Role of occupational health services in workplace drug testing

In Finland, workplace drug testing is mainly performed in accordance with the Act on the Protection of Privacy in Working Life (759/2004), (http://www.finlex.fi/en/laki/kaannokset/2004/20040759) [1], the Occupational Health Care Act (1383/2001), (http://www.finlex.fi/en/laki/kaannokset/2001/20011383) [2] and the Decree on Workplace Drug Testing (218/2005) [3]. The role of occupational health services is stated in the Occupational Health Care Act. All workplace drug tests are carried out by health services according to good occupational health care practice. A referral for a drug test is given by a physician or a nurse working in health care services. When giving the referral, the physician or nurse should inform the person to be tested of the purpose and content of the test, record any medication they may be using, and make sure they are aware that they can later dispute the result of the test. The identity of the person should be checked before taking a sample. The analysis laboratory sends the result of the drug test to the health care service unit that has given the referral. If the test result is positive, the laboratory gives a detailed analysis of the test result. The health care service personnel provide the testee with the result. If it is negative, it may be given by a nurse. When the test result is positive, a Medical Review Officer (MRO) should interpret the answer and evaluate whether the positive result is due to medication, or another reasonable explanation offered by the person tested. The MRO informs the person of the options of rehabilitation treatment available to drug abusers stated in the written drug testing policy/programme of the employer/company. The testee takes the test result report to his/her employer personally.     

The Finnish legislation on workplace drug testing

In Finland, the Act on the Protection of Privacy in Working Life (759/2004) that entered into force in 2004 incorporates provisions related to drug use testing, e.g. on the employers' right to process in certain situations information on job applicants' and employees' drug use. In the same context, provisions were added to the Occupational Health Care Act (1383/2001) on the employer's obligation to draw up, together with the staff, a written programme dealing with alcohol and drugs for the workplace. The programme defines the overall objectives for and the practices to be observed at the workplace in order to prevent substance abuse and to refer the problem users to treatment. The Occupational Health Care Act also includes provisions on drug tests and the drug test certificate as well as on reimbursement of the expenses of drug tests. Furthermore, the Act lays down a definition of drug tests. Every workplace shall have a plan/programme on drug-free workplace, where the jobs in which the workers have to present a drug test certificate to the employer must be defined. This plan/programme shall be discussed in cooperation on tripartite basis at the workplace. A Government decree on drug use testing (218/2005) has been issued in virtue of the Occupational Health Care Act. It lays down provisions on the practical performance of drug tests, i.e. taking and analysis of samples, and interpretation of the test results. The purpose of the Government decree is to ensure that workplace drug testing is carried out in a way presupposed by a good occupational health care practice and the laboratory quality standards, taking into account the integrity and protection of privacy of the persons tested as well as their other fundamental rights.     

Workplace drug testing in Europe

Not much information is available on workplace drug testing (WDT) in Europe. There is no specific legislation and there are no generally accepted guidelines. Many companies establish a drug policy with little or no provisions for drug testing. Often, testing is performed on-site by occupational physicians, with little or no quality control, no systematic confirmation of positives, no chain of custody and no adulteration testing. In some parts of Europe, e.g. in the United Kingdom and some Scandinavian countries, WDT is increasing in importance, but it is not as widespread as in USA. The most frequently performed tests are amphetamines, cannabinoids, cocaine, opiates and alcohol. The percentage of positives is variable, but seems to decrease with the years following the introduction of WDT. Cannabis is the drug that is most frequently found.Recently, the European Workplace Drug Testing Society (EWDTS) was founded, with the aims to ensure that WDT in Europe is performed to a defined quality standard and in a legally secured way and to provide an independent forum for all aspects of WDT.A working group in the United Kingdom has recently finalised the United Kingdom laboratory guidelines for legally defensible WDT and discussions are under way with the EWDTS to establish common guidelines.Many efforts will be needed to establish WDT as an accepted part of a company policy on drugs: establishing and maintaining the confidence in the results of the laboratory, establishing the legal status of WDT, preserving the privacy and rights of the employees, proving the cost-effectiveness of WDT in a European context, finding a balance between strict guidelines and enough flexibility to tailor testing to the changing needs. It is hoped that the exchange of experience between different countries will contribute to reaching these goals.     

