? I don't even think that the Division of Workplace Programs knew that that was going to be an announcement made by the HHS secretary. Remains to be seen what that will mean ultimately for drug testing for marijuana. That's the end of my report. Good, thank you, Donna. And Michael, in the world of forensic toxicology and laboratory testing, how's the game of cops and robbers going and what's going on there with the invention of new methamphetamines and new opioids that haven't been included in the federal test list? Well, I mean, we all know the federal test list is like 30 years behind its time. I mean, today in a heartbeat, people can change a structure of an amphetamine or fentanyl or an opioid or cannabinoid and put it on the street. So that's not what DOT is intending to do. They're intending to discourage obviously the quote unquote illegal drugs, but there really is nothing new in the federal programs toxicology wise. I mean, it'll be certainly interest in any final version of the hair testing, which as Donna has mentioned, it's probably not going to be satisfactory from a number of points of view. And then secondly, the potential action on THC to become a level three drug is going to cause a lot of heartache if that proceeds because there are some states as we categorize them as red that would certainly not appreciate that. And so it's going to be interesting the next year or so, but like Donna said, I don't see all fluid testing and the devices and the labs being all ready by, I'll be really surprised if it's the first six months of next year, nevermind the first quarter of next year. So, you know, we're just going to move that way. But on the test, because I'm sure some people on this group are getting ready to do that, maybe at the live meeting at the end of the month. And from a toxicology perspective, this is probably one area together with parts of the DOT where you're really going to have just to memorize because it can be confusing questions if you think about putting down on a piece of paper the opioid cutoffs for screening and confirmation and mixing them up, but that can probably cause quite a lot of heartache. So I always recommend that people even have their cheat sheets handy for those sorts of things. If they're taking it off online, you're taking it in person, you're going to have to remember that stuff because you can't work it out. So you're going to have to remember. And that's it for me. Good. Thank you, Mike. So that was a question that was raised in the chat, Chris, for the people who are taking this course, they get a syllabus. We do encourage you as students to make your cheat sheets or basically copy the tables and the pages that you will find most useful in your day-to-day activities as an MRO. And those are also the tables that you will want to study and have available if you're taking the online course because you have a limited amount of time. And so what you're doing to prepare for taking the exam will be useful in terms of being able to prepare to function as an MRO. When you're taking the live exam though, Chris, there are no cheat sheets permitted. Is that correct? That is correct. And again, when the exams are selected, the fact that one is open book versus one is closed book is kept in mind with the questions that are selected. That being said, Mike had an excellent point. You do need to at least know your confirmation levels and you can't have a cheat sheet for that. So be prepared for that if you're taking the on-site. Good. I guess I might raise the question to you as the Executive Director of MROCC. Would MROCC consider allowing those who take the test to bring in two or three sheets of paper with numbers on them that would help them in taking the exam? I'm not making that as a suggestion, but I'm raising a question because it would make the online and the live exam taking more comparable. This was broached a few years back with the psychometrician who does the exam and he did have some issues with the on-site exam being open book. I don't recall exactly what the issues were. I mean, it's definitely something that could be discussed, looked into, but there were some issues with the psychometrics with having an open book. And like I said, when selecting the exam, different questions are chosen for on-site versus online with that being kept in mind. I think a more likely solution, which again, maybe wouldn't be chosen, would be to have some of that built into the exam book rather than letting people bring something into the exam. Interesting ideas. Well, I may bring that up with the new president of MROCC, but it just occurred to me now. So as far as tonight, because we have no questions that have been submitted in advance, I want to start with the basics. I know many of you here are here preparing to be an MRO for the first time and you're studying to pass the exam and you really have questions that you may consider dumb. We don't consider any questions to be bad questions, but we want to start with sort of the fundamental questions. So I will go through any questions that you have posted in the chat, and I'm going to try to pick out as a priority the more basic questions. After we do that, I know that there are many very sophisticated and seasoned MROs who join us monthly, and then we will take your questions as well. I'll do my best to sort them out. I have not looked at the chat, but I will look at them now and