Public Policy Statement on the Role of Medical Review Officers
The function of a Medical Review Officer (MRO) to review, interpret, and recommend action on the results of workplace drug testing, is critical. The person executing this function must be trained in medicine, be well-versed in laboratory testing processes and interpretation of laboratory results, and be knowledgeable about: (1) the spectrum of organic diseases which require treatment by controlled substances or by other substances that produce metabolites that are controlled substances or that are indistinguishable from controlled substances, and (2) legally available substances that may test positive for proscribed substances.
Given the multiple points in the drug testing process where errors of commission or omission can occur, and given the potentially devastating consequences to the individual tested, to the employer sponsoring the test, and to the larger society that relies on the test, it is clear that the Medical Review Officer must be a licensed physician. While other health care disciplines may have the training to perform certain components of the MRO function, only a licensed physician has the skill, training, state-sanctioned authority, and risk management aptitude appropriate for the complete spectrum of MRO activity.
To promote adequate knowledge, training, and skills, and to determine the duties of the MRO, the American Society of Addiction Medicine recommends the following:
A. The MRO is a licensed medical doctor or doctor of osteopathy. The MRO has a recognized medical degree, including M.D., D.O., or M.B. The MRO has a license to practice medicine which is current, unrestricted, and in good standing.
B. The MRO has appropriate knowledge of substance use disorders. Knowledge is evidenced by medical training and/or practice experience in the fields related to MRO duties. The MRO has successfully completed at least one of the following: a residency/fellowship program which devotes a significant amount of time to substance use disorders; or the MRO has successfully completed a minimum of 40 hours of continuing medical education, including 20 hours of accredited category I CME in toxicology, pharmacology, use and abuse of controlled or addictive substances, the interpretation of laboratory test results, and assessment, referral, and treatment of those with chemical dependency.
Alternately, this knowledge should be evidenced by certification in addiction medicine or occupational medicine by a member board of the American Board of Medical Specialties or successful completion of an MRO certification examination given by a national medical specialty society recognized by the American Medical Association (AMA) or the American Osteopathic Association (AOA).
C. The MRO should have the ability and training to interpret and evaluate urine, blood, breath, or both body fluid or body substance test results.
1. Training for this is evidenced either by certification in medical toxicology by a member board of the American Board of Medical Specialties or by a national medical society recognized by the AMA or AOA, or by the successful completion of approved courses in toxicology and pharmacology in medical or osteopathic school, residency, fellowships, or by approved continuing education recognized by the AMA or the AOA.
2. The MRO has appropriate knowledge of methods and procedures of drug testing laboratories, as evidenced by medical training in this subject area, or by practice experience in testing laboratories, or that involves the use of testing.
3. The MRO keeps abreast of literature on pharmacokinetics and toxicology in order to recognize and understand the latest developments in drug testing capabilities and potential sources of error in the drug testing process, and attend continuing medical education courses on laboratory methods and the role of the MRO.
4. The MRO has appropriate knowledge of addiction medicine.
D. The MRO is informed about relevant rules and regulations pertaining to drug testing, including the current regulations of the federal and/or state agency that is responsible for implementation of testing in the industry in which the MRO is working, and the drug testing policies of the company for which the MRO is working.
E. The MRO is knowledgeable about workplace operations and issues, including employee fitness for duty issues related to psychoactive substance use and workplace and public safety, including interpretation of functional job requirements, employment of those with a history of substance use, and workplace safety and security considerations. He or she is knowledgeable about the relationship between the medical requirements of the particular industry for which the MRO services are being performed and employee fitness for duty issues raised in the course of MRO evaluations.
F. The MRO exercises care to assure that reports are confidential as required by applicable law and regulation, and are accessible only upon written authorization for release of information or to persons who have a legitimate need to know test results, as required by law, or who have a fiduciary relationship with the MRO in the exercise of the MRO function. All information, unless legally excepted, is deemed confidential, and where medical information that is provided to the MRO by an individual is kept confidential. Where required and legally permissible, medical information that suggests that an individual is a safety risk may be disclosed to employers, regulatory bodies, or other reasonably identifiable third parties who have a legitimate legal need to know. Where disclosure of medical information is required and legally permissible, the individual is given notice prior to the exploration of the positive result that such medical information may be disclosed.
II. Essential Duties of an MRO Include:
A. Evaluation of drug laboratory reports in a timely fashion.
B. Assessment of the collection process through careful review of custody and control documents, and verification of appropriate documentation through a uniform and systematic set of procedures. The MRO assesses such critical information as name, signature, social security number, and specimen identification number. The MRO assesses whether the custody and control documents have proper collection site signatures. The MRO assesses custody and control forms and laboratory results for documentation of suspicious behavior or adulteration (pH, specific gravity and creatinine), as required under different testing programs.
C. Prompt reporting of negative tests to the employer, and maintains confidentiality of test results and medical information. Care is taken that reports are accessible only to persons who have a need to know test results, or who are employees of the MRO associated with the MRO function.
