I was just asking if the if I'm going to be able to read off my slides. Yes, you will be able to share your screen. I'll stop sharing mine, you can start sharing yours. And we'll see your slides. Okay. Okay, sounds good. Then I better get that up. All right. Let's, let's begin. So welcome, everyone. I'm Dr. Kent Peterson, and I'll be hosting this monthly discussion of the MRO online faculty. There are 16 people who are online right now. The number may grow. And you see that we are missing a familiar face, and we've added a new face. So let's just briefly begin with introductions. To my left is Danielle Feinberg, the ACOM staff person who supports us and hosts us and keeps us going. And your title keeps changing. For a while, you were manager of e-learning, and now I see you're the manager of education. So thank you for being with us. We appreciate your support, Danielle. Secondly, we have Dr. Michael Peete, our forensic toxicologist. And Mike has been with us since practically the beginning of this course, and we'll have a focus on some of his expertise tonight. As you know, I'm the physician MRO member of the team. Mike is from Houston, Texas. I'm from Charlottesville, Virginia. And Christine Paciak is the executive director of MROC. She's a very key person, as you all know, because she is the one who can answer questions about studying for the MROC exam, qualifying to take it, being able to take it, and getting your scores. And if you have questions about preparation and study, that's open game for our discussion tonight. And Chris and Danielle are both from the Chicago area. And finally tonight, we have Michael Levine, who is an MRO. He's a member of the ACOM board of directors, and he's a co-author of a paper that has just been released on cannabinoids and their implications for workplace worker safety. And so he's going to be talking with us a bit tonight. We may or may not have Donna Smith join us. She is currently traveling. And if she's able, she'll join us. But if not, we will do our best to do without her. So I'm going to begin by sharing my screen. I have a couple of announcements. And then Mike is going to talk about the ACOM paper, and he has a few slides to share. We did get a couple of queries from you during the month, but not a lot of questions. And so after we've done those things, we will be open to the chat. And if you have questions that you want us to discuss, you can type those into the chat. We always like to get your questions in advance so we can be a little better prepared. But we will take whatever you offer us and ask us tonight. So that's our agenda for this evening. And I'm going to begin then by showing my screen with you. So first is a couple of announcements. Our MRO online course, which now has almost 800 registrants, was inaugurated in August of 2020. And it has been recently reviewed and updated. And an MRO online 2023 version is going to be posted to the internet, hopefully within this month of September. Danielle and I are working on that. And when that is ready, you'll all get a notice about that. The syllabus has been updated. Some of the presentations have been updated. The questions and answers have not been updated. Secondly, as many of you know, ACOM is going to offer another live course. It's going to be a day and slightly more than a half course. It's going to be offered at the ACOM headquarters at the Learning Center in Elk Grove, Illinois, on October 28 and 29. And so Dr. Pete, Dr. Smith, and I will be the primary teachers. And Dr. Doug Martin, who's going to be taking my place in the future, is also going to be with us. We have, I think, 28 people who have registered for that. And if any of you are interested or know someone who would like to have a live course with all of our faculty present, registration is still open for that. My third announcement is about the recently released position paper called Legalization of Cannabis Implications for Workplace Safety. And you can see a brief summary of what ACOM stated in its release. It was developed by a task force on cannabis with a number of ACOM members on it. And I highlighted Dr. Michael Levine as one of the co-authors. You see here a link, and that will get posted. The paper will also get posted tonight. But I'm going to, at this point, stop and turn the discussion over to Dr. Levine to give a brief summary of this paper. And then there will be a chance for you to ask questions of Dr. Levine. Thank you, Kent. I'm going to see if I can successfully negotiate share screen. Oh, it's looking good. Let's see. And let me try doing this. OK. I hope that's displaying acceptably for folks. Well, thank you for the nice introduction. I've been in MRO for about 20 years. And I've done a lot of work for ACOM of various kinds and been involved in various committees. Somehow fell into the cannabis position paper work group many years ago. I believe we published it last in 2019 and then was included in this work group for the revision. So here's our title, Legalization of Cannabis Implications for Workplace Safety. And there's a beautiful picture of the front page of the document with the list of the folks who participated. A pretty illustrious group of folks from all walks of the MRO world, occupational medicine. There are toxicologists. There are attorneys. There are MD, JDs. And we each brought a little something to the table. So what does this position statement do? It really does kind of four things. And I'm just going to summarize it for you. It identifies