we can take the first question. There is one thing in the chat about asking about the difference between the sixth edition MRO manual and the course and whether one has more information than the other, which could probably be addressed. Okay, so we're talking about not the manual, but we're talking about the Swietynski textbook. Is that right? Yes. Right. So the textbook did get an update, and Donna, you are familiar with this book intimately. You're preparing periodic updates of it for the publisher. What would you say in terms of the currency of the fifth edition, the older fifth edition, versus the sixth edition in terms of the kinds of questions that an MRO has to master in order to pass the exam? This is the cover of the newer sixth edition. Yeah, and Chris and I are working on the updates Yeah, and Chris and I are working on the updates, et cetera. The fifth edition, as it is in print and as it's available online, is certainly correct and comprehensive enough for passing the exam because there are no questions on the exam about, for example, the final rule for oral fluid testing. There are no questions on the exam yet about the designer drugs, the differences in, for example, testing for 9-Delta versus 8-Delta versus 10-Delta THC. Those things are not on the exam, and so I don't see... Chris, I can't remember anything that really would have an impact that we did for exam prep. Is that right? I would agree. And actually, the question, I think, was the course versus the sixth edition manual, not the course. That's what I thought it was, too. You know, one thing that I would point out about the course, about the manual versus the course is the manual is meant to be a guide for practicing MROs, and the index and table of contents in the sixth edition manual are excellent. They are so detailed, and it really does help you find what you need very quickly. Okay, as far as the course manual is concerned, you're right. The original online course syllabus was created in 2020, and as Danielle reminded us early in 2023, it needed to be reviewed, and we went through it extremely carefully. There were only a couple of tabs that really required updating, and those were ones about the most recent epidemiologic data on the prevalence of drug use, and I did very carefully update each of those tabs. Those have been submitted to you, Danielle, and do you have any idea when that will be released to the learners as the online version of the syllabus? I am hoping. I don't want to say this week's end because this week is kind of nutty, but I will say by midweek next week, it should be in there, and I will send an email somehow. I will add it to our announcement for our MRO monthly discussion. I think that's how I will do it. That way it will reach everyone, and they will know that there's a new syllabus in there. Right, so when you go online as a student and you look at the syllabus, you'll see a 2023 date as opposed to a 2020 date, but just like the Swietynski book, there are not huge changes, but we have diligently reviewed everything. There are updates as well in the oral fluids section, but those are not ones for which there are many questions on the exam, so are there any other questions in the chat that are substantive that we should... Someone said they mailed a question in. I did not get that. Can you find it, Danielle, and read that to us? I found it, and I apologize. We had a big migration on our computer system, so we do have some emails that didn't necessarily go through. May I share my screen? I put it in a Word document because I'm sure that I will absolutely butcher these terms. Please, go right ahead. Not to butcher, but share your screen. Okay, can you see the screen okay? Yeah, can you read the question? Sure. It says, I took your MRO online course last year. I came across a drug test that had the following information. Sample oral fluid. Positive for the following. Amphetamine, methamphetamine. Verbal history obtained from the donor during telephone interview. Home medications, ibuprofen, Benadryl, Sudafed, Zyrtec. Additional OTC allergy medication that was unnamed. Has not used any OTC inhalers, not on any prescription medications. Neighbor gave her a pain pill for a toothache recently, Percocet. She denies use of illicit methamphetamines. Would I request an... Entomometer testing, yeah. Entomometer testing of this oral fluid. If she had pseudoephedrine in one of their OTC medications, would this explain her result? Thank you. Good, thank you, Danielle. Michael, do you want to walk us through the... And you might keep that up on the screen while Michael talks. I found my memory test, Danielle. It would have been interesting to know what the exact concentrations of methamphetamine and amphetamine are here. It really is not much useful information apart from it was positive for both the parent drug and the metabolite. In terms of the medications, I'm gonna come back to the pseudoephedrine in a few minutes, in a few seconds, but none of the other material in the first paragraph is gonna cause amphetamine and methamphetamine positives. Now, the other interesting piece of information, what useful information would have been if the substances were confirmed by a mass spectrometer, a GCMS, LCMS, or whatever type of confirmation assay, because that would have ruled out the pseudoephedrine as well. The pseudoephedrine can be differentiated from methamphetamine and