AAMRO Exam Review
What are the required Specimen validity checks?
* pH * Creatinine * Specific gravity * Oxidation * Visual inspection * Color differences between bottles
Adulterated or Substituted Specimens: How is an adulterated or substituted result reported by the lab to the MRO?
1) Must report laboratory results directly, and only, to the MRO at his or her place of business. You must not report results to or through the DER or a service agent (e.g., C/TPA). 2) Quantitative values including Creatinine and SP Grav 3) Quant for opiate results morph/cod > 15,000 ng/mL 4) Copy 1 CCF
What are the steps for an initial test STT or BAT?
1. ID Donor 2. <0.02 complete form, report to DER 3. >0.02 go to confirmation test BAT only
What are the 5 classes of drugs on the DOT testing panel?
1. Marijuana 2. Opiates 3. Cocaine 4. PCP 5. Amphetamines
What steps must a driver take before he/she may return to work?
1. Negative Return-to-work test 2. SAP determines completed education or treatment
DOT testing For Alcohol
1. Screening Test - Breath or Oral 2. Confirmation Test-Evidentiary (EBT) . ONLY breath
How long must the MRO keep a positive result on file? Negative?
5yrs/1 yrs
What happens after alcohol confirmation test results?
<0.02 end =/> 0.02 employee sign Invalid- cancel repeat if possible Valid results to DER
How much L-methamphetamine must be present to say the cause was "vicks"?
>80% L . or <20% D (methamphetamine)
MRO's Reporting of Result: What part of the chain-of-custody form to report results to the employer?
CCF2
What is the only drug that produces 6-AM on the urine test?
Heroine
Can passive inhalation of cocaine lead to a (+) benzoylecgonine?
NO
How may the testing results be transmitted from the laboratory to MRO?
Secure fax
What percentage of l-methamphetamine would be consistent with the use of Vicks Inhaler?
The 80% or greater . <12,000ng/ml l-meth
Who is the only person allowed to change the SAP's recommendations?
The SAP
MRO Contact and Interview with the Donor: What is the time frame for initial contact?
o 3 attempts in 24 hours -document o DER to contact - if contact 72 hours to MRO, No contact 3/24 hrs document leave message to contact MRO in 72 hrs o If donor decline interview, report results
MRO Review of Results: What functions may be fulfilled by a staff person working under the direct supervision of an MRO?
o Contact the donor to schedule a discussion o Advise donor to have medical information for the interview o Cannot gather medical information o No inquire if they want to speak with you
How long must the laboratory retain positive specimens?
one year MRO may request to hold longer if it looks like a legal case
1/3 What factors are SAPs prohibited from considering when making an evaluation and recommendations?
(1) A claim by the employee that the test was unjustified or inaccurate
3/3 What factors are SAPs prohibited from considering when making an evaluation and recommendations?
(3) Personal opinions you may have about the justification or rationale for drug and alcohol testing.
What are correctable flaws?
* Collector's signature omitted * Non-federal CCF * Expired federal CCF
Shy Bladder What if the employee does not prove 45ml of Urine?
* Discard insufficient specimen and note time on CCF * Encourage to drink up to 40oz * Patient has 3 hours to provide (always a fresh cup) * no specimen within 3 hours, discontinue, note on CCF, contact DER
Lab on finding a correctable flaw?
* Document findings on CCF * Continue testing * Attempt correction * Retain for minimum 5 days attempting to correct MFR from collector
What are the first steps of Alcohol confirmation?
* Ensure at least 15 min waiting period * Tell employee test at end of waiting period * ID donor * Steps 1 & 2 on AFT * >30 minutes do confirmation test * enter elapsed time * not invalidated, compliance DOT sanction
Under what conditions may the donor request a test of split specimen?
* MRO verified specimen Positive and/or adulterated, or substituted * Donor has 72 hours to request * Additional tests (DNA) no authorized
What is a Fatal Flaw?
* No CCF with the specimen * No specimen with the CCF * No printed collector's name and no signature * Two separate collections and one CCF * Specimen ID and CCF do not match * Specimen seal is broken or tampered and split cannot be re-designated * insufficient volume and split cannot be re-designated
What are the MRO's responsibilities in regard to split specimen testing?
* Notify right for a split for (+) or adulteration or substitution * No split for an INVALID * Donor has 72 hours to request * Inform how to request * Employee may be billed by the employer * Inform lab to split * Inform DER of split order
How is a D.O. collection conducted?
* Same gender "body to bottle" * Observer does not need to be trained * Employee declines it is "refusal"
What steps does the collector take... before the employee provides a Urine specimen?
