1. Improving America’s health, one patient at a time. Urine Drug Screening Update and the Role of the Medical Review Officer Joseph C. Eshelman, MD,MPH Area Medical Director Concentra Medical Centers Concentra Medical Centers

2. Improving America’s health, one patient at a time. Majority of Drug Users are Employed

3. Improving America’s health, one patient at a time. Illicit Drug Use Among Full-Time Workers Trends by Major Occupation/Industry Code: 2002-2004 Occupation /Industry % Illicit Drug Use Food Services and Preparation16.9 Construction13.7 Arts, Entertainment, and Recreation 11.6 Information11.3 Management of Companies, Admin, Services 10.9 Retail Trade 9.4 Professional, Scientific, and Technical Services 8.0 Mining 7.3 Transportation and Warehousing 6.2 Health Care and Social Assistance 6.1 Educational Services 4.0 Utilities 3.8 Source: Worker Substance Use and Workplace Policies and Programs, 2007

4. Improving America’s health, one patient at a time. Percent Past Month Use of Any Illicit Drug by Age Source: National Survey on Drug Use and Health: 2007

5. Improving America’s health, one patient at a time.

7. Overall Reduced Costs Decrease Substance Abuse Increase Health & Wellness

8. Improving America’s health, one patient at a time. Historical Perspective Workplace testing evolved after military testing began in the late 60’s, early 70’s 1986 Ronald Reagan’s War on Drugs Mandated drug free workplace in all federal agencies 1988 HHS published Mandatory Guidelines for Federal Workplace Drug Testing Programs

9. Improving America’s health, one patient at a time. History Continued 1996 Drug Free Workplace Act 2004 DHHS proposed testing hair, sweat and oral fluids 2010 New (5 th ) Revision of Mandatory Guidelines for Federal Workplace Drug Testing Programs Effective date changed from May 1 to October 1.

10. Improving America’s health, one patient at a time. Collection Procedures/Sites Split specimen Collection Only (no single) Procedures now consistent with DOT Regs. Enhanced proficiency training of collectors mandated including refresher training Enhanced security of stored specimens Annual Inspections Randomly of 5% of Sites

11. Improving America’s health, one patient at a time. Laboratory Testing Ecstasy added to the original 5 drugs Ecstasy – hallucinogenic amphetamine AKA: MDMA (Methylenedioxymethamphetamine )

12. Improving America’s health, one patient at a time. New Confirmatory Test Technologies Federal law requires HHS to establish comprehensive standards for federal drug testing programs requiring the use of the best available technology to ensure accuracy of the test Current test is GC/MS

13. Improving America’s health, one patient at a time. New Type of Testing Permitted Instant testing at the collection facility now permissible Instant tests negative will be reported as such All other specimens must be sent to HHS certified lab, ie drug positive, adulterated, etc.

14. Improving America’s health, one patient at a time. Revised MRO Requirements Must be an MD or DO who has undergone formal training and passed a nationally recognized exam Currently 2 organizations fulfill criteria for formal training and exam: AAMRO MROCC Currently recognized as being equivalent

15. Improving America’s health, one patient at a time. Elements of New Guidelines Unchanged Urine remains the only substance that can be collected by federal workplace drug testing programs. Permitted Reasons for Testing Pre-employment, Random, Reasonable Suspicion, Post Accident, Return to Duty, Follow-up Test, Voluntary Test

16. Improving America’s health, one patient at a time. MRO’s Role Independent and Impartial Advocate Gatekeeper for the integrity and accuracy of the drug testing process Maintenance of Confidentiality

17. Improving America’s health, one patient at a time. Confidentiality Results released only to authorized persons or parties (DER, SAP, DOT, TPA etc.) Results released only after verification process is complete Quantitative (numerical) results are only released to the SAP and employee Employer may receive quantitative results in the event of a legal challenge

18. Improving America’s health, one patient at a time. Relationships Laboratory Designated Employer Representative (DER) Collectors Substance Abuse Professionals (SAP) Third Party Administrators (TPA)

19. Improving America’s health, one patient at a time. MRO Functions Review of all laboratory confirmed drug tests PositiveAdulteratedSubstitutedInvalidDilute

20. Improving America’s health, one patient at a time. MRO Functions cont. Review CCF for validity Interview employee/candidate Determine if legitimate explanation for test result exists Report the test as negative, positive, or cancelled. If Test +, Rx legitimate: MRO negative If this presents a potential safety risk employer and/or appropriate agency is notified.

