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  • ACOEM Comments on DOT Proposed Revisions to Transportation Workplace Drug and Alcohol Testing Program Procedures

    March 30, 2010

    Docket Management Facility
    U.S. Department of Transportation
    1200 New Jersey Ave., SE., West Building
    Ground Floor Room W12–140
    Washington, DC 20590–0001

    Docket OST–2010–0026

    To Whom It May Concern:

    The American College of Occupational and Environmental Medicine (ACOEM) welcomes the opportunity to submit the attached comments on the Notice of Proposed Rulemaking (NPRM) to revise certain procedures for Transportation Workplace Drug and Alcohol Testing Programs.

    As ACOEM’s membership consists of a number of physicians who are medical review officers (MROs) and/or who are involved in the transportation industry, we are keenly aware of the issues that have been brought forth in this NPRM. In response, ACOEM offers the attached recommendations and observations.

    Sincerely,
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    Pamela A. Hymel, MD
    President

    cc:  Douglas Martin, MD, Chair, ACOEM Medical Review Officers Section
           Daniel M. Janiga, MD, Co-Chair, ACOEM Transportation Section

    Enclosure

    -------------------

    American College of Occupational and Environmental MedicineMedical Review Officers SectionTransportation Section 

     Comments in Response to Notice of Proposed RulemakingDocket OST-2010-0026/Procedures for Transportation Workplace Drug and Alcohol Testing Programs 

     The American College of Occupational and Environmental Medicine (ACOEM) welcomes the opportunity to provide comments to the Notice of Proposed Rulemaking (NPRM) concerning changes to the Procedures for Transportation Workplace Drug and Alcohol Testing Programs. As ACOEM’s membership consists of a number of physicians who are medical review officers (MROs) and/or who are involved in the transportation industry, we are keenly aware of the issues that have been brought forth in this NPRM. In response, ACOEM offers the following recommendations and observations:

    Addition of MDMA to Testing Panel, Requirement for 6-AM Testing and Lowering of Cutoff Testing Levels for Amphetamine and CocaineACOEM understands the need for the Department of Transportation (DOT) to be in concert with the regulations for laboratory testing as mandated by the Department of Health and Human Services (HHS) and the importance of maintaining consistency across all federal drug-testing statutes. MROs are supportive of adding methylenedioxymethamphetamine (MDMA) to the testing regimen, and very  much in support of lowering the cut-off levels for amphetamine in particular because of the increase in the number of safety-sensitive employees who are using either legitimate or illegitimate amphetamines. There can be no doubt that MRO work concerning amphetamine-positive results has escalated in recent years, secondary to the increased diagnosis of ADD/ADHD disorders among adults who frequently are treated with amphetamine containing medications. We are also concerned with the increasing number of individuals who are using prescribed amphetamines for purposes other than for which they were intended. We applaud any effort that identifies more safety-sensitive issues in this regard as the overall goal of this program is focused directly on safety and prevention of the deleterious or inappropriate use of these substances in this regard.

    In addition, ACOEM again calls for a comprehensive review of DOT’s 5-panel-test. Although the amphetamine issue indicated above is an escalating concern, the skyrocketing misuse and abuse of synthetic and semi-synthetic opioids is of even greater concern. Given that the current 5-panel laboratory test only checks for codeine and morphine, and will not detect synthetic opioids, ACOEM calls upon DOT to add opioids to the testing regimen. As MROs and physicians, we recognize that by not testing for these substances there are likely hundreds if not thousands of safety-sensitive transportation workers who escape detection and thus pose a significant risk to public safety.  We cannot be stronger in our recommendation concerning this topic and plead with the Department to take action immediately.

    IITFsACOEM is concerned about introducing instrumented initial test facilities (IITFs) into the drug-testing process. Several of our MRO members have indicated that there continues to be a problem with specimen leakage in transport and also with specimens not arriving at the testing laboratory. The introduction of IITFs into the process potentially doubles the risk of transport problems, as these specimens would be transported twice in the case of initial non-negative samples as opposed to just once in the current regulations.

    Blind Sample TestingExcept for the purposes of harmonization between HHS and DOT requirements, we are unclear as to the reasoning behind increasing the blind sample submission requirement from DOT’s current 1% to HHS’ proposed 3%. We are unaware of any problems with the current 1% submission rate. We question why the imposition of additional submission is needed, and note that this will add costs to the process.

    MRO RecordkeepingRegarding the appropriate length of time and composition of records, ACOEM (and other organizations) teach MROs that it is important to retain all records involved in the drug-testing process. This includes notes that the MRO keeps concerning conversations with laboratories or any other notes or documents involved in the determination process. This is important in order to provide a clear and precise map in the case of a legal challenge. ACOEM teaches its physician MROs about the fundamentals of ethics and legalities in the drug-testing process and our MROs understand the need for clear and complete recordkeeping, especially in the case of positive results which may be challenged legally.

    Concerning the issue of the length of time required for retention of records, we believe that anything longer than a 1-year retention for negative results is burdensome for the MRO and his or her staff. Regarding positive results, while our collective experiences have found that it is rare for any legal challenges to non-negative results to occur after 2 years, we recommend that MROs retain their records on positive results for 5 years, the same time length required of employers.

    MRO Training and CertificationACOEM welcomes the invitation to comment on MRO continuing medical education requirements and certification. Most of our physician members have no difficulty with the proposal to harmonize the HHS and DOT certification of MRO certifying bodies. We are equivocal with respect to the annual requirement to do this as has been proposed. We would point out that it is somewhat unusual for any medical certifying organization to be approved on an annual basis – thus, this may be overkill. Perhaps approval every two or three years would make more practical sense.

    Regarding the proposal to remove the requirement that MROs complete 12 hours of continuing medical education (CME) every 3 years and instead require MROs be recertified every 5 years – as MROs, we have struggled somewhat with the concept of having a 5-year certification period and a 3-year continuing education requirement and welcome a move that would match these times frames. While we recognize that DOT might feel that they are reducing the cost burden on MROs by suggesting that the CME requirement be dropped in favor of a singular recertification requirement, we would argue against that move. The reason is that physicians are required by other entities to attend a certain number of continuing medical education hours (CMEs) within a certain timeframe as required by their state licensing bodies, their specialty or subspecialty organizations, or their privilege granting clinics or hospitals. Because science and evidence is always changing and never static, we operate with the understanding that CME is crucial in order to maintain core competence in any medical discipline. We also operate under a CME protocol established by the Accreditation Council on Continuing Medical Education, whose mission is to certify entities that provide CME hours based upon principles that new knowledge in medicine MUST be incorporated as part of the professionalism of any physician, and as MROs we see this as a critical process. Thus, we strongly urge that the CME requirement be maintained, but that the recertification requirement be at a timeframe that is of some integer multiple of the CME timeframe requirement (e.g., 12 CME hours every 3 years and recertification every 6 years; or 24 CME hours every 5 years and recertification every 5 years).

    Thank you for the opportunity to comment upon these proposed rules. We are available to discuss any of the issues further at your request.