problems that are posed by cannabis legalization as ACOM sees it. And it's intended to provide background for public policymakers. It focuses on the implications of cannabis policy for workplace safety. And there are a number of groups in the House of Medicine that have put together position papers on cannabis legalization. But it's almost always from the perspective of how is it good for the practice of our members. It hasn't taken really a public health look. And it hasn't looked at workplace safety in particular. So we've carved out a particular niche with this paper. And finally, probably the most important contribution is simply underscoring for decision makers, and hopefully people who can provide funding for scientific research, identifying areas where additional research is really needed to help solve the actual problems. And speaking of problems, most of the problems relate to what we do not know about cannabis and its implications for safety in the workplace. We don't really know how to correlate drug test levels in really in any matrix. I've written urine here, but it could be anything else with impairment. It's very challenging. There's no good correlation as there is to some extent with alcohol, for example. We also can't accurately measure impairment directly very well. It's very difficult to measure impairment of your employee in the workplace, whether that impairment is due to cannabinoids or anything else, be it another substance or a medical problem. And this is an area where as we move into an era of legalizing potentially impairing substances, we need to have a better understanding about how to address impairment. We don't really understand many things about the toxicology and the details of marijuana and other cannabinoid use. So for example, do frequent users of cannabis or cannabinoids have the same level of impairment at a specific, say, blood level of the substance as those who use it very briefly or sporadically? We don't really know the answer to that question. Is there some form of tolerance? What causes it? How do we measure it? And these are things that go well beyond our role as MRO. We don't really understand how to assess the potency of what people are using. It's very difficult to know what people are getting, particularly if we're looking at things like CBD, where these things are made entirely without adult supervision, basically. The route of administration and the presence of non-Delta-9 cannabinoids, how do these things affect impairment? These are a lot of unknowns, and we need to have a little better clarity about these things if we're going to be making rules. Things that we do know are that the existing and evolving patchwork of new state and local laws and regulations are often internally inconsistent, and they conflict with present federal law. And I think all of us understand that that creates difficulties for us in our role as MRO. For the time being, nothing has changed with federal law, and so if you're working exclusively within the confines of federally-regulated drug testing, it's business as usual. You do need to be aware of state laws, and how they apply, but in terms of interpreting results, there isn't much change. But I think all of us are aware that there is now talk of rescheduling marijuana, and that will make a large difference for us in terms of how we're going to be handling the federally-regulated drug tests. It will be very interesting to see how that evolves. We also provided a series of recommendations to decision-makers, and I'll just summarize them for you here, and then I'll take any questions you might have. We made the point strongly that we feel employers are best positioned to determine which jobs are safety-sensitive in their workplaces. They understand what's going on in the workplaces, what the potential hazards are, and what people need to be able to do. And then we listed a variety of areas in which additional research is clearly needed, among which is identifying very clearly the challenges that are posed for employers by this regulatory patchwork. It's all, at the moment, very anecdotal, and that doesn't really serve anyone's interest. It really does need a more comprehensive look. The means of assessing the safety hazard of cannabinoids, how do we measure cannabinoid level and correlate it with an individual's workplace safety? If it's a legal substance in particular, you know, that's going to be an interesting challenge, and we have some recommendations about what needs to be done in the meantime, but ultimately, we need to start thinking about how can we make some measurements that might help us make a legitimate determination of impact on fitness for duty? And fitness for duty, in general, is an area in which we need additional research to determine, I mean, you can think of fitness for duty essentially as the converse of impairment. We need field methods for assessing an individual in the workplace. Somebody has had an incident with some material handling equipment, and they've created property damage or worse, perhaps injury to life or limb. We want to have an understanding of whether that individual is impaired or not, and then we want to figure out maybe why if, you know. However, this methodology is really quite poor. We rely instead on looking for the presence or absence of substances, which is really only a small component of the potential contributors to incidents. And finally, we need to be looking at some of the relevant variables that affect the impact