Drug Testing in the Workplace by AOM

Drug Testing in the
Workplace
Presented by Dr. Ramesh
Certified Medical Review Officer
Alliance Occupational Medicine

Substance Abuse in the News
The largest oil spill in over 2 decades in the San Francisco Bay
occurred due to substance abuse by the pilot, Capt. John Cota, of a
cargo ship. The Cosco Busan's collision with a Bay Bridge tower in
2007 tore a 211-foot gash in the Hong Kong cargo ship, spilling
bunker fuel. The Cosco Busan spill oiled 69 miles of shore, closed
fisheries and killed more than 2,500 birds.
The NTSB concluded it was caused by Cota's "degraded cognitive
performance from his use of impairing prescription medications.“
The National Transportation Safety Board found that Cota had a
drunken driving conviction, a history of alcohol abuse and
prescriptions for at least nine medications, including Valium;
Vicodin; Zoloft for depression; Ativan, an anti-anxiety drug; Provigil
for sleep disorders; Imitrex for migraines; and Darvon for pain.

Substance Abuse In the News
The accident was the largest oil spill in the bay since 1988. The Cosco
Busan's owner, Regal Stone Ltd., and its operator, Fleet
Management Ltd., both of Hong Kong, agreed to pay $44 million to
settle the civil case.
Capt. John Coto is currently trying to get his Mariner’s license back,
however, the Coast Guard found that Cota "did not meet the
medical standards and the professional qualifications requirements
for renewal." They issued a final denial in Feb. 2012.

Agenda
 Substance Abuse Statistics
 What is Reasonable Suspicion?
 Signs and Symptoms of Substance Abuse
 Components of a Drug Free Workplace Program
 Specimen Testing and Confirmation
 MRO Role in DOT Testing
 Differences in DOT and non-DOT Testing
 Alcohol Testing
 Alternative Testing
 Case Studies

Substance Abuse Statistics
Prevalence of Illegal Drug Use
• Percent of persons 12 years of age and over with any illicit drug use
in the past month: 8.7% (2009) and 8.9% (2010)
• Percent of persons 12 years of age and over with marijuana use in
the past month: 6.6% (2009) and 6.9% (2010)
• Percent of persons 12 years of age and over with any non-medical
use of a psychotherapeutic drug in the past month: 2.8% (2009) and
2.7% (2010)
Source: CDC

Results from the 2010 National Survey on Drug Use and Health
Summary of Findings:
• 2010, Marijuana was the most commonly use illicit drug with 17.4
million current users.
Past month illicit drug use
among persons aged 12 or older

Past Month
Use of
Selected Illicit
Drugs among
Persons Aged
12 or Older:
2002-2010

Past month illicit drug
use among persons
aged 12 or older by
age: 2009 and 2010

Alcohol Use Among Person Aged 12 or Older
• Slightly more than half of Americans aged 12 or older reported
being current drinkers of alcohol in the 2010 survey (51.8%). This
translates to an estimated 131.3 million people, similar to 2009,
130.6 million (51.4%)
• Nearly one quarter (23.1%) of persons aged 12 or older participated
in binge drinking at least once in the 30 days prior to the survey in
2010. This translates to 58.6 million people, similar to 2009 (23.7%)
• 2010, heavy drinking was reported by 6.7% of the population aged
12 or older or 16.9 million people, similar to 2009 (6.8%)
Definitions:
Current Use (past month) –at least 1 drink in the past 30 days
Binge Use- > 5 drinks on the same occasion on at least 1 day in the past 30 days
Heavy Use - > 5 drinks on the same occasion on each of 5 or more days in the past 30
days.

Current binge
and heavy
alcohol use
among
person aged
12 or older by
age: 2010

Driving under the
influence of
alcohol in the
past year among
persons aged 12
or older: 2002-
2010

Driving under the
influence of alcohol
in the past year
among persons
aged 16 or older:
Grouped By age:
2010

What is Reasonable Suspicion?
Must be base on a reasonable belief that the employee is under the
influence of alcohol or drugs on the basis of specific observations
concerning the employee’s:
• Appearance
• Behavior
• Speech
• Body odor
Before
After

EXAMPLES:
Worsening of Personal Appearance
• dress, speech, gait, body odor
Decreased Reliability
• absences, late, sick leave, missed deadlines, etc.
Loss of Problem Solving
• Ignores problems, covers up, blames others, etc.
Decrease in Job Knowledge
• Reduced skills, needs supervisor, slow learning, etc.