D. Reviewing positive tests to determine on a case-by-case basis whether there could be an alternative medical explanation for the presence of a drug or class of drugs, or whether there could have been a laboratory error. The employee is notified about positive test results in such a way as to elicit accurate information concerning possible legal medical alternatives for that positive test result, including pertinent medical status, medications, and history. The MRO knows procedures for initiating contact with the employee in such a way as to verify his or her identity, without a prior disclosure of the positive result.
The employee is informed that no physician/patient relationship exists beyond the purpose of determining whether a legal medical alternative exists for the positive result. Unless state law creates a physician/patient relationship, the initial function of the MRO is restricted to the determination of a legal medical explanation for a positive result, or to the determination that errors in the collection or in laboratory process are responsible for the positive result. Unless legally forbidden, the disclosure of safety-related medical information is not considered a breech of medical confidence.
Discussion with the employee focuses on specific medications, drugs, or drug-taking experiences. If the employee denies inappropriate use, the MRO seeks to verify, using current medical knowledge, any claim that the drug was medically prescribed or administered, or to document that there was, in fact, inappropriate use. For example: (i) If the test is positive for an opioid, the MRO must be familiar with specific federal regulations regarding opioids, and determine whether there is physician determined clinical evidence that inappropriate use of the drug took place; (ii) if the test is positive for marijuana, the MRO determines whether the presence of cannabinoids is due to the medical use of marijuana or other cannabinoid containing drugs; (iii) if the test result is positive for cocaine, the MRO determines whether local anesthesia was administered for ENT, ophthalmologic, dental, or emergency room procedures within a reasonable time prior to the testing; (iv) if the test result is positive for amphetamines, the MRO determines whether the anti-Parkinson drug selegiline hydrochloride was used; (v) if the test is positive for phencyclidine (PCP), no medical treatment explanation is valid, but the possibility of errors in laboratory procedures or at the collection site should be investigated.
The MRO assesses employee's medical history and current medical status by interviewing the employee by phone, face-to-face, or as required by company policy. In a face-to-face interview, the MRO observes for drug-taking indications. Where required, a clinical examination should occur. Where necessary, the MRO contacts the employee's physician, dentist, pharmacist, or other health care professional to verify prescriptions for medical purposes, medications recently administered, or to request patient approved release of medical records. The MRO responds to the employee's request for repeat laboratory analysis by following the federal regulations or company policy, with respect to the original specimen or split specimens. If the MRO is unable to contact the employee, he or she follows the procedure specified in the federal regulations, state law, or company policy, whichever controls the situation.
E. Reporting results to the employer according to federal regulations and/or company policy and with special regard to confidentiality. Under current federal regulations, the MRO reports the class of drugs which was positive, but does not report actual measured laboratory levels or any confidential medical information about the individual tested. The MRO reports information only to a specific person and alternate as recipients of appropriate MRO information.
F. Maintaining complete and detailed records which are secure and maintained with confidentiality.
III. Optional Duties.
A. Evaluating and acting upon suspicious specimens or suspicious results. The MRO, where required by company policy or when concerned with the integrity of the testing process, shall bring to the attention of the employer suspicious specimens, as indicated by faulty custody and control forms, abnormal temperatures, or comments from the collection site directly to the MRO. The MRO, where required by company policy or when concerned with the integrity of the testing process, shall bring to the attention of the employer suspicious test results, as indicated by abnormal pH, specific gravity or creatinine, as indicated on the laboratory results. The MRO shall be knowledgeable about techniques used to alter, dilute, adulterate, or substitute specimens during the drug testing process. The MRO shall be knowledgeable about submission of blind specimens, as required by federal/state law or corporate policy.
B. Conducting return to work assessments: Substance use fitness for duty. The MRO may be required to assist in recommending a diagnostic facility, rehabilitation program, or schedule of rehabilitation activities for the employee who tests positive for a proscribed substance. The MRO shall be familiar with the requirements of the company in order to determine when an employee who has tested positive for a proscribed substance is drug test negative and is ready to return to work. The MRO may conduct an assessment of the employee based on an evaluation of any required rehabilitation or routine monitoring through which the employee has gone prior to returning to work.
C. Monitoring after return to work. The MRO may establish a schedule for random drug testing for the employee after the employee has returned to work, consistent with federal/state regulations or company policy. The MRO may consult with the employer, the employer's employee assistance program (EAP), or designated representative to establish a post return to work monitoring program. The MRO may consult with the employer, the employer's EAP or designated representative to establish a post return-to- work treatment program.
D. Developing drug-free work place policies. The MRO may provide drug education to the employees of the employer, at the employer's request. Drug education may be provided to managers and supervisors so that they are familiar with drug-affected behaviors in the workplace setting. Drug education may be provided to employees, so that they are aware of the physical, psychological, social, and economic impact of drug use. The MRO may assist the employer to establish a comprehensive policy and program of a drug-free work- place.
E. Other educational aspects. The MRO may provide training for EAPs, supervisors, other management personnel, and employees in the workplace about the relationship between drug use, accidents, injuries, infectious diseases, and other diseases. The MRO may review serious accidents and worker's compensatory claims to determine if substance use is a correctable factor.