of cannabinoid use on people. Are regular users different from people who use it occasionally? Is tolerance important to us to consider? How do we estimate whether or not it exists? We feel that the authors of the paper basically have indicated that until some of this information is better understood, we need to consider some very practical methods used in testing samples so that we can make operational decisions about an individual's ability to either be in the workplace or not be in the workplace. Per se levels, such as are commonly used in alcohol testing throughout the world, are one reasonable approach that's used in at least two states. Another way of looking at this would be creating a policy with regard to time since last use. You know, for example, the FAA has a bottle-to-throttle rule, which prevents pilots from or prohibits pilots from consuming alcohol within so many hours of a flight. So there are ways that employers can use, even in states where cannabinoids are legalized, can make estimates of the impact on workplace safety. However, we think that we can do better with additional testing, additional research. So I'm going to terminate this here, and please ask any questions you may have. So I'm looking in the chat, and so far we have a couple of links, but we don't yet have any questions. So we may defer, Mike, until you get a question or two. Sure. You can stop sharing your screen now. Okay. Thank you. Good. Thank you, Danielle. I'm going to share my screen again because I said that we did have a couple of topics that were raised before tonight's session, and I'm going to go into that. One of them, that's a question that is not directly related to our teaching because fentanyl is one of many metabolites, but it was a question that was raised in terms of a urine toxicology report of a nurse who had a urine level of fentanyl of 0.77, and the cutoff is 0.5, so it's above the cutoff level. The donor questioned the accuracy of the test, but a split specimen was done, and it showed the same result. So the split was not inconsistent. So the question came up because of two potential challenges that might or might not be made by the donor. The first is that a healthcare professional might have been administering fentanyl patches and putting them on or taking them off of a hospitalized patient while not wearing gloves. So that's one possible explanation, and as MROs, we are constantly confronted with people who give us various explanations. The other one is that the urine results might be attributable to sexual contact with a partner who used fentanyl, and we have, as MROs, heard that frequently for all kinds of substances. So these are not rare questions. I know we've covered them in our class, and maybe, Mike, you can give us a brief response to this question. Yeah, let's deal with the second one first because, as you mentioned, Kent, that has been a fairly common excuse proposed over the years, particularly with cocaine and cocaine metabolites. There's no evidence in the literature for any drug that sexual contact of any nature will lead to a positive urine on a passive drug tester. That is, who's not using drugs, even though she or he may be having sex with a user of drugs. There's just absolutely no evidence of that. I do know of fentanyl, but certainly with cocaine, a colleague of mine many, many years ago calculated how much seminal fluid would have to be transferred to result in the positive urine test in the passive individual, and it was a considerable, considerable amount of seminal fluid. So that excuse, although it's been proposed, is certainly not one that gets much credence in the forensic toxicology community. The second one, which is about the handling of the patches without gloves and absorption through the skin. Again, that would require such a large dose of fentanyl to be absorbed through the skin that really is an impractical issue. So I don't necessarily buy credence in either of those, though there's no controlled studies obviously published on either. The logic would tell me that there is no adequate excuse in either of those quotes. And as an MRO, I would concur with you, Mike. I'm not aware of MROs who are taking a laboratory confirmed positive and verifying it as a negative based upon those explanations. So that really addresses that question. The other question that was raised is also for you, Mike. And I know that you recently wrote an article for the MROCC newsletter, and it was an outstanding article. I can show it if you want me to bring it up. But Dr. Sauter said recently there's growing concern in the addiction medicine world about synthetic delta-8 THC. I know Dr. Peet has talked about this in terms of urine drug testing when a person wants to contend that they're using CBD and not marijuana. But it raises new issues. So again, there was a request, Mike, that you briefly discuss that. So you can do that with or without my bringing up your wonderful article, which is published by MROCC and which Christine Paciak has posted in the chat. Let me address this without the article. I think there's a couple of issues in here. There is no doubt that the use of synthetic THC delta-8, the isomer, the delta-8 isomer, is supposedly increasing. However, that does not mean that it will be confused for delta-9. The two drugs, delta-8 and delta-9, are distinctly different. They're positional isomers. They're not stereo isomers. Delta-8 has less potency than delta-9. And it can be differentiated quite routinely and is