Common Components

Regardless of whether the testing protocol is regulated or nonregulated, there are common components. Collection and consent forms are necessary to document the identity of the donor using a driver's license or similar identification and to maintain a chain of custody. Proper collection procedures, either witnessed or nonwitnessed, are required to ensure the donor is actually providing the urine sample. It may be necessary to turn off water to sinks and to use bluing agents in the toilet water in the collection room to prevent the donor from using water from the sink or toilet. In addition, measuring urine temperature, creatinine, and specific gravity can help to assure the substance in the collection bottle is urine from the individual being tested.

Circumstances also dictate whether the donation of the specimen is witnessed or not witnessed. The only way to effectively prevent the use of specimens hidden on the donor's person is to witness the collection, yet this invades the person's privacy and takes more time. Many drug protocols call for a witnessed sample only if there is a specific indication that the person is using drugs or might hide the specimen in a container on his or her person (Figure 10.1).

Specimen security is important in ensuring the specimen is not tampered with between collection and testing. Measures may include secured refrigerators and the use of forensic containers and security sealing tape. All regulated and most unregulated testing requires a two-step laboratory

Figure 10.1. This artificial penis and bladder apparatus was used by an agricultural worker to provide a specimen for drug testing.

process of screening with an inexpensive kit and confirmation of positive results with the more expensive, but highly accurate, gas chromatography and mass spectrometry units.

The choices of illicit drugs to be tested vary from the five plus alcohol required by SAMHSA (the so-called SAMHSA Five: cocaine, amphetamines, opiates, marijuana, and PCP) for regulated testing, to 15 drug panels provided for nonregulated testing. Some companies, disappointed at the small number of drugs being tested for in the regulated testing program, test an expanded panel at the same time.

All regulated and many nonregulated programs require that laboratory reports be sent to a physician acting as a medical review officer (MRO). It is the MRO's responsibility to ensure that the process was done properly and to call the donor to make sure none of the substances are being taken by prescription for a legitimate medical reason. Medical review officer qualifications include training and certification through the Medical Review Officer Coordinating Council (www.ACOEM.org).

The American College of Occupational and Environmental Medicine teaches in its MRO course that the responsibilities of the MRO include:

1. Receive the results either by mail or secure fax.

2. Review the results.

3. Investigate, inquire, or interview the donor if there is an unexplained positive.

4. Record the findings.

5. Record the donor's excuses for a positive response (and do not be tricked by them).

6. Order a reanalysis or retest if appropriate.

7. Refer the donor for a medical evaluation if necessary.

8. Interpret the findings.

9. Report the results to the employer.

10. Release the medical information appropriately.

11. Keep appropriate records.

The MRO must be aware of scams used by drug users to falsify drug test results and the sources of false positives (20).

When positive reports of drug or alcohol testing are transmitted to the employer, the employer has four choices, depending on whether the testing is regulated or unregulated and what the company drug policy says:

1. Do nothing.

2. Remove the employee from duty until rehabilitation is completed.

3. Keep the employee on duty until rehabilitation is completed.

4. Terminate the person's employment.

Each of the six federally regulated programs has different requirements for removal from duty and rehabilitation. All require input from a substance abuse professional (SAP) to organize and supervise the rehabilitation and repeat negative testing. Requirements for rehabilitation in nonregulated testing depend on the company policy, state law, and union agreements. While programs vary, rehabilitation typically includes 12-step groups, counseling, group therapy, education, and repeat drug testing. In regulated and most nonregulated programs, repeated drug tests and ongoing participation in 12-step groups and counseling are required for the employee to remain at work.

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