* Secure bathroom for the exam * Check donor ID * Collector has ID * Basic procedure explained * Outer clothing removed * Donor washes hands * Select urine kit * Direct to bathroom (45ml, no flush, reasonable time) * Be alert for attempts to adulterate
Adulterated or Substituted Specimens: How does the MRO report adulteration or substitution to the employer?
* Secure transmission * No preliminary reporting * Copy 2 of CCF and retain a copy, NOT COPY 1 CCF * NO Quant levels to DER or C/TPA but can for consulting SAP
When is a directly observed collection conducted?
* When directed by DER * Invalid result no medical explanation * Canceled (+) test- no split available * Negative-dilute with Creatinine concentration > 2mg/dl but < 5mg/dl * Return to Duty or Follow Up test * When determined by the collector
Adulterated or Substituted Specimens: What doe DOT define as a substituted specimen (specific gravity/creatinine levels)?
*Creatinine < 2mg/dL Specific gravity < 1.0010 * Or > 1.0200 on BOTH initial and confirmatory creatinine tests AND on BOTH initial and confirmatory specific gravity tests on @ separate aliquots
What is the function of the SAP?
*Face to Face assessment and eval *Recommend course or education/treatment *Provide direct report to DER
What does the collector check for when the employee presents a specimen?
*Temperature * Signs of adulteration
When is a SAP evaluation required?
*Verified Positive Drug test * Alcohol >0.04 * Refusal to test *Violation of Drug and Alcohol rule
1/3 Under what circumstances may the MRO report a positive test to the employer without first having spoken with the donor?
1. You may verify a test result as a positive or refusal to test, as applicable, if the employee expressly declines the opportunity to discuss the test with you.
2/3 What factors are SAPs prohibited from considering when making an evaluation and recommendations?
2) Statements by the employee that attempt to mitigate the seriousness of a violation of a DOT drug or alcohol regulation (e.g., related to assertions of use of hemp oil, "medical marijuana" use, "contact positives," poppy seed ingestion, job stress);
What levels of opiates require an exam for "clinical evidence" of abuse or unauthorized use?
2,000-15,000 ng/ml
2/3 Under what circumstances may the MRO report a positive test to the employer without first having spoken with the donor?
2. If the DER has successfully made and documented a contact with the employee and instructed the employee to contact, you and more than 72 hours have passed since the time the DER contacted the employee.
3/3 Under what circumstances may the MRO report a positive test to the employer without first having spoken with the donor?
3. If neither you nor the DER, after making and documenting all reasonable efforts, has been able to contact the employee within ten days of the date on which the MRO receives the confirmed test result from the laboratory.
MRO Contact and Interview with the Donor: When the donor is notified of positive test how long does he have to validate with RX
5 days to produce a Rx if valid 5 days to have doctor produce fit for work
How long after use can the cocaine metabolite benzoylecgonine be detected by urinalysis?
60 hours
MRO Contact and Interview with the Donor: What is the time limit for the donor to respond when told to contact the MRO?
72 hours
What are the pH ranges?
Adulterated: > 11.00 Invalid basic: > 9.0 to <11.0 Normal: 4.5 to 9.0 Invalid acidic: >4.0 to <4.5 Adulterated: 1.0 to <4.0
What information can be released to the donor?
Any tests from MRO Lab package SAP evaluation report NOT SAP Follow up plan
Who can be the representative observer?
As the BAT or STT, you must not allow any person other than you the employee or DOT agency representative to actually witness the testing process
Benzoylecgonine can be detected in the urine of donor using?
Cocaine
MRO Contact and Interview with the Donor: What steps should the MRO take if unable to contact the donor?
Contact the DER to have employee contact MRO (3/24)
What does DOT define as a dilute specimen (specific gravity/creatinine levels)? (40.93)
Creatinine Concentration: > 2mg/dL but < 20mg/dL
What does the screening test technician (STT) do if a saliva screening device does not activate?
Discard and repeat
True/False Consumption of cocoa teas can be accepted as an explanation for verifying a cocaine test as NEGATIVE?
False
True/False Consumption of hemp or other non-prescription marijuana related products can be accepted for basis of a NEGATIVE marijuana test?
False
What are the testing requirements after he/she has returned to work?
Follow up testing at least 6 times in the first year and then as required by the SAP
When can quantitative results be released to the employer?
For legal cases only
MRO Contact and Interview with the Donor: What steps should be followed when neither the employer nor the MRO is able to contact the donor?
Give DER results if no contact in 10 days
What are the metabolites of Heroin?
Heroine --> 6-AM --> Morphine
What may the presence of morphine without codeine indicate?
Heroine abuse
What is Urine specimen is found to be dilute after DO collection?
