2018 Medical Review Officer (MRO) Case Studies

1 March 2018 Medical Review Officer case StudiesDepartment of Health and Human ServicesSubstance Abuse and Mental Health Services AdministrationCenter for Substance Abuse PreventionDivision of Workplace Programs1 2018 Medical Review Officer (MRO) case Studies These case Studies provide examples to supplement the Department of Health and Human Services (HHS) MRO Guidance Manual, effective October 1, 2017. The manual and case Studies apply to federal agency drug testing programs that come under Executive Order 12564 dated September 15, 1986, section 503 of Public Law 100-71, 5 section 7301 note dated July 11, 1987, and the HHS Mandatory Guidelines for Federal Workplace Drug Testing Programs using Urine (January 23, 2017 Federal Register, 82 FR 7920), effective October 1, 2017.

2 The manual and case Studies do not apply to specimens submitted for testing under Department of Transportation (DOT) Procedures for Transportation Workplace Drug and Alcohol Testing Programs (49 CFR Part 40). The MRO case Studies will be updated as needed to reflect new information. The current version is available on the Drug Testing page under Medical Review Officer (MRO) Resources on the Substance Abuse and Mental Health Services Administration (SAMHSA) website: 2 Table of Contents case #1: Specimen Test Result: Positive for M arijuana Metaboli te ( 9-Tet rah ydrocannabinol-9-Car boxyli c Acid [ 9- THCA]) 30 ng/mL.. 4 case #2: Specimen Test Result: Positi ve f or Morphine 5,200 ng/mL.. 5 case #3: Specimen Test R esult : Positi ve f or C odeine 4,800 ng/mL and Morph ine 2,500 ng/ mL.

3 6 case #4: Specimen Test R esult : Positi ve f or C odeine 17,340 ng/mL and Morph ine 6,350 ng/ mL.. 7 case #5: Specimen Test Result: Positi ve f or M ethampheta mi ne 950 ng/ mL.. 8 case #6: Specimen Test Result: Posit ive for C ocai ne M etabolite (B enz oy lec gonine [BZE]) 1,200 ng/mL.. 9 case #7: Specimen Test Result: Positi ve f or Morphine 3,150 ng/mL..10 case #8: Specimen Test R esult: P ositiv e for Methampheta mi ne 1,250 ng/mL with 225 ng/mL Amphetamine..11 case #9: Specimen Test Result : Positi ve f or M ethampheta mi ne 942 ng/ mL with 250 ng/mL Amphetam ine..13 case #10: Specimen Test Result: Adulter ated; Nitri te = 850 m cg/m L..15 case #11: Specimen Test Result : In valid Result; O xidant Ac tivi ty 50 m cg/mL Chromiu m(VI) equiva lents.

4 16 case #12: Specimen Test R esult: Adulte rated Nit rite = 1800 mcg/ mL and Inva lid Resul t Bot tl e A and Bottle B Different Physical Appea ranc e..17 case #13: Specimen Test R esult : Positi ve for M orphi ne 5 ,000 ng/mL and Adultera ted Ch ro miu m(VI) = 90 mcg/ mL..18 case #14: Specimen T est R esult : Positive f or M arij uana Metabolit e ( 9-T HCA) 6 0 ng/mL and Cocaine Metab olite (BZE) 120 ng/ mL..19 case #15: Specimen Test R esult: Substituted Creatinine = m g/dL and Speci fi c Gravi ty = 05..20 case #16: Specimen Test R esult : N egative and Dilute Creatinine = m g/dL and Speci fi c Gravi ty = 2..21 case #17: Specimen Test R esult: Substituted Creat in ine = m g/dL and Speci fi c Gravi ty = 05 a nd Inv ali d R esu lt Abnormal pH = 4.

5 0..22 case #18: Specimen Test Result: Rej ect ed for T esting Fatal Flaw : Bottle A la bel/seal broken..23 3 case #19: Specimen Test Result: Inv alid t wo times, different reasons Negative on second observed collec ti on..24 case #20: Split S pecimen Test Result: F ail ed to R ec onfirm f or Marij uana Metabo li te Reaso n: Invalid Resu lt Ox idan t Ac tiv ity 200 mcg/mL Nitr ite Equivalen ts..26 case #21: Split S pecimen Test Result: Failed to R econfirm Cocaine Metabolite (B ZE) BZE no t detect ed..27 case #22: Split Specimen Test Result: Failed to Reconfirm [Chromium(VI)] ..28 case #23: Medical Marijuana Specimen T est Result: Positi ve f or Marijuana Metabolite ( 9-T HCA) 420 ng/mL..29 case #24: Morphine Not R eported P ositive Specimen Test Result: Positi ve f or 6- Acet ylm orphi ne (6-AM) 17 ng/mL.