amphetamine in those assays, but obviously, pseudoephedrine can't cross-react with both the methamphetamine and amphetamine immunoassays that are used. So, one can only hope that these were confirmed. So, nothing in there is telling me that the prescriptions, the OTC inhalers, et cetera, would have given her positive amphetamine and methamphetamine or him. There is a Vicks inhaler, old-fashioned Vicks inhaler, which is an over-the-counter inhaler that can result in methamphetamine and amphetamine concentrations that can be detectable. That is L-methamphetamine and not the D-isomer, which is a psychoactive form, and that can be differentiated quite cleanly by a mass spectrometer assay, but most labs would have to go ahead, and most MROs would have to go ahead and request that from their labs before it was done. So, that could take that one out. It is not common. The Vicks inhaler is not prescribed anymore or available over-the-counter anymore. So, it's not common, but people obviously store it and may use it. So, I think an enantiomer testing of the oil fluid would be helpful, but I would not expect it to be anything but L-methamphetamine in this situation. Well, but she denied using any, Mike, she denied using any OTC inhalers. Would you still go for the process of doing the isomer? Only, yes, I would, but simply the rule, she came back and said, oh, by the way. Yeah, okay. If I used an inhaler, you'd have that information. Your general advice, Mike, is if there's a positive methamphetamine to routinely request the DL separation, and that's the enantiomer testing that we're talking about. Yes, that's what I'm talking about. And my general advice is still that. That's not going to necessarily be a very easy assay to do in oil fluid. Right, that was my point, Mike. Because of the quantitation and the low concentrations and the low volume of specimen, that may not be a very easy assay to do, but certainly the better labs would have that available. Well, and the questioner has said that this was a confirmatory test, so that, you know, which would have to be a mass spec, as Mike was mentioning. It is unusual, though, if it was a mass spec confirmatory test, that they did not quantitate it. That's very unusual, to just say that it was greater than apparently the cutoff this lab is using is nine nanograms. So that seems kind of weird, doesn't it, Mike? Yeah, it does. That's a low cutoff for amphetamines, but that's what they reported. So certainly this will not arise in oil fluid of a DOT testing. No, it wouldn't. Those concentrations of amphetamine and methamphetamine are too low. Right. So the other comment I would make as an MRO is that you see that long laundry list of medications. And in my experience, when talking with someone and confronting them and saying that they have a positive laboratory-confirmed test and that they're gonna have to provide a valid medical explanation, many donors will bring out long laundry lists and sometimes attach to very interesting stories. And this is a good example of that. So by the way, a neighbor did give her a pain pill because she didn't know that the pain pill would not cause those results. And so this is not unusual behavior on the part of an anxious donor who is caught in the headlight of a positive test and wants to go to their medicine cabinet and tell you everything they're taking. And if they go to their supplement drawer, they can give you a long list of supplements that they take as well. I know, Mike, I once called you by somebody who was a health food nut and I gave you the list of nutritional supplements and you thankfully went through all of them and basically said, no, none of these would explain the methamphetamine result. Okay, so thank you for sharing your screen, Danielle. And I hope that satisfactorily answers the question. Are there any other questions? And if somebody does want to speak live, can they go to raising their hand on the bottom of their screen and you can do raise hand and Danielle can allow you to make a comment if you want to have a live discussion with our faculty. I'm just raising my hand to give you an example. You want a live discussion with the faculty, Ken? I always have lively discussions with our faculty. Okay. So let's wait a minute or two and see if any of you participants do have questions that you'd like for us to discuss. I know we're now up to 20, so that's five on screen and 15 who are around our table. And we are very happy to talk with you or answer any questions that you pose. Thank you. Meanwhile, I gather there's a very important baseball game going on and there are more brave fans than others. How are the Tampa Bay team faring, Donna? I have not- They got swept in the first two games, which was awful. And it's all because I wasn't there to go to the game. I was out of the country and so I could not go, but yes, they were miserable, miserable, miserable. So now I have to root for other teams and I want the Phillies to beat the Braves because the Braves, everybody thinks the Braves should win the World Series. And so I want the underdogs and I want somebody to beat Michael's Houston Astros because I still think they're cheaters. Nothing to do with the Astros. Or the Texans. So there's the MLB postseason summary from Donna Smith. All right. Well, the seven to one Phillies over the Braves was certainly a strong start. Yes. Okay. Jennifer, welcome. Can you allow us to