Improving America’s health, one patient at a time. Urine Drug Screening Update and the Role of the...
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Improving America’s health, one patient at a time.
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
Improving America’s health, one patient at a time.
24.7%
75.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Not Employed Employed
Majority of Drug Users are Employed
Improving America’s health, one patient at a time.
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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Improving America’s health, one patient at a time.
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