ChesterCountyMedicineWinter2018 - 22

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Occupational Medicine
and Opiates:

Doing our part
BY DR. RICHARD DONZE

A

sk anyone inside or even outside the healthcare profession/
industry which medical specialties would most likely
be on the front lines of the opiate crisis, and you would
likely hear Emergency Medicine, Pain Management, Surgery,
Primary Care, etc., and common stories about OD's, narcoticsseekers, and chronic pain management. Probably no one would
mention Occupational Medicine, partly because this specialty-
although a legit ABMS specialty, organizationally housed in the
American Board of Preventive Medicine-is not very well-known
or appreciated, even among educated medical professionals.
When I name my discipline other docs may say, "Oh, so you're
a Rehab doctor?" Less knowledgeable lay folk may say, "Oh,
right, Occupational Therapy; like when my dad had a stroke the
therapist made him a splint."
The other part of partly is that even when colleagues do recognize the occupational physician's expertise navigating the often
murky waters of workers comp, our unique fund of knowledge
in toxicology, and that we must declare current and prospective
workers fit or unfit for duty across a wide range of industries and
workplace safety hazards, they may not know much about one of
our central roles that brings us face to face with the opiate crisis
every day. I'm not talking about managing work-related chronic
low back pain or upper extremity RSD that often results in patients requesting narcotic analgesics (often by name, and of course
nothing else has ever worked), although that would have been a
good guess. No, I'm talking about something called the Medical
Review Officer (MRO) function-the federally stipulated role for
a trained and certified physician who interprets urine drug test results in federal-regulated workplace drug testing programs. When
a certified forensic laboratory identifies and reports the presence
of a controlled substance in a donor's urine, it's the MRO's job to

22 CHESTER COUNT Y Medicine | WINTER 2018

determine whether or not the donor has a legitimate prescription
that explains the result, and if so, the MRO can report a "verified
negative" to the employer. In other words, the MRO turns a laboratory positive for the presence of the substance into a MRO-verified negative for unauthorized use of the substance.
If you think this all sounds pretty simple-as in, receive a
positive result, get a copy of a prescription, and verify it negative,
or not-so why all the hype about training and certification, you
would often be correct. However there is some specialized knowledge required at times (such as knowing that there are no authorized uses of phencyclidine, aka PCP or angel dust, that codeine
metabolizes to morphine but not the other way around, or that
the fleeting metabolic presence of 6-acetylmorphine, if detected,
is the fingerprint of heroin use); but more often, what makes this
work challenging is interpreting the results in light of a number of
regulatory requirements, such as when the testing is performed to
comply with federal Department of Transportation (DOT) regulations. In this context, a positive urine drug test is automatically
disqualifying (I hope I wouldn't have to point out that this is a
good thing when it means that someone with cocaine or marijuana
or morphine in his or her system won't be able to step up into the
cab and behind of the wheel of a 26,001+-pound tractor trailer).
That disqualification lasts until two things happen: (1) the person
undergoes a prescribed rehab program under the direction of
someone trained and certified to hold another federally-defined
title-a Substance Abuse Professional or "SAP"; and (2), the person has a negative Return-to-Duty drug test. And even after that,
there is usually more counseling and series of random drug tests.
While there are a number of custom drug test protocols in
non-regulated industries, the DOT has always had a relatively
limited panel. Since inception over 30 years ago, they have only
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