EXAMPLES (cont.):
Decrease in Productivity
• many breaks, wastes time, does not complete tasks
Poor Judgment
• bad decisions, tactless, illogical behavior, etc.
Difficulty Working with Others
• poor listening and communication skills, hostile, argumentative, etc.

Signs and Symptoms of Substance
Abuse
• Odor of alcohol
• Odor of marijuana
• Slurred speech
• Flushed swollen face
• Red or runny eyes or nose
• Pupils dilated or constricted or
unusual eye movements
• Lack of coordination
• Tremors, sweats
• Exhaustion, fatigue
• Sleepiness
• Nausea
• Reduced concentration/focusing
• Unauthorized possession of
alcohol or illegal drugs
• Any other suspicious behavior

Components of a Drug Free Work
Place Program
Issued by President Regan in 1986:
• Written policy regarding substance abuse
• Supervisor training
• Employee education
• Employee Assistance Program
• Methods for identifying drug users
(drug testing)

Place Program
Purpose of Drug Testing:
• Reduce illicit/inappropriate use of drugs among workers
• Educate workforce managers and employees
• Identify and remove drug users from safety sensitive jobs
• Treat and rehabilitate drug abusers
• Create a deterrent against drug use/abuse

Place Program
Types of Drug Testing:
• Pre-employment
• Post accident
• Reasonable suspicion/for cause
• Random
• Return to duty
• Follow up to treatment
• Periodic/voluntary

Place Program
Standards of Practice:
• Federally regulated
- DHHS
- DOT
- DOD
• Non federally regulated
- State laws
- Workers compensation
- Union Contracts

Place Program
Drug Testing – 3 Steps
1. Specimen Collection
2. Specimen Testing and Confirmation
3. Medical Review of Results (MRO)
Test for:
- Illicit drugs (urine)
- Alcohol (breath, saliva)
- Other specimens (oral, fluids, hair)

Place Program
DOT Urine Specimen Collection Procedures
1. The collector will ask the donor for photo identification
2. After verification of the donor’s identification, the collector will
complete Step 1 of the Custody and Control Form (CCF)
3. The collector will ask the donor to remove any unnecessary outer
clothing (coat, jacket, hat, etc.) and to leave hand carried items (i.e.
briefcase, pocketbook bags, etc.) outside the toilet enclosure. The
collector will secure these items and provide a receipt if requested
by the donor. The donor may retain his/her wallet, money clip etc.

Place Program
DOT Urine Specimen Collection Procedures (cont.)
4. The collector will direct the donor to empty his/her pockets and
display the contents. Any items which can be used to adulterate or
substitute the specimen must be left outside the toilet enclosure. If
the collector believes that any items were brought specifically with
the intent to adulterate or substitute the specimen, the collector
shall conduct the collection under direct observation.
5. The collector will instruct the donor to wash and dry his/her hands.
6. The collector will provide the donor a wrapped/sealed collection
container and specimen bottle (s). Either the collector or the donor
may open the container/bottle (s) in the donor’s presence.

Place Program
7. The collection container and the specimen bottles must be
separately wrapped. Only the collection container should be taken
into the toilet enclosure. The wrapped bottles should remain
outside the enclosure and be opened in the donor’s presence when
the donor presents the filled collection container to the collector.
8. The collector will accompany the donor to the toilet enclosure where
the donor will provide the urine specimen. The donor will enter the
toilet enclosure and shut the door, the collector remains outside the
close door.
9. The donor will hand the filled collection container to the collector.
Both the donor and the collector should maintain visual contact of
the specimen until the labels/seals are placed over the bottle cap(s).

Place Program
10.The collector checks the specimen, reading the specimen
temperature indicator within 4 minutes of receiving the specimen
from the donor. The collector marks the appropriate box in Step 2
of the CCF. If the specimen temperature is outside the acceptable
temperature range (90-100° F), the collector must direct the donor
to provide another specimen under direct observation. The out-of-
temperature-range specimen is not discarded.
11.The collector checks the specimen volume, ensuring that there is at
least 45 ml. of urine. If the employee is unable to void or voids an
insufficient amount of urine, the employee will be provided up to 40
oz. of fluids and up to three hours to provide the specimen. Any
partial specimen will be discarded.