The U.S. Mandatory Guidelines for Federal Workplace Drug Testing Programs: current status and future considerations

The U.S. Department of Health and Human Services (HHS) drug testing standards were published in 1988 and revised in 1994, 1998, and 2004. In 2004, significant revisions defining, standardizing, and requiring specimen validity testing on Federal employee donor urine specimens were included. In a separate notice, HHS proposed to establish scientific and technical guidelines for the Federal Workplace Drug Testing Program to: (1) permit laboratory testing of hair, oral fluid, and sweat patch specimens in addition to urine specimens for marijuana, cocaine, phencyclidine, opiates (with focus on heroin), and amphetamines [including methylenedioxymethamphetamine (MDMA), methylenedioxyethamphetamine (MDEA), methylenedioxyamphetamine (MDA)]; (2) permit use of on-site point of collection test (POCT) devices to test urine and oral fluid at collection sites; (3) permit use of instrumented initial test (screening only) facilities [IITF] to quickly identify negative specimens; and (4) add training requirement for collectors, on-site testers, and MROs. This proposal was published in the Federal Register on 13 April 2004, with a 90-day public comment period. The Substance Abuse and Mental Health Services Administration, HHS, reviewed those comments and is preparing the Final Notice that will define the requirements for such testing, including: specimen collection procedures, custody and control procedures that ensure donor specimen identity and integrity, testing facility, initial and confirmatory test cutoff concentrations, analytical testing methods, result review and reporting, evaluation of alternative medical explanations for presence of drug or metabolite in the donor's specimen, and laboratory certification issues. Voluntary pilot performance testing (PT) programs for each specimen type are on-going since April 2000 to determine how to prepare PT materials for specimens other than urine to evaluate laboratories' ability to routinely achieve accuracy and precision required. Certification programs will be developed using the current urine drug testing National Laboratory Certification Program model. The addition of accurate and reliable workplace drug testing using hair, oral fluid, and sweat patch specimens will complement urine drug testing, and aid in combating industries devoted to suborning drug testing through adulteration, substitution, and dilution. For example, hair testing may detect chronic drug use for up to 90 days and be useful in pre-employment situations; oral fluid testing may detect drug use in past hours and be useful in post-accident situations; sweat patch testing may be useful in follow-up drug testing and treatment programs; POCTs and IITFs may be most useful for quickly identifying specimens that are negative for drugs and indicate that the specimen is valid.     

Interpretation of GC-MS opiate results in the presence of pholcodine

Although the cross reactivity of pholcodine with opiate immunoassays has been well documented there is little published information the potential for pholcodine interference with chromatographic analyses. Wilson and Smith [Ann. Clin. Biochem. 36 (1999) 592] recently described the 'misidentification' of morphine in quality control specimens that had been spiked with pholcodine. This report describes a sensitive, rapid gas chromatography-mass spectrometry (GC-MS) method for the detection and quantitation of pholcodine and morphine, together with 6-monoacetylmorphine (6-MAM), codeine and dihydrocodeine in urine. This method was used to analyse urine specimens collected from volunteers given single and multiple doses of pholcodine to establish the significance this drug on the analytical results obtained when performing drug screening according to the proposed UK and EU legally defensible workplace drug testing guidelines. The maximum urinary free morphine concentration achieved following a single 10mg oral dose of pholcodine was 1.39 mg/l at 2-4h post dose. Following multiple 10mg oral doses of pholcodine the maximum urinary free morphine concentration was determined as 0.4 mg/l at 170 h after the final dose was administered. This apparent anomaly in the morphine concentrations obtained following single and multiple pholcodine doses can be explained in part by differences in the concentration of the specimens, and may be overcome by applying a correction factor for specimen dilution using their creatinine concentration. The data from this study suggests that even following one single 10mg dose of pholcodine, free morphine concentrations greater than both the proposed UK workplace drug testing guidelines threshold of 0.3mg/l total morphine and the proposed European Union threshold of 0.2mg/l total morphine can be achieved. This highlights the need for caution when interpreting confirmatory opiate data, especially in medicolegal and clinical cases, and in cases where the use of pholcodine is suspected.     

Workplace drug testing in a military organization: Results and experiences from the testing program in the Finnish Defence Forces

In the military environment drug abuse is a particular risk for occupational safety. In the Finnish Defence Forces a drug testing program was conducted in 2002–2005; soldiers, professional civilians, and military students were tested when applying for a work or right to study; furthermore, annually 5% of the personnel were subjected to random testing. In total, over 2000 urine samples were analyzed in an accredited laboratory for cannabis, opiates, amphetamines, or cocaine. In this article, the drug testing program as a part of the anti-drug strategy of the Finnish Defence Forces is described, and the findings including practical experiences and financial expenses are reported. Only one person applying for a civilian post tested positive for amphetamine and cannabis. In seven other samples codeine and morphine were detected; these were, however, due to prescribed medication, not drug abuse. In the execution of the program, no particular difficulties were reported. In conclusion, it seems that the use of illicit drugs in the Finnish military is extremely rare, at least partly due to the successful anti-drug strategy. After an elaborate planning, even an extensive drug testing program can be executed without substantial setbacks. In the future, the effectiveness of drug testing programs as a means of improving occupational safety needs to be investigated in controlled studies using comparative design.     

