the medical review officer: an addiction medicine perspective csam october 9, 2004 by david e....
TRANSCRIPT
![Page 1: The Medical Review Officer: An Addiction Medicine Perspective CSAM October 9, 2004 By David E. Smith, M.D. Past President, CSAM Past President, ASAM](https://reader035.vdocuments.mx/reader035/viewer/2022062421/56649ca55503460f94965ec2/html5/thumbnails/1.jpg)
The Medical Review Officer: An Addiction Medicine Perspective
CSAM October 9, 2004By David E. Smith, M.D.Past President, CSAMPast President, ASAM
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Addiction- Scope of the Problem
• In 1998 6.6% of employees reported current drug use
• Absent from the job 100 hours per year• 3.5 times as likely to be involved in an accident• 5 times as likely to file a Workman’s Comp claim• 3 times as likely to be fired• Alcohol- $ 120 billion• Nicotine- $ 60 billion• Illicit drugs- $ 60 billion
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The Drug Free Workplace Act
• 1996 Executive Order 12564• A comprehensive program prohibiting workplace
drug use• Employees will be educated about drug use• Supervisors will be trained regarding their
responsibility• EAP helping hand programs will be available• Ability to identify drug users including urine
testing
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Civil and Criminal Aspects of Addiction and the Expert Witness
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The Role of the Medical Review Officer
• A positive test does not always identify and illicit drug user
• Must be a licensed Medical Doctor• Knowledgeable of substance abuse disorders• Knowledgeable about how to interpret positive
tests• Verify is there is a legitimate medical explanation• Gatekeeper (Narrow) vs. Addiction Medicine
Specialist (Expanded) Role
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Types of Tests
• Pre-employment
• For Cause
• Return to Duty and Follow-up
• Random- Most controversial– Not triggered by workplace impairment
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Toxicological Considerations
• Screening and Confirmatory tests• Types of Samples- Urine, Hair, etc.• Detection Windows• Screening levels and cutoffs• Drug testing technologies• Validity testing- dilution, temperature,
contaminants• New Regs- Stand downs and PIE’s and NOPE’s
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Scope of Addiction Expert Witness
• Criminal and civil cases• Family custody disputes• Return to work• Appeals evaluations• Professional re-entry evaluations• Complicated workplace situations
– Following an accident• Interpretation of toxicological test results• Compliance with governmental regulations
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Workplace Issues
• Case may be criminal followed by civil – Employer often becomes the deep pocket
• Post Accident- Exxon Valdez Case
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Criminal Issues
• Toxicity
• Developmental Model Issues
• Recall
• Amnesia
• Non-toxic psychiatric co-morbidities
• Intent issues– New Brain, Old Brain dilemma
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Validity Testing
• Verify a urine specimen is consistent with normal human urine– Adulterated– Diluted– Substituted
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Validity (2)
• Treated the same as a confirmed positive– The adulterant got there by physiologic
means– Employee can produce the dilute specimen by
physiologic means– MRO must use best professional judgment– Employee may be directed to get a medical
evaluation by another MD
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Americans with Disabilities Act
• What is covered– Illicit drugs are not covered under ADA
• A using heroin addict is not covered• A heroin addict stabilized on methadone is covered• A recovering (abstinent) addict is covered
**Alcohol is covered under ADA– However, if there are other federal regulations re: alcohol
the employer must comply i.e. B.A. > .02
**A person falsely accused is also covered
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The HHS Certified Laboratory
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HHS CERTIFIED LAB
• Introduction
• Chain of Custody Procedures
• Overview of Testing Procedures
• Drugs Included in the Testing
• Adulterant Testing
• Summary
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Chain of Custody
• Custody and Control Form