unmute? Danielle, can you unmute Dr. Sauters? I'm unmuted and I grew up in Philly and I'm wearing my Bryce Harper jersey as we sit here, just so you know. And I love how the Houston Astros have OxiClean as a sponsor because I guess that makes them think they're not dirty anymore. Yes, that's what I figured too, right? No, but I guess a serious question. This was a, this is a weird one and this might be out of you guys' range, but since nobody else asked anything, I thought, well, okay, let's toss this out here. Employment testing, someone for alcohol. So someone is suspected of alcohol use on the job and the employer takes the person to the testing site or an employer's representative. And then that person leaves and there is a person whose breath test then comes back over 0.08. And what do you do with that person? Like you can't let them leave and drive home. What do you do? From a DOT perspective, actually the level, Dr. Souders, that is that if they are at 0.02 or greater on a DOT employee being tested, the regulation says that the tester, the breath alcohol technician or the clinic or wherever this is being done is to have them sign a statement that they cannot operate a vehicle and cannot leave and the employer is to be called to provide transportation for that individual from the site. Now, in a non-regulated arena where you're doing breath alcohol testing and you're using a 0.08 as a cutoff, it would seem to me that to protect their potential liability, the testing agent or the breath alcohol technician or the clinic should similarly advise the person that they cannot leave the center operating a vehicle. And that if they do, that the clinic will contact law enforcement and let them know that the person has left driving who may be under the influence. That's about the only thing that you can really do. Yeah. I figured, but thank you for just confirming that. I appreciate it. Yeah, I was in an emergency room, not for me personally, a few weeks back and there was obviously somebody who was intoxicated in that emergency room and they had never let go of that car keys and all that had the examination, et cetera. But what they did was that they had somebody who didn't leave his side and then when he started to go outside, they didn't try to rest, take the keys from him, but the hospital security people were lined up outside preventing him from driving. So there are ways to do that, but I think Donna's right. All you can do is try to cover your own liability if they were to leave and have a crash and obviously you can do a citizen's favor and call the police as soon as they leave and tell them what's going on. I do think it's the responsibility of the employer and I do not think they should have had someone escort the employee to the test location and then leave. I think that was an error on the part of the employer. I, as a collector, I would contact the employer, tell them that they have a extremely elevated level and that the company may want to offer to pay for a Uber home or to have someone escort them home because the employer does have some responsibilities since they brought them there. But again, this is beyond the functioning of an MRO and one of the things you'll need to learn quickly as an MRO is what are your responsibilities as an MRO? What are the responsibilities of the collection site and what are the responsibilities of the employer? Just like employers want to play MRO, sometimes MROs want to play employer. So we do have a question that will require a bit of discussion in the Q&A and this comes from Dr. McMillan, who says, after 30 years of testing for marijuana, what do you all think would be the scientific basis to make it easily prescribable? And that's a little unclear in terms of the question, but what is the scientific basis for being able to make cannabis prescribable? Any comments on that, Mike or Donna? Well, that takes in sociology, takes in diction, takes in this, takes in that. That's really a question that can't be answered tonight. That's a whole discussion panel. I mean, obviously people believe it is impairing, but alcohol is impairing. So, you know, the argument there is level three or over the counter alcohol. I mean, it's not an easy question to answer. Well, and of course, typically, you know, in the prescribing of medications, there is a dosage and, you know, prescribing instructions for use in terms of a regimen of use. And, you know, quite frankly, you know, certainly the cannabis industry today with medical marijuana, et cetera, they are in no means, by no means, would they favor it becoming a, I don't think, a schedule three drug or a schedule, you know, four drug or whatever, so that it had to have a prescription, if you will, that identified dosage. You know, I don't see that happening. I honestly don't. And I think it's important to clarify the word prescription. Physicians are not able to prescribe marijuana. They may recommend it, they may authorize it. It depends on the language and the state law, but never do we prescribe it. The only way that physicians prescribe marijuana is to prescribe THC, as in the form of the schedule three drug, dronabinol. There are indications for that. People who are on cancer therapy, who have nausea, who have cachexia, who need appetite stimulation, that's one example. And if you look at the state laws, many of them state that there are particular illnesses or particular diagnoses for