The medical review officer: a potential role for the medical examiner

Drug use in the workplace is a problem, both in terms of public health and expense. Workplace drug testing programs serve as deterrents to drug use. Model programs, such as that of the Department of Transportation, use urine screening and are federally regulated or follow federal standards. An essential participant in this process is the medical review officer (MRO), a licensed physician who interprets the laboratory results generated from a workplace drug testing program. As a result of their training and experience with toxicology, collection of evidence, testimony, and recognition of the physical signs of drug abuse, medical examiners and forensic pathologists are well suited to serve as MROs. Recent regulations require the completion of training courses and MRO certification as prerequisites for participation in federal drug testing programs. Several courses are available to train physicians to participate as MROs.     

New technology and new initiatives in U.S. workplace testing

A current perspective of workplace drug testing in the USA is presented covering three major issue areas: (1) epidemiology, (2) new technology and (3) initiatives to reach out and assist small business. First, national illegal drug-use self-reported survey data is compared with national laboratory drug testing results, illustrating a number of inconsistencies. During the 17-year period (1988-2004) the number of laboratory positive test results has decreased by 66% while during the same period self-reported drug-use has increased by 30%. The lack of concurrence between lab results and self-report surveys are examined in light of the typical panel of drugs being tested in U.S. laboratories, the increased specificity of immunoassay screening tests, and the critical issues of adulteration and substitution. Second, a brief review of the state-of-the-science in rapid point-of-collection (POCT) oral fluid drug-testing devices is presented along with some device evaluation findings. In general the window of drug detection in oral fluid is measured in hours. Most of the available oral fluid POCT devices can detect methamphetamine and amphetamines and opiates very well. The ability to detect cocaine appears to vary significantly across devices, while the ability to detect cannabis use is generally poor across all devices. Finally, efforts to reach out and assist small businesses in the development of workplace anti-drug programs are discussed in the context of increasing workplace programs in the European Union.     

Society of Hair Testing guidelines for drug testing in hair

The Society of Hair Testing (SoHT) Guidelines for Drug Testing in Hair provide laboratories with recommended best practice guidelines whether they are currently offering drug testing in hair, or plan to offer a hair testing service in the future. The guidelines include reference to recommended sample collection and storage procedures, through sample preparation, pre-treatment and analysis and the use of cut-offs.     

Hematology and pathology devices; reclassification; restricted devices; OTC test sample collection systems for drugs of abuse testing--FDA. Proposed rule

The Food and Drug Administration (FDA) is proposing to reclassify over-the-counter (OTC) test sample collection systems for drugs of abuse testing from class III (premarket approval) into class I (general controls), and to exempt them from the premarket notification (510(k)) and current good manufacturing practice (CGMP) requirements. FDA is also proposing to designate OTC test sample collection systems for drugs of abuse testing as restricted devices under the Federal Food, Drug, and Cosmetic Act (the act), and to establish restrictions intended to assure consumers that: The underlying laboratory test(s) are accurate and reliable; the laboratory performing the test(s) has adequate expertise and competency; and the product has adequate labeling and methods of communicating test results to consumers. Finally, FDA is proposing a conforming amendment to the existing classification regulation for specimen transport and storage containers, to clarify that it does not apply to specimen transport and storage containers that are part of an OTC test sample collection system for the purpose of testing for the presence of drugs of abuse or their metabolites in a laboratory.     

Hematology and pathology devices; reclassification; restricted devices; OTC test sample collection systems for drugs of abuse testing. Food and Drug Administration, HHS. Final rule

The Food and Drug Administration (FDA) is reclassifying over-the-counter (OTC) test sample collection systems for drugs of abuse testing from class III (premarket approval) into class I (general controls) and exempting them from premarket notification (510(k)) and current good manufacturing practice (CGMP) requirements. FDA is also designating OTC test sample collection systems for drugs of abuse testing as restricted devices under the Federal Food, Drug, and Cosmetic Act (the act) and establishing restrictions intended to assure consumers that: The underlying laboratory test(s) are accurate and reliable; the laboratory performing the test(s) has adequate expertise and competency; and the product has adequate labeling and methods of communicating test results to consumers. Finally, FDA is adding a conforming amendment to the existing classification regulation for specimen transport and storage containers to clarify that it does not apply to specimen transport and storage containers that are part of an OTC test sample collection system for the purpose of testing for the presence of drugs of abuse or their metabolites in a laboratory.     

