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.

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Urine Drug Screening Update Urine Drug Screening Update and the Role of the Medical and the Role of the Medical

Review OfficerReview Officer

Joseph C. Eshelman, MD,MPHJoseph C. Eshelman, MD,MPHArea Medical DirectorArea Medical Director

Concentra Medical CentersConcentra Medical Centers

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24.7%

75.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Not Employed Employed

Majority of Drug Users are Employed

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Illicit Drug Use Among Full-Time Workers Trends by Major Occupation/Industry Code:

2002-2004Occupation /Industry % Illicit Drug Use

Food Services and Preparation 16.9Construction 13.7Arts, Entertainment, and Recreation 11.6Information 11.3Management of Companies, Admin, Services 10.9Retail Trade 9.4Professional, Scientific, and Technical Services 8.0Mining 7.3

Transportation and Warehousing 6.2Health Care and Social Assistance 6.1Educational Services 4.0Utilities 3.8

Source: Worker Substance Use and Workplace Policies and Programs, 2007

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9.5 %

19.7 %

5.8 %

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Per

cent

age

of P

ast M

onth

Use

12-17 y.o. 18-25 y.o. 26 or older

Percent Past Month Use of Any Illicit Drug by Age

Source: National Survey on Drug Use and Health: 2007

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13.60%

86.40%

3.60%

96.40%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Perc

ent

1988 2008

Year

US Workforce Urine Tests for Drug Use

Positive Negative

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Non-Negative Rates By Drug Category - Urine Drug Tests

Marijuana46.1%

Cocaine10.0%

Amphetamines 11.1%

PCP0.6%

Opiates8.7%

Other 23.6%

Amphetamines

Cocaine

Marijuana

Opiates

Other

PCPQuest Diagnostics Incorporated, 2009. "Cocaine Use Among U.S. Workers Declines Sharply in 2008, According to Quest Diagnostics Drug Testing Index™." The Drug Testing Index. (c) 2009.

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Overall Reduced Costs

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Historical Perspective

Workplace testing evolved after military testing began in the late 60’s, early 70’s

1986 Ronald Reagan’s War on DrugsMandated drug free workplace in all federal agencies

1988 HHS published Mandatory Guidelines for Federal Workplace Drug Testing Programs

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History Continued

1996 Drug Free Workplace Act

2004 DHHS proposed testing hair, sweat and oral fluids

2010 New (5th) Revision of Mandatory Guidelines for Federal Workplace Drug Testing Programs

Effective date changed from May 1 to October 1.

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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

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Laboratory Testing

Ecstasy added to the original 5 drugs

Ecstasy – hallucinogenic amphetamine

AKA: MDMA (Methylenedioxymethamphetamine)

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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

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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.

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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

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Elements of New Guidelines Unchanged

Urine remains the only substance that can be collected by federal workplace drug testing programs.

Permitted Reasons for TestingPre-employment, Random, Reasonable Suspicion, Post Accident, Return to Duty, Follow-up Test, Voluntary Test

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MRO’s RoleMRO’s Role

Independent and Impartial AdvocateIndependent and Impartial Advocate

Gatekeeper for the integrity and accuracy of Gatekeeper for the integrity and accuracy of the drug testing processthe drug testing process

Maintenance of ConfidentialityMaintenance of Confidentiality

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ConfidentialityConfidentiality

Results released only to authorized persons Results released only to authorized persons or parties (DER, SAP, DOT, TPA etc.)or parties (DER, SAP, DOT, TPA etc.)

Results released only after verification Results released only after verification process is completeprocess is complete

Quantitative (numerical) results are only Quantitative (numerical) results are only released to the SAP and employeereleased to the SAP and employee

Employer may receive quantitative results in the event of a Employer may receive quantitative results in the event of a legal challengelegal challenge

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RelationshipsRelationships

LaboratoryLaboratory

Designated Employer Designated Employer Representative (DER)Representative (DER)

Collectors Collectors

Substance Abuse Substance Abuse Professionals (SAP)Professionals (SAP)

Third Party Administrators Third Party Administrators (TPA)(TPA)

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MRO FunctionsMRO Functions

Review of all laboratory confirmed drug testsReview of all laboratory confirmed drug tests

PositivePositive

AdulteratedAdulterated

Substituted Substituted

InvalidInvalid

DiluteDilute

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MRO Functions cont.MRO Functions cont.

