The role of Medical Review Officer (MRO) for physicians to obtain and understand drug test results have been shaped by a number of employers and federal regulatory authorities. The intention of this chapter is to provide the person who reads with a common idea of frequently tested drugs, and their features that may affect analytical results, and issues significant for the medical review officer. Moreover, the basis of justifiable medical explanations for positive tests that are laboratory-confirmed are discussed, and distinguished from those details that may be convincing or probable. With the omission of opiates, lawful medical descriptions are supposedly considered to be authenticated current directions from a physician (that is licensed) in the name of the person submitting the drug test specimen. A optimistic opiate outcome creates distinctive challenges for the MRO, and these will also be highlighted in details. The consequences of over-the-counter food items, prescriptions, and occupational as well as environmental exposure to drugs as a result giving positive test results will also be highlighted. It may also be said that medical doctors serving as medical review officers must be well-known with the legal, medical and toxicological concerns for the drug testing.
The goal of a drug-free federal workplace was established by the President Reagan’s Executive Order # 12564 of the year 1986, leading to which the Congress approved legislation effecting implementation of the executive order (Section 503 of Public Law 100-71, August 14, 1987). The secretary of the Department of Health and Human Services (DHIIS) prepared the obligatory Guidelines for Federal Workplace Drug Testing. These guiding principles also appeared in the Federal Register on April 11, 1988, which also helped to produce reliable and accurate drug testing, design uniformity in federal agency drug-testing plans, employee access to records, and privacy of drug test results, and also to ensure central oversight of the federal workplace drug-testing program. Workplace Performance and Technical Research Branch of the National Institute on Drug Abuse (NIDA), a division of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) were given the responsibility for the administrating of the workplace drug testing program, but later, under the Clinton administration, ADAMHA was dissolved and these tasks were transferred to the newly developed Substance Abuse and Mental Health Services Administration (SAMHSA), which was a separate body from NIDA.
The Department of Transportation (DOT) showed their concerns and issued drug-testing regulations in 1989 that made obligatory for employers in transportation industries to put into practice drug testing of workers in safety-sensitive situations. The DOT practical rule (49 CFR Part 40) covers the complete drug-testing procedure which the employers must exercise in implementing their programs. It can be said that the 49 CFR Part 40 is modeled after the DHHS guiding principle, although it have some provisions. After the DOT’s issue, the Nuclear Regulatory Commission (NRC) department also issued guidelines mandating drug testing in the nuclear power industry, and also highlighted the procedures used in those programs which we also largely based on the DHHS Guidelines model.
Many other states also oblige that all workplace drug testing conducted by employers pursue any of the DHHS Guidelines or DOT regulations, which also included the use of a certified drug-testing laboratory for sample analysis. One key component common to DHHS, DOT, and NRC drug-testing regulations is the requirement that a medical review officer interpret urine drug test results. The statutes of 17 states include necessities for an MRO. Whereas, most workplace drug-testing programs have incorporated a requirement for an MRO; to analyze and understand laboratory-confirmed positive drug test results.
The DOT regulation highlights the MRO to have the following characteristics; most important being working as a licensed physician, have clinical experience in controlled substance and or abuse disorders, including medical explanations for laboratory-confirmed drug test results and other detailed medical alternatives information and is well-informed and up to date about these characteristics. Furthermore they also require the MRO to be outstanding with issues connecting to adulterated and substituted samples, and also the possible medical causes of samples leading to an illogical outcome. And they also require knowledge of the DOT rules. The DOT regulations further highlighted that the MRO must be given qualification training, including instruction on the following topics:
1. Collecting procedures for Urine samples;
2. Chain of custody, reporting and record keeping;
3. Explanations and validity of drug test results;
4. The guidelines for an MRO while working in the DOT drug-testing program;
5. The communication with other members participating or in some way concerned in the program (e.g., substance abuse professionals, employer representatives);
6. Requirements of DOT rules applying to all people whom the MRO reviews experiment consequences.
The MRO must satisfactorily complete an examination after completion of qualification training, administered by a nationally renowned MEMO certification board or subspecialty board for medical practitioners in the field of medical review of DOT-mandated drug tests. The examination must broadly cover all the essentials of qualification training listed above.
The DOT regulations require that MROs complete ongoing education requirements of at least 12 professional growth hours every 3 years after passing the certification examination, in order to maintain qualification standards. This ongoing education must contain substance regarding inventive technologies, rule changes, interpretations recent guidance and other information about developments in MRO practice and must include assessment tools. There is no authoritarian requirement to take supplementary certification examinations.
Thousands of physicians have contributed in training courses for MROs sponsored by various organizations, including the American Society of Addiction Medicine, the American Association of Medical Review Officers and the American College of Occupational and Environmental Medicine. Moreover, a few thousands have passed certification examinations offered by the American Association of Medical Review Officers and the Medical Review Officer Certification Council. essential guidance for federal MROs is given in the Medical Review Officer Manual for Federal Agency Workplace Drug Testing Programs, November 1, 2004 (id. Additional sources of information for the MRO include Medical Review Officer’s Manuals by Swotinsky and Smith and several newsletters.
MRO laboratory relationships are also prohibited by the Federal regulations as follows: the MRO shall not be an employee or agent of or have any monetary interest in the laboratory for which the MRO is reviewing drug test results. Also, the MRO shall not derive any financial advantage by having an organization use a particular drug-testing laboratory or have any agreement with the laboratory that may be construed as a potential offender of interest. Thus, most employers arrange for MRO services separately from their contract or arrangement with a drug testing laboratory.
This chapter gives an impression of frequently tested drugs and reviews the genuine medical explanations for positive test results as well as reasons that may affect the analytical outcomes. A basic understanding of the analytical techniques used in the drug-testing laboratory is assumed. Discussions are generally limited to OTC medications and prescriptions that are officially obtainable in the United States. Other countries have different pharmacopoeias and practices in providing medication. Guidelines have been developed by various regulatory agencies to deal with the issue of prescription and OTC medications acquired in other countries.
The DOT rule, for instance says the following about MROs consideration of medications acquired in a remote country. In determining whether a legitimate medical explanation subsists, you may consider the employee’s use of a medication from an overseas country. Specialized judgment must be exercised constantly with the following principles:
1. There can be a legal medical clarification only with respect to a material that is obtained officially in a distant country.
2. There can be a legal medical explanation only with respect to a substance that has a legal medical use. Use of a drug of abuse (e.g., heroin, PCP, marijuana) or any other substance that cannot be viewed as having a legal medical use can never be the basis for a rightful medical explanation, even if the substance is obtained legally in a foreign country.
3. Use of the material can form the basis of a legal medical explanation only if it is used constantly with its appropriate and intended medical purpose.