• Tamper Evident Bag and Tamper Evident Bottle
• Secured Laboratory
• Internal Chain of Custody
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Introduction
• HHS Certified Lab Procedures
• Two Step Testing Procedure– Screening Test
--Confirmation Test
• HHS Drugs or Drug Metabolites
• HHS Specimen Validity Testing
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Overview of Testing Procedures
• Screening Test or First Test– Immunoassay
• Enzyme Multiple Immunoassay (EMIT)• Florescent Polarization Immunoassay (FPIA)• Kinetic Immunoassay (KIM)• Radio Immunoassay (RIA)
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Overview of Testing Procedures
• Confirmation Testing– Separate aliquot of the Specimen– Gas Chromatography Mass Spectrometry
(GC/MS)
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Quality Controls
• Open Quality Controls
• B Quality Controls for the Analyst
• Minimum 10% Quality Controls
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Overview of Testing Procedures
• Review all the Chain of Custody
• Review the Quality Controls
• Review the Blind Controls
• Review the Screening Test Data
• Review the Confirmation Test Data
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DHHS Drugs
• Cannabinoids
• Cocaine
• PCP
• Opiates
• Amphetamines
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Marijuana metabolites
• Screening 50 ng/ml
• Confirmation 15 ng/ml
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Cocaine Metabolites
• Screening 300 ng/ml
• Confirmation 150 ng/ml
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Phencyclidine (PCP)
• Screening 25 ng/ml
• Confirmation 25 ng/ml
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Opiates
• Screening 2000 ng/ml
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Opiates Codeine
• Confirmation 2000 ng/ml
• Quantitation if Concentration ≥ 1500 ng/ml
• Codeine Metabolites to Morphine
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Opiates Morphine
• Confirmation 2000 ng/ml
• Quantitation if Concentation ≥ 15000 ng/ml
• Heroin Metabolites to Morphine
• Coedeine Metabolites to Morphine
• Morphine as a drug
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Opiates – Heroin6- Monoacetyl Morphine
• An Intermediate Metabolite of Heroin
• Confirmation 10 ng/ml
• Heroin Metabolites to 6- Monoacetyl Morphine and also to Morphine
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Amphetamines Amphetamine
• Screening 1000 ng/ml
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Amphetamine
• Confirmation 500 ng/ml
• Methamphetamine Metabolites to Amphetamine
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Methamphetamine
• Confirmation 500 ng/ml
• Note: In addition 200 ng/ml Amphetamine present
• Methamphetamine Metabolites to Amphetamine
• D- isomer or L-isomer
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AmphetaimesD & L Isomers
• D- Amphetamine
• L- Amphetamine
• D- Methamphetamine
• L- Methamphetamine
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Adulterant Testing
• Creatinine: Normal- greater than 19.9 mg/dl• Specific Gravity: Normal – greater than 1.001 or
less than 1.020• pH: Normal 4.5-9• Nitrite and Other Oxidants• Soap• Bleach• Others
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Reporting Adulterants
• Adulterated: Nitrite 500 mcg/ml or greater. pH 3 or less; pH 11 or greater. Chromium VI 20 mcg/ml or greater (Lab has the option for cut off)
• Substituted: Creatinine 5.0 mg/dl or less Creatine 5.0 mg/dl or less and Specific Gravity 1.020 or greater. Challenge 3.8
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Invalid Result
• Creatinine ≤ 5.0 mg/dl; Sp. Gr. Sp. Gr. ≥ 1.003 & < 1.020
• Specific Gravity ≤ 1.001; Creatinine > 5.0 mg/dl• Abnormal pH (outside 4-10)• Possible (Characterize as Oxidant, Halogen,
Aldehyde, or Surfactant) Activity• Immunoassay Interference• GC/MS Interference• Abnormal Physical Characteristics – (Specify)• Bottle A and Bottle B – Different physical
Appearance
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Rejected for TestingFatal Flaw
• Specimen ID number mismatch / missing
• No collector printed name & no signature
• Tamper- evident seal broken
• Insufficient specimen volume
• Wrong CCF used
• Collector signature not recovered
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Conclusion
• Chain of Custody
• Two Step Testing Protocol
• Five HHS Drugs
• Adulterant Testing
• Reviewed and Certified Results