Place Program
12.The collector checks the specimen for unusual color, odor, or other
physical qualities that may indicate an attempt to adulterate the
specimen. If present, the collector must direct the donor to provide
another specimen under direct observation.
13.The collector will pour at least 30 ml of specimen into a specimen
bottle (Bottle A). The remainder of the specimen (at least 15 ml) will
be poured into a second bottle (Bottle B)
14.The collector immediately places the lid/cap (s) on the specimen
bottles, and then applies tamper-evident label/seals (CCF, Step 3).
15.The collector will write the date on the label/seals. The donor will
be asked to initial the label/seal (s) once they are affixed to the
bottles.

Place Program
16.After sealing the specimen bottles, the donor will be permitted to
wash and dry his/her hands, if he/she do desires.
17.The donor will be instructed to read and complete the donor
certification section of the CCS (Step 5), including signing the
certification statement.
18.The collector will complete the chain of custody section of the CCF
(Step 4), including signing the certification statement, recording the
date and time of the collection, and entering the name of the
Delivery or courier service (e.g. FedEx, DHL, USPS, LabCorp
Courier).
19.The collector will record any remarks concerning the collection
process in the “remarks” in Step 2 of the CCF.

Place Program
20. The collector will place the sealed specimen bottles and Copy 1 of the CCF
into the polyurethane bag and seal it. If the specimens are being
transported by express or common carrier, the bag is placed in a hard-sided
shipping container.
21. The collector will give the donor his/her copy of the CCF (copy 5). The
donor may leave the collection site at the completion of this step of the
collection process.
22. The collector will distribute the remaining copies of the custody and control
form. Copy 2 should be faxed to the MRO listed in Step 1 of the CCF.
Copy 3 is retained by the collector for 30 days. Copy 4 is faxed to the
Designated Employer Representative (DER) listed in Step 1 of the CCF. If
Copy 2 & 4 are not faxed to the MRO and DER respectively, they must be
mailed or send within 24 hours or the next business day of the collection.

Place Program
DOT’s Direct Observation Procedures
1. DOT’s 49 CFR Part 40 directly observed collections are authorized
and required when:
 The employee attempts to tamper with his or her specimen at
the collection site.
 The specimen temperature is outside the acceptable range.
 The specimen shows signs of tampering ∼ unusual
color/odor/characteristic
 The collector finds an item in the employee’s pockets or
wallet which appears to be brought into the site to
contaminate a specimen: or the collector notes conduct
suggesting tampering

Place Program
DOT’s Direct Observation Procedures (cont.)
 The Medical Review Officer (MRO) orders the direct observation
because:
 The employee has legitimate medical reason for certain atypical
laboratory results or
 The employee’s positive pr refusal (adulterated/substituted) test
result had to be cancelled because the split specimen test could
not be performed (for example, the split specimen was not
collected).
 The test is a Follow-Up test or a Return-to-Duty test.

Place Program
2. The observer must be the same gender as the employee.
3. If the collector is not the observer, the collector must instruct the
observer about the procedures for checking the employee for
prosthetic or other devices designed to carry “clean” urine and urine
substitutes AND for watching the employee urinate into the
collection container.
 The observer requests the employee to raiser his or her shirt,
blouse or dress/skirt, as appropriate, above the waist, just
above the navel, and lower clothing and underpants to mid-thigh
and show the observer, by turning around, that the employee
does not have such a device.

Place Program
 The observer requests the employee to raiser his or her shirt, blouse or
dress/skirt, as appropriate, above the waist, just above the navel, and
lower clothing and underpants to mid-thigh and show the observer, by
turning around, that the employee does not have such a device.
 If the Employee Has a Device: The observer immediately notifies the
collector; the collector stops the collection; and the collector thoroughly
documents the circumstances surrounding the event in the remarks
section of CCF. The collector notifies the DER. This is a refusal to
test.
 If the Employee Does Not Have a Device: The employee is permitted
to return clothing to its proper position for the observed collection. The
observer must watch the urine go from the employee’s body into the
collection container. The observer must watch as the employee takes
the specimen to the collector. The collector then completes the
collection process.