which the state considers cannabis to be legitimate. But the only prescript, and I'm not sure how loose prescribers are of dronabinol. Have you seen, Donna, the loose dispensing of dronabinol? Or you, Mike? I've never seen that come up as an issue. It's very rarely prescribed. I had one case of someone who was prescribed it, and it was a friend of mine who was dying of metastatic breast cancer. And she tried a variety of things to relieve her suffering, but she was not working. She was not driving. She was in a nursing care facility at the end of her life. So in that situation, I felt like anything that she tried that would relieve her nausea was worth doing. And of course, her behavior at the end of her life was not her typical behavior, but I did not have concerns about her taking it. I see that Dr. Greer would also like to speak. So can you unmute him? Please go ahead. Yeah, so I think this is an excellent case. So I'll apologize first for being late. I was on a call with East Palestine and some of that exposure stuff with ODH there. So I've missed part of this conversation, but I actually had an individual who understood that at the Ohio State University, that since they have federal contracts, it was not an acceptable, medical marijuana was not an acceptable approach. And so he went to his neurologist and had a prescription for Dramanol, but that's the only one that I've seen so far. So it does occur, but as you said, Dr. Peterson, it's, I mean, it's very, very rare to see. Very interesting case. Yeah, it is. And of course, if you're treating someone with a controlled substances and there's a concern about potential addiction, then you're gonna go through all of the very carefully prescribed steps of doing a physical examination and describing to your patient the benefits and the potential hazards of taking it. There'll probably be an agreement that your patient will sign indicating that if the symptoms are not relieved, that they will agree to stop taking the medication. You're not basically putting them on it for life. And that under circumstances, you will be able to stop prescribing it. So there are standard agreements for dealing with patients who have addiction potential. And those are covered in almost all the mandatory CME programs that almost every state requires. And with respect to that, I've even seen, part of my work is with regulatory programs. So chemical personnel reliability programs out of the army, biological programs and the DOEs, human reliability programs. I've had pain management specialists, surprisingly in these programs, they get access to their records, surprisingly pencil whip, a lot of their electronic records. I've reviewed many that have had six months worth of exactly the same stuff, word for word, where it looks like they just checked off on their document and moved on to the next. And so having the capability from personnel reliability programs to review some of those records was very helpful in monitoring their capabilities. And we've had a number of success records where people have actually been in a situation where they're not allowed to work in these reliability programs unless they really aggressively pursue kind of a more holistic non addiction to these medications. So really interesting opportunities. Good points. Thank you very much. So are there any other questions or comments? If not, October could be the shortest month. Not February. Just one comment of something new. How many of you last week noticed that the military, in particular the Navy, are now doing performance enhancing drug testing on the SEALs? They are doing what, Mike? Like the athletics, performing enhancing drug testing on the SEALs. Yes, I noticed that. Yep. So that will be interesting. And the Air Force and the Army apparently are looking at the same type of program. Now, is the Navy doing it across the board? Doing it across the board in the SEALs, yes. Both the training programs and in random testing. And in random testing, okay. And that was because there were several deaths from people under grueling conditions. And it turned out that a large percentage of the Navy SEALs were taking performance enhancing drugs. And they wanted to discourage that. So that's why they began that testing. Okay, we have another person commenting. I don't see your last name except Norman. So please join us. Yeah, my name is Norman Schwartz. I'm a physician. Been doing some screening for companies, but I want to get up to speed with the federal regulations of DOT. So I'm taking this course. But it came as a talented discussion, but I didn't get the headlines. So if you can summarize them, the potential conflict between the federal and state marijuana regulations. And another question, how's Rabinol come up on testing? What, how does that show up? Well, genabinol is THC, delta-9-THC. Oh, but is it a delta-9 form? I thought it was a different form. No, it's a delta-9 form. So it will show up. Yeah, it'll show up as the THC metabolite. Do people get high from it? I thought they did not. No, they probably don't get high from it because the dose is pretty well controlled. And secondly, it's taken orally. So it's obviously subject to pretty fast first pass metabolism. Okay, so there's minimal oral absorption from the high standpoint, but as far as the- Minimally inducing a high. It's not absorbed fairly, I believe fairly slowly, but that's going back into some of my