If recollection under DO is repeat neg-dilute: 1) Ensure recollection was DO 2) If DO report to DER neg-dilute 3)If not DO, immediate recollection under DO
What are the cutoff levels for Oxycodone/Oxymorphone?
Immunoassay: 100ng/mL GC/MS: 100ng/mL
What is the cutoff level for 6-AM?
Immunoassay: 10ng/mL GC/MS: 10ng/mL
What are the cutoff levels for Cocaine (Benzoylecgonine)?
Immunoassay: 150ng/mL GC/MS: 100ng/mL
What are the cutoff levels for Codeine/Morphine?
Immunoassay: 2000ng/mL GC/MS: 2000ng/mL
What is the cutoff level for PCP?
Immunoassay: 25ng/mL GC/MS: 25ng/mL
What are the cutoff levels for Hydrocodone/Hydromorphone?
Immunoassay: 330ng/mL GC/MS: 100ng/mL
What are the cutoff level for amphetamine/methamphetamine?
Immunoassay: 500ng/mL GC/MS: 250ng/mL
What are the cutoff levels for MDMA/MDA?
Immunoassay: 500ng/mL GC/MS: 250ng/mL
What are the cutoff levels for THC?
Immunoassay: 50ng/mL GC/MS: 15ng/mL
What happens if the employee leaves the collection site prior to completion of the testing process?
It is a refusal.
What happens it the employee refuses to hand his hands?
It is considered a refusal
Which form of methamphetamine can be sold legally?
L-Methamphetamine
What prescription medications would cause a positive amphetamine?
L-meth: selegiline, Vicks (OTC) D-meth Desoxyn, Gradumet LD- meth didres, famprofaxone ADHD meds: Vynase, Adderall, ritalin etc
What happens if a correctable flaw is not corrected?
Lab reports "rejected for testing"
Who is authorized to act as a SAP to act as a SAP under the DOT regulations?
MD or DO, Licensed Social Worker, Licensed psychologist, Licensed employee assistance professional, Licensed marriage/family therapist Drug/alcohol counselor.
What are the Amphetamine analogues?
MDMA, MDA, MDEA (not tested)
Split specimens are for:
MRO Verified Positive, Adulterated or Substituted specimens. NOT INVALID
What are the metabolites of morphine?
Morphine --> Normorphine & Morphine glucuronides Morphine --->hydromorphone
Is there any alternative medical explanation for PCP?
NO
Are employers required to offer a SAP?
NO. However to have the employee return to work, SAP eval must be conducted and compliance with SAP recommendations
How is an codeine/morphine test less than 2000 ng/ml interpreted?
Negative lab report. Can be reported by the staff
Can the employee or employer seek a second SAP's evaluation for recommendations?
No
Will synthetic narcotics (such as methadone) test positive for morphine and/or codeine?
No
MRO's Reporting of Result: May the MRO use the lab copy of the chain-of-custody form to report results to employer?
No send CCF2 all reports are signed, stamped and dated
If the donor has a positive opiate test between 2,000-15,000 and has a Rx for an opiate, do they require a physical exam for abuse?
No, the results are determined to be negative
Is a monitored collection a DO?
No. Conducted in multi-stall restroom to assure no tempering
Is the SAP an advocate for the employee or employer?
No. Function is to protect the public interest in safety
May the laboratory transmit results to the MRO via a third-party administrator (C/TPA)?
No. Lab must contact the MRO directly
Can passive inhalation be an acceptable reason for (+) THC on urine exam?
No. Levels are not high enough
Can/should the split specimen test be done at the same laboratory as the first test?
No. Sent to a 2nd lab
When can the collector give the employee permission to leave?
Only after the testing process is complete; urine obtained (45ml) and both collector and employee complete CCF
What are the metabolites of Oxycodone?
Oxymorphone --> Oxymorphine glucuronide also hydrocodone impurities
MRO's Reporting of Result: Transmitted to employer
Phone, fax, mail and via C/TPA
· MRO's Reporting of Result: How should the MRO report the use of family member's prescription medication?
Positive , Authorized only in the donor's name
What steps may the employer take if urine specimen is found to be dilute?
Positive is positive even if dilute Request collect immediately DO for Cr Conc of neg dilute > 2mg/dL but < 5mg/dL Cr. Conc > 5 mg/dL may but not required to test immediately - Test not under DO unless other reason - Treat all employees equal
What are the reasons for a Direct Observation?
RTD Invalid no med explanation Cancelled (+) and no split Creatinine concentration > 2 and < 5 Creatinine concentration >5 if other reasons Observed tampering by collector, adulteration Temp out of range
Adulterated or Substituted Specimens: What are the consequences for the donor of the adulterated or substituted specimen?
Removal from performing safety-sensitive functions
What are the consequences of a positive test?