AIDS and infection control in forensic investigation

Infection control in the workplace is becoming an increasingly important issue, not only for health care workers, but also for any workers who could potentially be exposed to infectious material. We discuss the nature, modes of transmission, and infectivity of important infectious agents likely to be encountered in the course of forensic investigations. We provide principles and guidelines for appropriate procedures and practices to be followed in a program of infection control.     

Current status of accreditation for drug testing in hair

At the annual meeting of the Society of Hair Testing in Vadstena, Sweden in 2006, a committee was appointed to address the issue of guidelines for hair testing and to assess the current status of accreditation amongst laboratories offering drug testing in hair. A short questionnaire was circulated amongst the membership and interested parties. Fifty-two responses were received from hair testing laboratories providing details on the amount and type of hair tests they offered and the status of accreditation within their facilities. Although the vast majority of laboratories follow current guidelines (83%), only nine laboratories were accredited to ISO/IEC 17025 for hair testing. A significant number of laboratories reporting that they were in the process of developing quality systems with a view to accrediting their methods within 2-3 years. This study provides an insight into the status of accreditation in hair testing laboratories and supports the need for guidelines to encourage best practice.     

Forensic textile fiber examination across the USA and Europe.

Crime laboratories in the USA, who undertake fiber examinations, together with members of the European Fibres Group (plus representatives from Israel, Japan, Canada, and Australia) were surveyed in 1994 and 1995, respectively, and asked to provide subject-specific information relating to personnel, equipment, training, quality control, and techniques available. The information obtained showed that generally more fiber casework is carried out in Europe than in the USA. Most laboratories are quite well equipped but those in Europe seem to be able to obtain more state-of-the-art instrumentation. Proficiency testing and peer review is accepted practice worldwide. Americans appear to update fiber collections on a more regular basis than Europeans but both keep literature up to date. Contamination is a major issue, as with all areas of trace evidence. The results from the survey suggest that minimum standards are clearly not always being observed. Careful consideration also needs to be given as to whether legitimate contact could have occurred prior to an offense being committed. The standard of forensic fiber examination worldwide is generally high. With laboratory management continuing to support the work of the Scientific Working Group for Materials and the European Fibres Group and by instigating "best practice" as set out in their guidelines, standards should continue to improve.     

Reform, change, and continuity in Finnish health care

This article describes some essential aspects of the Finnish political and governmental system and the evolution of the basic institutional elements of the health care system. We examine the developments that gave rise to a series of health care reforms and reform proposals in the late 1980s and early 1990s and relate them to changes in health care expenditure, structure, and performance. Finally, we discuss the relationship between policy changes, reforms, and health system changes and the strength of neo-institutional theory in explaining both continuity and change. Much of the change in Finnish health care can be explained by institutional path dependency. The tradition of strong but small local authorities and the lack of legitimate democratic regional authorities as well as the coexistence of a dominant Beveridge-style health system with a marginal Bismarckian element explain the specific path of Finnish health care reform. Public responsibility for health care has been decentralized to smaller local authorities (known as municipalities) more than in any other country. Even an exceptionally deep economic recession in the early 1990s did not lead to systems change; rather, the economic imperative was met by the traditional centralized policy pattern. Some of the developments of the 1990s are, however, difficult to explain by institutional theory. Thus, there is a need for testing alternative theories as well.     

Occupational workplace and traffic fatalities in Alsace, France (2000–2005): Results of toxicological investigations

France ranks as leader country in Europe for the consumption of cannabis as well as of psychoactive medications. Whereas the relationship between psychotropics and road accidents is now well-established, few data are still available on the influence of drugs on occupational accidents. The purpose of the present study was to measure the prevalence of psychoactive drug intake (alcohol excepted) among victims of occupational fatalities (including workplace accidents + traffic accidents, i.e. on the way to and from work) occurred in the region Alsace over the period 2000–2005. Data were collected by compiling files on occupational accidents from two different public agencies (CRAM, Regional Sickness Fund Alsace-Moselle; DRTEFP, Regional Department of Work, Employment and Professional Training) together with those from the Medico-Legal Institute of Strasbourg over the period tested. Data analysis showed that 3% of the victims of workplace fatalities were under the influence of drugs (alcohol excluded) at the time of accident, as well as 5% of the victims of occupational traffic accidents. Our results also highlight a low rate of toxicological analyses, since these investigations were requested by the authorities in 41% of traffic victims and only 15% of workplace victims. In France, the relevance of psychoactive drug intake in occupational deaths is much better targeted in the case of traffic fatalities (due to the existence of specific regulations, e.g. compulsory urinalysis for drugs of abuse in drivers involved in a road accident) than in those occurred at workplace (no specific regulations).     