memory cells that are pretty deficient at this point. But enough of a benefit for the nausea then? Yeah, yes. But as far as that potential conflict, if the federal and state are- Well, the feds have one rule about THC, not genabinol, but about THC. The feds say that's a positive, full stop. Even if it's medicinal marijuana, et cetera, it's not an excuse, it's still a positive. Genabinol would be a positive, but you as a medical review officer would overturn that result based on the donor having a prescription. But if a state allows the suggestion, it's not actually a prescription by the doctor, would that be considered- So that's where there's not a potential conflict, there's a very definite conflict. And the way that we do this is to build a very firm wall between federally regulated testing. Under federally regulated testing, the use of THC except for prescribed genabinol is not an acceptable medical explanation. And that's true in medication, that's also true in hemp seed oil and in seedy sweeties or other food substances. And if there's a high enough dose in CBD and a test positive for THC, that will be reported as a positive. So there's a very, very firm wall that applies to federally regulated testing. In the non-federally regulated testing, that's where you have differences, many differences between states. A physician does not prescribe marijuana, but they may recommend or authorize or give an indication on some different form that the person may have marijuana, but it is not a medical prescription. The person then goes to the state registration, the person state to state, and they can then be allowed to get a marijuana card and go to a dispensary. Now, what happens in terms of workplace drug testing is it all depends on the employer's policy. So you can be in Colorado, for example, where both psilocybin and marijuana are legal, but an employer may have a policy that says that we will not accept marijuana in our workplace because of safety concerns. And if you test, and if you test positive, we will refuse to hire you and we can terminate your employment. So that is in conflict with state laws, but the Supreme Court of Colorado indicated that the employer regulations overtake the state law. Now, Donna's done an extensive review of state laws, and that's available in the resource manual, not in the syllabus, but in the resource manual. And Donna, you may wanna comment about some of the interesting differences between states. Well, and one of the things that has occurred more recently in the past couple of years is that many states have actually enacted or amended their medical marijuana law or their adult cannabis use laws to insert in them user protections that actually prohibit an employer from having a policy that says we're not hiring anyone who uses marijuana, either for medical purposes or for recreational or purposes where it is legal in the state. And so that has really made a big difference and has been a consternation for many employers, particularly those employers who feel that there are safety concerns related to marijuana use. So at last count, I think there were a total of 16 states that had placed some protections in their medical marijuana or their adult cannabis use regulations or statutes so that employers cannot refuse to use marijuana or refuse to hire or to take an adverse employment action on the basis of a positive test for THC. They can refuse to hire or they can take adverse employment actions if they can prove that the person used the drug while on duty or that they were impaired by the drug. Well, you can't do that with a urine positive test for THC. You can't do that with an oral fluid positive test for THC because neither, and certainly not with a hair test that may be positive for THC. It doesn't tell you anything about when the drug was used or whether they were impaired at the time the specimen was taken. So that has made a big difference quite frankly in the last couple of years that there are these now protections for use of those substances being written into the laws that is constraining employers from having a quote, no marijuana in this workplace under any circumstances. And that was demonstrated in the Quest Diagnostic Index drug use data last year, because the number of drug tests, pre-employment drug tests they did for oral fluid, the number that they did for THC in oral fluid for pre-employment purposes plummeted. It was only about 4%, 5% of what they did in the year prior. Yeah. So- Getting back to the question if the federal regulations changed to reclassify THC to schedule three, that would mean if it was prescribed as in a prescription by a doctor, it would be considered not a positive. I think we're gonna, and we probably don't have time for that tonight either, but that's certainly going to be whatever the, however they handle that, there'll be a lot of time between now and then if they decide to put it into schedule three. Right. And I wouldn't bet either way. Okay. And I take it there's no way you could establish a level of impairment of THC. That just what you haven't listened to me before, have you? No. The federal government in the 1980s spent millions of dollars trying to come up with an impairing concentration of THC in blood as there is for alcohol, the 0.08 or whatever the state may use. And they failed. There is no direct correlation between THC in blood and the impairing effect of marijuana or