Place Program
4. Failure of the employee to permit any part of the direct observation
procedure is a refusal to test.

Specimen Testing and Confirmation
Goals of a Forensic Drug Testing Laboratory
 To discriminate reliably between those specimens which contain
drugs or its metabolite at or above the cut off and those which do
not.
 To determine specimen validity.
 To identify specimens that are substituted or adulterated
 To perform these tests in a legally defensible manner.

Initial Test (Screening Test)
 Immuno assay test which meets the FAD requirement
Negative Specimen
 Any specimen whose apparent concentration of drug or metabolite
is less than the pre-established cut-off concentration fore that drug
or metabolite.
 Not necessarily a specimen containing no drug or metabolite.

Positive Specimen
 Any specimen whose apparent concentration of drug or metabolite
is greater than or equal to the pre-established cut-off concentration
for that drug or metabolite
What is a Cut-Off?
 An arbitrary point on a continuum of possible drug or metabolite
concentrations.
 Use to divide specimens into negatives and positives

HHS Mandated Screening Cut-offs (ng/ml)
• Marijuana Metabolites 50
• Cocaine Metabolites 150
• Opiate Metabolites 2000
• PCP 25
• Amphetamines 500

Confirmatory Test
 A second analytical procedure performed on a different aliquot of
the original specimen to identify an agent or the presence of a
specific drug or metabolite.
 Combination of gas chromatography and mass spectrometric
analysis GC/MS.

DOT Mandatory Confirmation Cut-offs (ng/ml)
• Marijuana Metabolites 15
• Cocaine Metabolites 100
• Opiate Metabolites 2000
• PCP 25
• Amphetamines 250

Validity Testing
 Specimen validity testing is the evaluation of the specimen to
determine if it is consistent with normal human urine.
 The purpose of validity testing is to determine whether certain
adulterants or foreign substances were added to the urine, if the
urine was diluted, or if the specimen was substituted.

Broad MRO Role In DOT Testing
 MRO is the “gatekeeper” of testing process.
 Responsible for review of custody and control form for errors
(negatives & positives).
 Must notify collector or employer when error causes cancellation of
test results
 Must offer to interview donor with Positive, Adulterated, Substituted
and Invalid test results.
 Must review “shy bladder” medical findings
 Must report medical information to employer when safety or medical
qualification is an issue

1. Receive Results
2. Review Results
3. Interview
4. Record Pertinent Findings
5. Revel (in donor explanations)
6. Reconfirm split sample
7. Refer for Medical Evaluation
8. Interpret Findings
9. Report to Employer
10.Release Medical Information
11.Record Keep
MRO Responsibilities in Regulated Testing (9 R’s; 2 I’s)

Laboratory Reporting to MRO
 All test results come from lab to MRO
 Cannot go to TPA or employer
 Negative results can be emailed without a CCF copy
 Lab must report quantitative results on all positive results
 Rejected for testing, adulterated and substituted results must
include standard explanatory remarks

MRO Review of Lab Negative Results
 Review lab results (electronic or CCF)
 Review CCF copy 2 for flaws
 Check negative on CCF copy 2
 MRO staff can conduct review and use signature stamp
 MRP must personally review and sign 5% of negatives

MRO Review of Lab Non-negative Results
 Non-negative result
 Positive adulterated, substituted and invalid
 Must have CCF copy 1 with lab scientist’s signature
 Review CCF copy 2
 Contact and interview donor

MRO Donor Contact Process
 MRO must document 3 attempts spaced over 24 hours to contact
donor.
 After above request, DER to contact donor
 DER must document 3 attempts in 24 hours
 No part of donor interview may be conducted by MRO staff

The Medical Review Interview
 Use standard check list form
 Identify self and affiliation
 Confirm identity of donor
 Explain verification process
 Inquire regarding illicit drug use
 Inquire regarding Rx/OTC drug use and diet
 Donor has 5 days to provide medical use documentation
 If there is a legitimate medical explanation, the test is reported as
negative

MRO Results Reporting
 MRO must review CCF copy 2 before reporting any DOT test results
 Negative results may be transmitted electronically
 Non-negative results must have MRO’s signature
MRO Record Keeping
 Must maintain all CCF copy 2 with signature or stamps with initials
 Negatives – 1 year
 Non-negatives – 5 years
 Drug test results should be separated from patient medical chart
because of confidentiality concerns.