Review CCF for validity Review CCF for validity

Interview employee/candidateInterview employee/candidate

Determine if legitimate explanation for test Determine if legitimate explanation for test result existsresult exists

Report the test as negative, positive, or Report the test as negative, positive, or cancelled.cancelled.

If Test +, Rx legitimate: MRO negativeIf Test +, Rx legitimate: MRO negativeIf this presents a potential safety risk employer and/or If this presents a potential safety risk employer and/or appropriate agency is notified. appropriate agency is notified.

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MarijuanaMarijuana

Cannabis sativa plantCannabis sativa plant

CannabinoidCannabinoid

THCTHC

Medical uses MarinolMedical uses MarinolSchedule III drugSchedule III drug

Approved for treatment of Approved for treatment of nausea, appetite stimulantnausea, appetite stimulant

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Marijuana cont.Marijuana cont.

Urine positive: 1-21 days (infrequent vs. Urine positive: 1-21 days (infrequent vs. frequent use)frequent use)

Using current cutoff values an infrequent user will test Using current cutoff values an infrequent user will test positive for only about 3 days.positive for only about 3 days.

Effects: Effects: hallucinogenic, drowsiness, impaired concentration and hallucinogenic, drowsiness, impaired concentration and perceptual skillsperceptual skills

Withdrawal: Withdrawal: nausea, insomnia, irritability, anxietynausea, insomnia, irritability, anxiety

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Marijuana DecriminalizationMarijuana Decriminalization

13 States so far: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 Under Federal Law it remains illegal

No effect on interpreting UDS resultsNo effect on interpreting UDS results

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Cocaine Cocaine

22ndnd most common drug most common drug of abuse for workplace of abuse for workplace testing programstesting programsMedical uses Medical uses uncommon (Topical, uncommon (Topical, and ENT procedures)and ENT procedures)Snorted, inhaled Snorted, inhaled (Crack), injected, and (Crack), injected, and used orallyused orally

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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

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AmphetaminesAmphetamines

Amphetamine/Methamphetamine Amphetamine/Methamphetamine Adderall, Ritalin Adderall, Ritalin

MDMA (Ecstasy) MDMA (Ecstasy) Methylenedioxymethamphetamine Methylenedioxymethamphetamine

Snorted, injected, inhaled, taken orallySnorted, injected, inhaled, taken orally

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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

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Opiates

CodeineCodeine

MorphineMorphine

HeroinHeroin

OxycontinOxycontin

PercocetPercocet

VicodinVicodin

Darvocet Darvocet

FentanylFentanylInjected, snorted, Injected, snorted, inhaled, taken orallyinhaled, taken orally

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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

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Phencyclidine (PCP)

Medical use: None

Smoked, injected or swallowed

Effects: hallucinogen (illusions, hallucinations, altered perception)

Urine positive: 2-4 wks

Overdose: panic, aggression, violence

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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

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Detecting Adulteration:

Specimen Validity Testing

Lab Tests PerformedpH

Creatinine

Specific Gravity

AdulterantsNitrites

Chromium

Halogens

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Common Adulterants

Acids, Bases and SaltRarely used today; easily detected by pH and specific gravity

OxidantsReact with drug metabolites preventing detection

Most effective with marijuana

Some effect with morphine

Little or no effect regarding other drugs

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Common OxidantsCommon Oxidants

NitritesNitrites Clean X, Clear Choice Instant Clean, Whizzies, Urine Luck Clean X, Clear Choice Instant Clean, Whizzies, Urine Luck 6.46.4

Elevations by Rx meds and various medical conditionsElevations by Rx meds and various medical conditions

Concentrations > 500ug/ml = adulterated Concentrations > 500ug/ml = adulterated

Chromium (VI)Chromium (VI)LL418, Randy’s Clear II, Sweet Pea SpoilerLL418, Randy’s Clear II, Sweet Pea Spoiler

Concentrations > 50ug/ml = adulteratedConcentrations > 50ug/ml = adulterated

HalogensHalogensUrine Luck 6.5Urine Luck 6.5

Concentrations > 100ug/ml = adulteratedConcentrations > 100ug/ml = adulterated

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Interesting websitesInteresting websites

http://www.passyourdrugtest.com/http://www.passyourdrugtest.com/

http://www.cleartest.com/http://www.cleartest.com/

http://www.detoks.comhttp://www.detoks.com

http://www.thealsshop.com/http://www.thealsshop.com/

(Warning: considered graphically adult in (Warning: considered graphically adult in content)content)

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Questions & Answers