whatever form of THC they've used. And that's reflected actually in the six states that currently have DUID regulations with regard to driving under the influence of marijuana as a drug, right? And one state, it will be that the per se level for driving under the influence of THC is 10 nanograms per deciliter of blood. In another state, it will be two nanograms per deciliter of blood. So it's all over the place, even with the states that have attempted to establish a per se level. And I mean, I don't know. Like Mike, I'm not convinced. It took us how many years, Mike? 40 years to get to per se levels for impairment for alcohol. It's a much easier substance for us to be able to document impairment. There's just so much individual variation with THC. Yeah. So we may devote one month's discussion in the future to the potential implications of reclassifying cannabis or THC as a Schedule III drug. But as Mike said, that's not coming anytime soon, particularly in a Congress that can't vote on anything right now and during an election year. So this is an idea that has been posed by public policymakers, but there's no way that it's gonna happen in the relatively near future. I think it would have a profound impact on drug testing, but that's worthy of considerable thought and discussion. And it's nowhere in the near term future. We're still hoping that we're gonna see oral fluid testing in 2024. It was five years ago that there was extensive work done to attempt to get marijuana reclassified from a Schedule I and under the US code. And it was rejected. At that time, it was determined that there was insufficient evidence to remove it as a Schedule I drug. And so, I mean, I don't know, would they do that again? Certainly this is what the Secretary of Health and Human Services is suggesting that they should again look at the reclassification of it. Now, that's not to make it, again, a quote, over-the-counter drug, but to reclassify it. It's hard to say. Again, I would think that it would be at least another two to three years before the FDA, before the DEA, before Congress, et cetera, would make a determination to remove it from a Schedule I to another schedule. I'll just follow up that point as far as what point THC would impair someone as far as balance and coordination. Is that covered? I haven't gotten that in the manual yet. Is that covered later on then in the course manual? No, no. We don't go into doses, but we do say that there's very clear evidence that THC does impair performance and behavior. The level at which that occurs is what we're saying varies hugely from individual to individual. But I think there's good evidence that these substances do impair performance and therefore do affect safety, just like there's good evidence now that opiates at any level also are potentially impairing. But a scenario where an employee was examined and balance and coordination were documented and they had a positive THC, that would be pretty good evidence for a problem. Yes, I do think that, again, in looking at, particularly with regard to these state statutes that have employment protections, they are saying that if there is other evidence that the person was impaired at work, in other words, balance and coordination, ability to do their tasks, all of that kind of thing, that that can be used for the employer to take adverse action. But not just on the metabolite, the inactive metabolite, THCA, being found in the urine. They would have to have other supporting documentation. Okay. Okay, well, we are at the hour. I don't see any new questions. So I would, again, close tonight by asking- Sorry, Dr. Peterson, Dr. Howard did have a question. She had posted to the chat and I unmuted her. Okay. I'm sorry. Please go ahead, Dr. Howard, and then we'll close. Hi, thank you for taking my question. I just wanted to know, regarding invalid urine samples, are there any common acceptable medical explanations for an invalid urine sample? And are there any examples of a prescribed medication that would cause a test to be invalid? There are, first of all, under the regulatory format used in federal testing, there are a number of things that the laboratory uses as criteria for determining a specimen is invalid. So there is everything from interference on the immunoassay causing specimen to be invalid result. Interference with the mass spectrometry testing for confirmation is a second for it being invalid. And elevated pH is the third reason. And inconsistent of creatinine and specific gravity measurements are also a criteria for calling it invalid. What am I missing, Mike? I'm probably- I guess maybe I should be more specific. So like when I've seen results that have come back, yes, they'll have specific information, like the pH or the specific gravity is off. So I do recognize that. But when I'm talking, when, you know, going over it with the donor, are there any explanations for those specific, you know, if it, you know, if it doesn't meet criteria as diluted or substituted or adulterated, you know, are there any other, you know, just actual medical explanations or prescriptions that could cause it? And what I'm going by is like in the manual on page 171, it talks about how if the donor provides a medical explanation such as a prescription medication for the invalid finding, the MRO reports a test canceled result with a reason for the invalid result. They go on to say that they inform the