6 30 case #25: Specimen Test R esul t: In valid Two T im es, Differe nt Reaso ns; Acceptable Expl anation for Abnormal pH (Transit T ime/Tem pe rat ure)..31 case #26: Specimen Test R esult : In valid Two Tim es, Same Reaso n; Negative Resu lt Req uir ed Med ical E valuati on ..33 case #27: Collector Errors MR O R esponsibiliti es Specim en Test Result: Positi ve for Coca ine M etabolite (B ZE) 10,564 ng/mL..35 Ca se # 28: Specimen Test Result : Posi tiv e f or C odeine 15,340 ng/mL, Morphi ne 4,350 ng/mL, and Oxycodone 2,320 ng/mL..36 Ca se # 29: Additi onal Drug; Veri fied Negative Drug Possi ble S afety Concerns Specimen Test R esult: Positive for Morphine 2,350 ng/mL..37 Ca se # 30: Specimen Test Result : Positive for Hydro morphone 600 ng/mL and Codei ne 3 ,350 ng/mL.

7 39 Ca se # 31: Specimen Test Result: Posi tiv e f or Oxycodone 2,510 ng/mL ..40 Ca se # 32: Specimen Test R esult : Posi tiv e f or C odeine 15,340 ng/mL and Morph ine 2,350 ng/m L..41 4 case #1 Specimen Test Result: Positive for Marijuana Metabolite ( 9-Tetrahydrocannabinol-9- Carboxylic Acid [ 9 -THCA]) 30 ng/mL. Laboratory Report: The la boratory s ent an electronic report and faxed a copy of the completed Federal Drug Testing Custody and Control Form (CCF) (Copy 1) . The i nform ation on t he el ectronic repor t matched the inform ation on t he F eder al CCF. The collector us ed the term expr ess car rier in S tep 4 of the Federal CCF rather t han stating the specific name of the deli very se rvic e. Otherwi se, t he Federal CCF was properl y co mpl eted by the coll ector and the labor ator y.

8 Discu ssi on: A collector is r equir ed to provide the specific name of the de liver y s ervi ce on the Federal CCF ; how eve r, it is considered an insignificant discrepancy w hen the correct name i s not provi ded. No acti on is nee ded to co rrect the discrepancy. Before a final determi nat ion can be made, the Medical Review Officer (MRO) must d iscuss the positi ve test r esul t wi th the donor. During the donor interview, the donor claims he tested positi ve because of passive i nhalation. He states that he w as at a par ty on Saturday ni ght at which seve ral individuals were smoking marijuana, but he did not s moke marijuana himself. The Federal CCF documents that the donor s specim en w as coll ected two d ays aft er the claimed pass iv e ex posure occ urr ed.

9 Conclusion: Clinical Studies have sho wn that it i s highl y u nlikel y t hat a n on-smoking individual could inhale suf ficie nt sm oke by passive i nhalation to r esult in a sufficient dr ug con centra tion in urine for detec tion at t he cuto ff concentrations used in t he fe dera l agency program. The circumstances descri bed by the dono r do not explain the presence of t he marijuana metabolite in the donor s ur ine . The MRO may not accept a claim that a laboratory positive result is due to passive inhalation or ingestion of edible products containing tetrahydrocannabinol (THC). MRO Report: Positive for Marijuana Metabolite. References: HHS Medical Review Officer Guidance Manual for Federal Workplace Drug Testing Programs (October 1, 2017, Rev.)

10 0318), item , page 4-8; item , pages 7-6 to 7-7. Mandatory Guidelines for Federal Workplace Drug Testing Programs using Urine, 82 Fed. Reg. 7920 (January 23, 2017), Section 5 case #2 Specimen Test Result: Positi ve f or Morphine 5,200 ng/ mL. Laboratory Report: The la boratory s ent an electronic report and an image of the compl eted Federal CCF (Copy 1) . The i nform ation on t he el ectronic repor t matched the inform ation on t he Feder al CCF. The F eder al CCF was pr operl y co mpl eted by the collector and the laboratory. Discu ssi on: Duri ng the interview wi th the donor, the donor does not recal l u si ng a ny pr esc ription medications t hat may have contai ned codeine or morphine. T he d onor als o does not recall having eaten any poppy seeds ar ound the time of the uri ne collection.