differentiated routinely from the delta-9 version. The immunoassays that are used for the preliminary detection of the cannabinoids will react to both the delta-9 THC metabolite and the delta-8 THC metabolite, but to much less of a degree with the delta-8 version. Secondly, if a urine does test for positive, the standard of care is to confirm the presence of the drug by gas chromatography, mass spectrometry, or some mass spectrometric procedure before reporting the result. And the differentiation of delta-8 THC metabolite and delta-9 THC metabolite by those techniques is certainly something that is routinely done. The labs are routinely performance tested on that, particularly the DOT, SAMHSA labs. And, again, that would not use a delta-8 once that has been worked through a reliable procedure in the lab would not result in a positive delta-9 THC result. Good. I think that's a nice summary. The good news from an MRO point of view is that if it is confirmed as delta-9 THC, it is not going to be a cross-reactivity from delta-8. So I feel confident in the laboratory results. Now we have a question, Danielle, from someone whom you said asked to unmute themselves and speak. So why don't we go ahead and take that question or comment now. Oh, hello. This is Dr. Mary Oberle. I'm a occupational health physician and MRO in New Zealand. And first of all, I'd just like to say, can you hear me? Yes. Yeah, I'd just like to say thank you, thank you, thank you for the position statement. This is really, really important all over the world. We have very similar problems in New Zealand, and we've been struggling with this by ourselves and reached the same conclusions. So it's really nice to actually get all of this confirmed by such experts as yourselves. I think that comments like the one in the chat next to us about, well, recent research indicates that even for tolerant users, five to seven hours should pass since the last use of medicinal cannabis. Well, it is so dependent on all sorts of variables, isn't it? Like the fat and the health condition and the other medications, et cetera, et cetera. So we can't really give an hour limit safely with employers. And so my question is, what's actually happening in the United States at the moment with this? Are people actually losing their jobs because they're on medicinal cannabis as they are in New Zealand? Well, I think from a federal government perspective, if it's medicinal cannabis or non medicinal cannabis, it doesn't matter. If you get the presence of the THC metabolite, the delta nine metabolite in the urine, then that is indicative of cannabis use and requires, obviously, an MRO review. But it certainly is indicative of cannabis use. Now, when you get to each individual states, I'm sure, quite honestly, without being rude, it's a crapshoot because some states have per se laws, but they have per se laws based on the concentration of the metabolite, not the concentration of THC. So it's very difficult to say outside the DOT arena, the federal government arena, what is happening at this point. Thank you. That's really useful. Thank you so much. Dr. Obele, I'll share that I do a lot of work for private companies, and I have one major industrial company that has a drug testing program for its workforce. And they have begun collecting so-called marijuana certificates, which are issued in the state of Virginia, where I live, often after a 15 minute telephone interview with a nurse practitioner in some remote city. It doesn't take long for them to find something that you need marijuana for. And so up to this point, the company has been collecting and dutifully accepting these certificates from employees, but we haven't had a test case. And I keep walking down to human resources to ask what corporate has made of this so far, and what's going to happen when the first person walks in the door, having dropped a roll of paper off a clamp truck or something of that nature, and now they're in a safety evaluation and they have a drug test and they're positive for marijuana. And they say, well, it's from the medicinal marijuana I used last night to sleep. And, you know, I just don't have an answer yet. It hasn't been worked out in the courts, and I don't think it's been worked out practically. And I don't even have an anecdote for you. I'm like you, waiting and wondering. Yes. Thank you. Thank you. I will say that the highway patrols of the states in this country tend to examine accidents that may have been caused by marijuana use based on three parameters. Essentially, you know, was the driver, did the driver cause the accident? Secondly, was there any other reason for that accident? And then thirdly, did the tox lab identify a THC metabolite in the urine or some evidence of THC use? And they go with that triangle of events on a DUI case. And, you know, most often the guys, the drivers plead not guilty, guilty, I mean, because they know that they're going to spend a lot of money and they're probably not going to be successful. It's, you know, I'm an old hand at this, I have to say. It's unlikely in my view that we will ever find a per se THC concentration in blood. There are just too many pharmacokinetic and pharmacodynamic variables in the use of cannabinoids, and I just do not believe that we're going to have that per se law. Unlike alcohol, which is a very simple drug pharmacokinetically, THC is much more complicated, and there's variable responses to an individual smoking a THC cigarette. Yep. So I don't believe we're going to