High prevalence of 6-acetylmorphine in morphine-positive oral fluid specimens

Identification of 6-acetylmorphine, a specific metabolite of heroin, is considered to be definitive evidence of heroin use. Although 6-acetylmorphine has been identified in oral fluid following controlled heroin administration, no prevalence data is available for oral fluid specimens collected in the workplace. We evaluated the prevalence of positive test results for 6-acetylmorphine in 77,218 oral fluid specimens collected over a 10-month period (January-October 2001) from private workplace testing programs. Specimens were analyzed by Intercept immunoassay (cutoff concentration=30 ng/ml) and confirmed by GC-MS-MS (cutoff concentrations=30 ng/ml for morphine and codeine, and 3 ng/ml for 6-acetylmorphine). Only morphine-positive oral fluid specimens were tested by GC-MS-MS for 6-acetylmorphine. A total of 48 confirmed positive morphine results were identified. An additional 107 specimens were confirmed for codeine only. Of the 48 morphine-positive specimens, 32 (66.7%) specimens were positive for 6-acetylmorphine. Mean concentrations (+/-S.E.M.) of morphine, 6-acetylmorphine and codeine in the 32 specimens were 755+/-201, 416+/-168 and 196+/-36 ng/ml, respectively. Concentrations of 6-acetylmorphine in oral fluid ranged from 3 to 4095 ng/ml. The mean ratio (+/-S.E.M.) of 6-acetylmorphine/morphine was 0.33+/-0.06. It is suggested that, based on controlled dose studies of heroin administration, ratios >1 of 6-acetylmorphine/morphine in oral fluid are consistent with heroin use within the last hour before specimen collection. The confirmation of 6-acetylmorphine in 66.7% of morphine-positive oral fluid specimens indicates that oral fluid testing for opioids may offer advantages over urine in workplace drug testing programs and in testing drugged drivers for recent heroin use.     

Confidentiality of genetic information in the workplace

This Article analyzes existing legal protections for the confidentiality of information collected through genetic screening or genetic monitoring in the workplace. It notes that there are a variety of protections, such as ethical codes for occupational physicians, statutes protecting health care information in the hands of the employers, and tort, contract and constitutional principles. It describes defenses to suits based on improper disclosure of medical information. The Article then analyzes legal bases for employee and third party access to the employee's genetic information. In response to gaps in existing legal protections, it suggests parameters for a model law protecting the confidentiality of genetic information collected in the workplace.     

Legal, workplace, and treatment drug testing with alternate biological matrices on a global scale

Global trends in drug trafficking and drug usage patterns indicate a continuing pattern of escalation throughout the world. Over the last two decades, urinalysis has evolved into a highly accurate means for determining whether individuals have been exposed to illicit drugs of abuse. Advances have also been made in the use of alternate biological matrices such as hair, oral fluids and sweat for drug testing. Often, these new matrices demonstrate some distinct advantages over urinalysis, e.g. less invasive procedures, different time course of drug detection. They may even indicate impairment. National and local laws of each country provide the underpinnings of drug-testing programs, but most countries have not addressed use of these alternate matrices. Currently, only a few countries have statutes that specifically mention use of alternate biological matrices, e.g. United States (Florida state law), Germany, Ireland, Poland and the Czech Republic. Conversely, few countries have prohibited collection of alternate biological specimens or drug test devices that utilize such specimens. In addition, guidelines for implementing drug testing programs have been slow to emerge and most deal primarily with workplace drug testing programs, e.g. United States. Currently, scientific technology utilized in drug testing is advancing rapidly, but there is a clear need for parallel development of guidelines governing the use of alternate matrices for drug testing. This article provides an overview of global drug trafficking patterns and drug use, and results from a survey of legal statutes in 20 countries covering use of alternate matrices for drug testing. In addition, elements needed for the development of guidelines for alternate matrices testing for drugs of abuse are discussed, and specific examples of use of alternate matrices in treatment monitoring are provided.