Remove the employee involved from performing safety-sensitive functions
Negative test results required for ?
Return to Duty Pre-employment Follow up Creatinine Conc >5
What if 2nd lab fails to reconfirm?
Run SVT Send to a third lab
What if the collector see signs of adulteration?
Second collection conducted under Direct Observation Remarks line links 1 of 1 (1st collection) and 2 of 2 (2nd collection) Notify DER was a DO
What is SAP's role in follow up evaluation?
Second face to face eval re-evaluation of requirements Determine success of treatment Written report to DER Must provide aftercare recommendations in report
What can be the medical alternatives for Cocaine?
Surgical use (in system 2-3 days after) TAC
What positive test would indicate the the donor was smoking or consuming marijuana?
THC-V
What are some causes of dilute specimens?
Tampered with, increase hydration
If drug test is (+) Codeine and (+) THC and the donor has a RX for codeine, how does the MRO proceed?
Test is negative for codeine Split can be ordered for THC but not codeine
What is being tested for in the split specimen?
Tests for whatever was confirmed positive in Bottle A
True/False You must not verify a test negative based on information a physician recommended medical marijuana?
The test will be positive
When should the MRO request a d- and l- isomerization?
To determine if the specimen has more than 20% of D-meth.
When can quantitative results be released to the donor?
With in 10 days of written request
Can the donor request a split specimen if he/she has admitted to drug use?
Yes
Are all DOT specimens split?
Yes. (a) 30ml/ (b) 15ml Collector dates label and employee initials Discard remainder if not needed for other testing
What are the major metabolites of codeine?
codeine-->morphine codeine --> hydrocodeine->hydromorphone
What are the metabolites of Hydrocodone?
hydromorphone 6-hydrocodone
Is there any medication used in dentistry that metabolizes into benzoylecgonine (other than cocaine)?
no
MRO Review of Results: May the MRO consider previous or subsequent drug test results when reviewing a positive drug test?
no
MRO Contact and Interview with the Donor: What are the specific objectives to be accomplished during the MRO's interview with the donor?
o Inform (+) for what drugs o Verification o Possible medical examination o Inform you can tell 3rd party if it affects safety o Obtain medical reasons for the results
MRO's Reporting of Result: What are the specific categories of drug test results?
o Negative o Positive o Rejected for testing o Adulterated o Substituted o Invalid
MRO Review of Results: What functions must be performed personally by the MRO?
o Provide a medical review of the test o Interview the donor o Determine legitimate medical explanation for non-negative tests o Timely flow of test results o Notify of drug results
MRO Review of Results: What are the MRO's responsibilities with regard to review of negative results?
o Review copy 2 CCF for errors o Review result and is consist with CCF o Have: Copy 2 CCF with employee signature, Copy 1 CCF or electronic las results o Check negative on CCF o Report in confidential manner
At what pH ranges should the MRO consider time and temperature affecting the specimen?
pH 9.0-9.5
Up to what positive codeine/morhine level can be attributed to poppy seed ingestion?
up to 15,000 ng/ml
Can extended use of CBD lead to a (+) THC urine?
yes
What may be included in the employee's evaluation by a Substance Abuse Professional?
· Clinical evaluation/assessment, recommend education and/or treatment, written report directly to DER
In federally regulated testing, what step is required for MRO during opiate verification that is not required when verifying the other 4 classes of drugs?
· Evidence of rx and physical signs of abuse.
What cutoff levels are used in split specimen testing?
· You must conduct this test without regard to the cutoff concentrations
MRO's Reporting of Result: At what point may the MRO report a positive, substituted, adulterated or invalid result to the employer?
·After 72 hours/10 days or safety issue A negative result? (40.127-161) after verification
Codeine/Morphine level reported between 2,000-15,000 ng/mL is negative if:
1) Donor has valid Rx 2) No admission of misuse AND no clinical evidence found
Prescription medications that cause (+) THC
1) Dronabinol (Marino, Syndros) 2) Sativex (CBD-Cananda) 3) Epidolex (CBD) 4) Protonix
What are the opioids tested for?
1) Morphine 2) Codeine 3) 6-Acetylmorphine 4) hydrocodone 5) hydromorphone 6) oxycodone 7) oxymorphone
What steps must the MRO take if a specimen is found to be dilute?
1) Report to DER that specimen is +/- and dilute 2) Check "dilute" box Copy 2 CCF 3) Employer May direct employee repeat specimen immediately (DO if Cr Conc of neg dilute > 2mg/dL but < 5mg/dL) 4) immediate recollect under DO
Codeine/Morphine level reported between 2,000-15,000 ng/mL is positive if:
1) admission of misuse 2) evidence of abuse on clinical exam