21. Improving America’s health, one patient at a time. Marijuana Cannabis sativa plant CannabinoidTHC Medical uses Marinol Schedule III drug Approved for treatment of nausea, appetite stimulant

22. Improving America’s health, one patient at a time. Marijuana cont. Urine positive: 1-21 days (infrequent vs. frequent use) Using current cutoff values an infrequent user will test positive for only about 3 days. Effects: hallucinogenic, drowsiness, impaired concentration and perceptual skills Withdrawal: nausea, insomnia, irritability, anxiety

23. Improving America’s health, one patient at a time. Marijuana Decriminalization 13 States so far: Alaska, California, Colorado, Maine, Massachusetts, Minnesota, Mississippi, Nebraska, Nevada, New York, North Carolina, Ohio and Oregon. Under Federal Law it remains illegal No effect on interpreting UDS results

24. Improving America’s health, one patient at a time. Cocaine 2 nd most common drug of abuse for workplace testing programs Medical uses uncommon (Topical, and ENT procedures) Snorted, inhaled (Crack), injected, and used orally

25. Improving America’s health, one patient at a time. Cocaine cont. Urine positive: 2-4 days Effects: stimulation and euphoria Overdose: Confusion, paranoia,seizures,respiratory depression, cardiac arrhythmias, death Withdrawal: fatigue, inc. appetite, depression

26. Improving America’s health, one patient at a time. Amphetamines Amphetamine/Methamphetamine Adderall, Ritalin MDMA (Ecstasy) Methylenedioxymethamphetamine Snorted, injected, inhaled, taken orally

27. Improving America’s health, one patient at a time. Amphetamines cont. Medical Use: ADD, Narcolepsy Urine positive: 2-4 days Effects: Inc. alertness, excitation, euphoria, loss of appetite Overdose: paranoia, psychosis, violent behavior, irregular heart beat, heart failure, death Withdrawal: apathy, depression, excess sleep, disorientation

28. Improving America’s health, one patient at a time.

29. Opiates CodeineMorphineHeroinOxycontinPercocetVicodinDarvocetFentanyl Injected, snorted, inhaled, taken orally

30. Improving America’s health, one patient at a time. Opiates cont. Urine positive: 2-4 days Medical use: pain relief; cough suppressant Effects: euphoria, drowsiness Overdose: confusion, respiratory depression, unconsciousness, death Withdrawal: agitation, anxiety, insomnia, abd. Pain, nausea, vomiting, diarrhea

31. Improving America’s health, one patient at a time. Phencyclidine (PCP) Medical use: None Smoked, injected or swallowed Effects: hallucinogen (illusions, hallucinations, altered perception) Urine positive: 2-4 wks Overdose: panic, aggression, violence

32. Improving America’s health, one patient at a time. Adulteration Definition: Addition to the urine of an “exogenous” substance (not normally found in the human body) OR presence of a “normal” substance at extremely high or low levels not consistent with human urine

33. Improving America’s health, one patient at a time. Detecting Adulteration: Specimen Validity Testing Lab Tests Performed pH Creatinine Specific Gravity Adulterants Nitrites Chromium Halogens

34. Improving America’s health, one patient at a time. Common Adulterants Acids, Bases and Salt Rarely used today; easily detected by pH and specific gravity Oxidants React with drug metabolites preventing detection Most effective with marijuana Some effect with morphine Little or no effect regarding other drugs

35. Improving America’s health, one patient at a time. Common Oxidants Nitrites Clean X, Clear Choice Instant Clean, Whizzies, Urine Luck 6.4 Elevations by Rx meds and various medical conditions Concentrations > 500ug/ml = adulterated Chromium (VI) LL418, Randy’s Clear II, Sweet Pea Spoiler Concentrations > 50ug/ml = adulterated Halogens Urine Luck 6.5 Concentrations > 100ug/ml = adulterated

36. Improving America’s health, one patient at a time. Interesting websites http://www.passyourdrugtest.com/http://www.cleartest.com/ http://www.detoks.com http://www.thealsshop.com/ (Warning: considered graphically adult in content) (Warning: considered graphically adult in content)

37. Improving America’s health, one patient at a time. Questions & Answers