employer that, you know, recollection is not required. So meaning, is there anything that will actually like satisfy that criteria? There are a few. Again, it depends. For the, if it's invalid because of immunoassay interference, that may be because of certain types of medications such as Flagyl, et cetera. It may be some of the supplements that people take can cause immunoassay interference. So yes, that is a possible explanation. It's very, very difficult to sort that out. I mean, Mike, do you want to talk about that a little bit in terms of- Yeah, I would just second it's very, very difficult to sort that out. Yeah. I mean, I think, you know, that periodically the new immunoassay kits are introduced and periodically when they're introduced, people find out there are interfering substances that interfere with that immunoassay and give a quote unquote, a false positive. Those matters are normally dealt with if the lab, if say you get a false positive on the immunoassay for marijuana metabolite, the lab will normally put that in the mass spec and it will confirm as negative if it's interference from immunoassay. But there are odd occasions that happen that you might find a substance that results in an invalid test report. And I would just encourage you when that happens to reach out to the lab. Right, talk to the scientists. Go to the certifying scientists and just talk through your questions with that individual because they're certainly, you know, the nearest point of contact that can provide you with the details. Right, and in the syllabus on tab 10, page 32, it says that for any invalid as an MRO, I always make two phone calls. I call the laboratory certifying scientists and say, what's going on here? And they usually have a better indication of what's happening than they're gonna issue in a report. The other phone call is to the donor saying, what are you taking that could possibly interfere with this test? And by those two phone calls, I've been able to sort out most of them. Now, you may have to repeat an invalid test. And again, there is a protocol for doing repeated testing. And that's in tab 10 on pages 1032, 1033. So we do deal with those. They used to be fairly uncommon, but now what we're finding is that laboratories suspect an adulterant, but they're not going through the two different methods of testing, right, Mike? So they report it as invalid because they don't wanna spend the money to do a confirmatory test of an adulterant. Well, that's not quite true. The lab doesn't wanna spend the money. It's the employer. It's the client or the MRO who doesn't wanna spend the money. Exactly, exactly. The one exception, Dr. Howard, I think is that at least what we find in our MRO practice is that elevated pHs, pHs that are reported as invalid between nine and 9.5. And again, we've seen a lot of this in the summer or the warm months. And so I have to say that we are routinely canceling those tests if that specimen, where the pH is nine to 9.5, if that specimen has been in transit more than two days, right, and it was not tested, more than two days, right, and it was collected and shipped in an area where you've got ambient temperature, it doesn't take much at all to elevate a pH to nine when it sits in a FedEx truck or in a pickup spot or somewhere else for a day or more. So that is probably the most common reason for an invalid result that we see in our MRO practice. Yeah, absolutely. Any common scenarios for anything above 9.5, like let's say it's 9.8 or something like that? Yeah, we feel that most of those are in fact adulterated and we do not- Okay. We have not found that there's any medication, that there's any real, at least, you know, that's been our experience. We have not been able to validate that anything that we can identify, even in talking with the person's own physician, you know. So those, generally speaking, we feel have probably, there's been an attempt to adulterate, although it didn't meet the 11, you know, pH. And so those, we have a recollection with a direct observation. Okay. So we are now at the close of this October call. Donna, I do need to tell you that the Braves have had a surge. And they now have two runs and they're now behind only 10 to two. But that's okay, that's okay. I'm convinced that the Phillies will pull it out. The Braves can not get as lucky as they did in the last game, where their left or whatever, right fielder made this preposterous, jumping, leaping catch. And then after slamming into the wall, was able to fire it up 90 miles an hour and throw out Bryce Hopper, Bryce Hopper at the base for a double play that ended the game. That can't happen again. The baseball guards will not allow it. Donna's version of the baseball guards. I've unmuted unprofessionally, just to say, they cannot. Oh, please no. All right, so we end this meeting on a note of humor and goodwill. Again, I implore you for our November call. If you have questions, send them to Danielle and you may find we're better prepared with graphics that can go along with our answers. But it's a joy to have you all here. Thank you for participating. Those who are preparing for the exam, good luck. And we hope to see you again. So good night to everyone. Good night. I'm going to watch the game, bye.

drug testing

MRO course

registration process

MRO exam

oral fluid testing

federal regulations

marijuana

impairment level

state laws

invalid urine samples