MRO’s and Medical Confidentiality
 MRO’s are required to release medical information to third party
(employer physician, etc.) if the information is:
1) Likely to result in disqualification or
2) Continued performance of the employee’s safety sensitive
functions likely poses a significant safety risk

Differences Between DOT & Non-DOT
Drug Testing
 Tests for additional drugs beyond the 5 drug panel used in DOT
 Tests are different (usually lower) cut-offs than the DOT
 Single specimen tests rather than split specimen tests
 Use of test specimens other than urine
 Collection of prescription medication information at the time of
specimen collection
 Immediate removal of workers from duty pending review by the
MRO if they have lab positive results.

Alcohol Testing
 No Direct MRO Involvement
 Trained Technicians Perform Test: BAT or STT
Alcohol Testing Forms
 Standard DOT form (3 copies)
Alcohol Testing Procedures Screening
 Use EBT or ASD
 Obtain breath or saliva sample
 Result < 0.02 is negative
 Result ≥ 0.02 requires confirmation test

Alcohol Testing
Alcohol Testing Procedures Confirmation
 Obtain breath sample
 Result < 0.02 is negative
 Result 0.02 – 0.039 employee cannot perform safety sensitive
functions
 Result ≥ 0.04 is a violation of rule
 Results ≥ 0.02 immediately reported to DER
 3 copies of printed results

Alternative Specimens
Hair
 Use for pre-employment and random
 Grows at 1 cm/month or 0.3 mm/day
Oral Fluid and Sweat
 Rarely used
Disadvantages
 Variation in detection windows
 Pharmacology not well known
 More expensive
 Proficiency testing programs – difficult to establish

Cases
Case #1: Mr. A is an 18 year old male who comes in for pre-
employment drug screen which comes back positive for
methamphetamines, amphetamines, marijuana, and cocaine. On
MRO review, he offers no medical explanation. He states he was at
a “party” where there was a bucket and everyone who came in was
pouring a lot of “stuff” into it, mixing it all. He drank from it and felt
very “fuzzy”. He knew it was a “stupid” thing to do.
Result: Positive for methamphetamines, amphetamines, cocaine, and
marijuana.

Cases
Case # 2: Mr. B is a 52 year old plumber who came in for pre-
employment drug screen which came back positive for THC. On
MRO review, he stated he had a medical prescription for Dronabinol
2.5mg capsules prescribed for appetite stimulation. He brought in
his medication. We confirmed his prescription use via “CURES”.
Result: Negative drug screen, however, employer was alerted to be
cautious in having him perform “safety sensitive” jobs.

Cases
Case # 3: Mr. C is a 33 year old male who was sent for random drug
screen which was positive for cocaine. On MRO review, he stated
that he had a “bad tooth” which was extracted and he couldn’t bear
the pain so his friend suggested he put some “powdered cocaine”
on the area to help with the pain
Result: Positive for cocaine.

Cases
Case # 4: Mr. D. Is a 36 year old male who came in for post-accident
drug screen which was positive for THC. On MRO review, he stated
he never inhaled or ingested marijuana. However, his room mates
smoked it causing his positive drug screen.
Result: Positive for THC

Cases
Case # 5: Ms. E is a 28 year old female who came in for pre-
employment drug screen who was positive for THC. On MRO
review, she stated she had a “cannabis card” for insomnia and
anxiety. Her employer however had a strict “drug free work place
policy.”
Result: Positive for THC

Cases
Case # 6: MR. F is a 22 year old male send in for pre-employment
drug screen which was positive for amphetamines. On MRO
review, he was prescribed (confirmed by me) Adderall for ADHD.
Result: Negative drug screen.

Thank you!
For Additional Resources, go to:
https://nsduhweb.rti.org/
http://www.dot.gov/odapc/employer.html
http://www.dot.gov/odapc/mro.html
Or contact Dr. Ramesh
(408) 228-8400
jramesh@allianceoccmed.com

Drug Testing in the Workplace by AOM

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