have a per se concentration. So in this country, we clearly have as MROs, a world divided into two parts. And under federal... Oh, the whole world knows about that. And we're not talking about that. I wasn't even bringing that up. Yes. So under federal authority, the answers are currently very clear. And as Dr. Levine mentions, if there's a change in the scheduling of cannabinoids, that could dramatically change the federal position. But in the non-federally regulated world, as an MRO, I am duty bound to follow the guidance of my employer. So I need to look at my employer's policy, how they want me to handle a positive test for marijuana. I am more comfortable telling the employer that the laboratory has tested it, and it is positive for marijuana, and that the donor alleges that they have a marijuana certificate. But I would like to put that monkey on the back of human resources within the company and not make that decision for them. But I'm an agent of the employer. Now, Mike, you mentioned in your paper that one of the other approaches beyond per se levels in the urine or oral fluid is the time elapsed since taking the drug. And I know that there's a precedent for that in the railroad industry, because some of the class A railroads have indicated that for other drugs, not specifically for marijuana, that they advise not using certain opioids, for example, within 8 to 12 hours prior to a work shift. Basically, what they're saying is, if you have an accident and if you test positive for the drug, the burden is going to be on you. So it's a warning to the employee not to take those drugs. And Mike, you commented on that briefly in a prior class. Do you have anything more to say about the railroads and the reason that they set those time limits? Well, I think they sent those time limits probably 20, 30 years ago. And they did it because they wanted to have something, I'm assuming here, something in their policies that they could refer to if there was an accident, which they deemed to be caused by a particular drug that was detected in a toxicology screen. It's OK to do that. Just be prepared that, you know, in the marijuana business, if you have a THC metabolite in the urine and the donor is a fairly heavy user of cannabis, that metabolite in the urine can last a long time. Not just hours, it can last days and occasionally more than that. Right. Now, we have a comment in the chat from Dr. Souders, who's an addiction medicine specialist, who said recent research has indicated that even for tolerant users, a five to seven hour window should pass since the last use to decrease the risk of impairment with respect to driving. Is that what you're thinking of, Dr. Levine, when you talk about a time period before since use? Yes, it is. And obviously, it's guidance. It's not something that, say, for example, an MRO could assess because we don't have like continuous esophageal monitoring or, you know, we don't know what's gone on for all of that period before. But it is guidance to give to an employee about how they should handle their medication responsibly. And that is worth doing. The question is, what are the numbers? I don't know how five or seven hours was arrived at for marijuana. And I'm not quite sure how that's determined, but that's where we need a little bit better understanding. And that's gonna involve probably testing people with simulators and doing potentially some dosing studies and things of that nature to try and get an understanding of at what point can you observe that their performance returns to baseline after use of a particular substance? Just to remind people, and many years ago the federal government spent millions of dollars trying to come to the answer to this question from THC use, and whether THC was impairing or not. And a lot of data was published in the 80s and 90s from those studies. The Dutch have continued to do studies of that nature and recently published a fairly good paper on the impairing effects of THC in driving. So there's a lot of data out there that people could refer to if they wish, but none of it has shown really a good correlation between blood concentration and impairment or necessarily between hours since last use and impairment. Good, well, I'd like to change the subject. Let's all take a deep breath and remember that we're here to help you as you're learning the basics of drug testing and the basics of being an MRO. And a question is posted in the chat and I will show it to you here. And so this is again for you, Mike, but it's an invitation to review the basics with regard to opiate use. If the morphine is confirmed positive between 2000 and 15,000 and the employee denies using poppy seeds and has no prescription, do we still treat that as a negative? So why don't you comment first, Michael, from a toxicology point of view, and then Mike, I'll ask you to comment from an MRO perspective. There are literature reports of use of poppy seeds, particularly in the Pacific Asian communities and some of the middle European communities, the Hungarians, et cetera, who cook with poppy seeds that you can get prescript concentrations in the urine between 10 and 12 or 13,000 nanograms per mil. So I think this rule that's been in place for a long time is probably very careful and being very conservative about that. But as I said, in the recent changes that were put up by DOT, they actually changed this. And Kent and Dr. Levine can certainly comment on that. And they changed it primarily because they view the studies that I just referred to as extreme in nature and not ones that would be routine. Your go, Kent. So basically, with the current regulations, if a person is below the level of 15,000, so 14,999, and they do not admit to using a prescription medication or using someone else's medication, and they really don't understand or know whether they use poppy seeds or not, and they have no prescription, that is going to be treated as a negative. However, at or above 15,000, then the burden of proof is on the donor. And at that point, they're responsible for producing a legitimate medical explanation, which in this case would mean producing a prescription. Do you want to comment on this, Michael? Michael Levine. As somebody who hasn't actively done a lot of MRO work for a number of years, my recollection is that the way I would handle a case like this is I might ask someone to come in for a medical evaluation to make sure there's no obvious signs of substance abuse. And the only other thing that I will contribute to this is from a culinary standpoint, one of my favorite desserts is a poppy seed strudel that you can often find in a Polish deli. And the poppy seed mixture that fills this strudel is literally an inch thick in a spiral, and it's rather generous. And I have no doubt had I ever tested myself after consuming a slice, I would have been in some trouble. So I've got nothing else positive or useful to add. Okay, good. So we have another question that we will take that I've posted, but Dr. Souders, you wanted to unmute yourself and pose a question. Why don't we go ahead with you now? All right, thank you so much. First, I'll need to take a couple of seconds on this about the time. I was referring to a paper by Danielle McCartney and all published in 2021. It was a meta-analysis. It might be interesting. It came to mind as a potential guideline for time of use, but obviously my opinion is the only way to not be impaired by cannabis is to just not use this stuff. So there's that. I think every addiction provider would agree with me on that one. I wanted to go back because I asked this question about the Delta-8. And the reason I wanted to just get on for a second was I wanted to clarify one thing with Dr. Pete and then ask a question. So my understanding was that with hemp products, when people claim that they're using hemp and not cannabis per se, that if they're testing positive, they could have Delta-9, but they could also have Delta-8. And that the presence of Delta-8 was one of the things that helped differentiate hemp use from active marijuana use, but it had to be in a certain ratio. So I was curious what that was. And am I understanding that correctly, first of all? You're sort of on the right track. It's what's called the Agricultural Act that was passed by the federal government, I think five years or so ago, that allowed the growing of hemp legally, but it only allowed legal hemp to have up to 3% THC. Over that, it was considered to be illegal. And the DEA jumped through many hoops to develop standard procedures to determine the amount of THC in hemp, Delta-9 THC in hemp to either qualify as legal or illegal. And that has caused a lot of issues, but it is actually the concentration of THC that is the key factor. So now what we're concerned about now, the new thing in addiction medicine is it's synthetic Delta-8. And these things are being sold in convenience stores and AM, PM mini markets and stuff. And so that would clearly differentiate from hemp use. That would mean to me too, that if it had large quantities of a synthetic Delta-8, it should still screen positive and then be flagged to go and have a confirmation which could then differentiate. And I assume if we see obviously enormous quantities of Delta-8, that would be an obvious positive test and or concern for negative effects either in safety sensitive occupations or in just as people being monitored for abstinence. But would the government have any position about high levels of Delta-8 or would that all still be an illicit substance? No, they would not have a position on that under the current regulations, it's Delta-9. The military actually do monitor Delta-8 in their drug testing program. I'm not sure what, how they treat it in terms of discipline, but there are disciplinary procedures I know for positive Delta-8 in a urine. Okay. I have no idea if it means, you know, kicking them out of the service or what. I doubt it, I really do doubt it. Yeah, but it's, I mean, I suspect we all need to be at least aware of it because it's becoming a problem. And if we're seeing it, it's only a matter of time before you guys are seeing it in the MRO world. I don't think in the MRO, and I understand Dr. Saunders, because I certainly agree it's becoming a problem, but in a DOT world drug testing, I don't think the MROs would be informed if Delta-8 was detected. Yeah, might be something worth discussing again in the future with cannabinoid safety in future DOT regulations, maybe. Yeah, I think we'll all be long gone by then. Yeah. Thank you so much for your time and your expertise. You're wonderful. Thank you. All right, I'm gonna change subjects once again. And again, we are here to make sure that all of you MROs understand the basics. So Dr. Cassandra Roberts has another question and it has to do with a very fundamental issue. Here's the question. With regard to medical safety concerns, do we submit these concerns to employers for every confirmed positive drug test with legitimate use or is it assessed based on drug and job title? I would say that there are no dumb questions. This is a wonderful question and I'm gonna try to give an answer to that. And Dr. Levine, you may want to add to this. By the way, I'm sorry about my hoarseness. I'm having vocal cord surgery a week from today. So I'm hoping that this will go away. So with regard to workplace safety concern, here's where as MROs, we're wearing a second hat. The first hat is whether there's a confirmed positive test for which there is no legitimate medical explanation. And if so, we verify that as a positive. So that's sort of our pharmacology hat. But then the second hat we wear is the one as an occupational physician concerned about workplace safety. So if we, in talking to a person, knowing relatively little about what their safety sensitive job is, if we learn about their taking a prescription medication and we're concerned that that could cause a workplace safety concern, then we have to make a clinical decision. And in the case of the Department of Health and Human Services, this is something done entirely at the option of the MRO. There's no obligation to report a workplace safety concern. If a federal employee under HHS is being tested, it's entirely a matter of choice on the part of the MRO. But with regard to the Department of Transportation, they have a very different point of view. They say that the MRO does have a duty, has an obligation to report a workplace safety concern. But that means a concern that you have as a physician, as an MRO, knowing what you know about the person's job title and their duties. And if you don't ask them, you're not likely to know anything. And based upon the particular medication or substance that was confirmed positive. So this most often would likely come up with regard to opioids. And it's a matter of your judgment. DOT has written, as you know, a very complex protocol where if you do have a workplace safety concern, you do not tell the employer about that immediately, but you talk with the employee. You tell the employee that you have a concern and that you would like to talk with their treating physician, their prescribing physician, and you will give them, if they agree, five days to have their treating physician contact you and you can talk about your concern. If the treating physician says, yes, I understand your concern. I think we can change the medication. Then that's something that treating physician can do. You can not report it to the employer because the employee is gonna take a different medication. If the treating physician says, I don't agree with you. I think this is a legitimate medicine. I don't have a concern about workplace safety. Then it's your judgment as an MRO. And if you still have a concern about workplace safety, then you have the duty and the obligation to notify the employer under DOT. So it is not for every confirmed positive drug test with legitimate use. It's only when you, in your clinical judgment, have a concern. And furthermore, when you've talked about it with the donor and given them a chance to have their treating physician talk to you. So it's a fairly complicated protocol. It's something that we've all now learned to do as MROs. The big concern that many of us have is what do we do during the five days? We know a person's tested positive. We have a concern about workplace safety. We're not allowed to report it yet to the employer. And so there's that pregnant pause or that horrid five days before we can actually make the report. And so that's a concern of many MROs about the current DOT regulations. Dr. Ledween, do you want to make any comments about this? No, I mean, I think you've covered it perfectly. Okay, well, let's see if there's any additional chats or questions. I don't see any at the moment. And we're three minutes from the hour. If anybody wants to unmute and make a comment, you can ask Danielle's permission. And if not, I will remind you that we will have another faculty discussion a month from tonight. It will be on the second Tuesday of October. It'll be on the 11th of October. We welcome your submitting questions in advance. And it's always the second Wednesday, not the Tuesday. Excuse me, the second Wednesday, yep. I mean, so that's a regular time. And hopefully by then, Danielle, you and I will have released the online MRO 2023 version to everybody. That's a goal we can shoot for. Thank you. All right, well, thank you all very much. Thank you, Dr. Levine for being with us. Chris, nobody asked you any questions tonight, but you're still one of the most important people on this panel because the people are all gonna be dealing with you. And you've been so helpful. I've heard so many great things about the way you've assisted people in studying for and preparing to take the exam. So thank you very much for your service. I'm just going to pop in very quickly. Dr. Peterson, from everyone here tonight, we want to wish you all the very best on your surgery on the 28th of September and hope that it yields the best results for you. So we are all sending you our positive vibes and our healing energy. Well, thank you. I'm not aware of any drugs that will help it, so I'm not at risk. Definitely not the poppy seed roll. I've had that. It would be dangerous. All right. Mike, thanks for being with us. You were a star tonight, both Mikes. All right, good night, everybody. Good night. Take care. Bye, everyone.

Dr. Kent Peterson

Dr. Michael Peete

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