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Operator Drug- and Alcohol-Testing Across Modes (2012)

Chapter: CHAPTER SIX Alternative Strategies

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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
×
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
×
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Suggested Citation:"CHAPTER SIX Alternative Strategies." National Academies of Sciences, Engineering, and Medicine. 2012. Operator Drug- and Alcohol-Testing Across Modes. Washington, DC: The National Academies Press. doi: 10.17226/14635.
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30 CHAPTER SIX ALTERNATIVE STRATEGIES Efforts were made to reach out to the regulated community to identify current practices used to deter drug and alcohol use among operators. Forty-six companies were contacted for the purpose of the synthesis. Although the original work plan specified that small, medium, and large companies should be sampled for each mode, it became clear early on in the data-collection phase that only large and medium compa- nies would have the resources and personnel to comply with requests for information. Regardless of size, few companies responded to the initial contact, and fewer than 10 agreed to provide information. The low level of participation may have resulted from the absence of a clear incentive, a reluctance to share alcohol- and drug-testing policies, a reluctance to participate in telephone surveys, or a combination of these factors. In any case, it is important to note that the responses only reflect the companies that agreed to respond. Whether these responses are representative of the entire industry is unknown. Table 23 shows the companies that responded to our initial contact and those that provided information. TABLE 23 COMPANIES SAMPLED FOR THE STUDY Mode Companies That Responded to Initial Contact Companies That Provided Information Aviation US Airways, Inc.; Southwest Airlines Co.; Continental Airlines Continental Airlines Maritime None None Motor Carrier IWX Motor Freight; McLane Com- pany, Inc.; Swift Transportation, Inc.; J.B. Hunt Transport Services, Inc. J.B. Hunt Transport Services, Inc. Pipelines Sunoco, Inc.; U.S. Steel Corp.; Koch Pipeline Co. LP; U.S. Pipeline, Inc.; Halliburton Halliburton Public Transit First Transit; Trailways Transportation System, Inc.; Greyhound Lines, Inc. Greyhound Lines, Inc.; Trailways Transportation System, Inc. Rail Amtrak, BNSF Rail Co., CSX Corp., Norfolk Southern Corp., Union Pacific RR, Watco Companies, Inc. BNSF Rail Co. Data were obtained through unstructured phone and e-mail interviews with assigned company representatives. No efforts were made to independently verify the represen- tatives’ claims. After the interviews, the relevant sections of this report were provided to the respective companies to confirm that the report accurately portrayed what they communicated. The following sections outline some of the procedures aimed at deterring employees’ drug and alcohol abuse that exceed the minimum regulatory requirements. Some proce- dures are applicable to all modes, whereas others are most likely limited to a single mode. Also, some procedures are already in place, whereas others are in the planning stage. ZERO-TOLERANCE POLICIES With zero-tolerance policies, if an employee has a positive drug or alcohol test, or the employee refuses to take the test, the employee is immediately removed from the safety-sen- sitive position and not given a second chance to return to that position. Of the companies responding to the request for information, Continental Airlines and BNSF have some variant of a zero-tolerance policy. Continental Airlines, operating a fleet of more than 300 aircrafts, implements a variation of a zero-tolerance policy. In general, no employee is guaranteed a second chance. After a confirmed positive test, an employee may be permanently removed from his or her position or offered a last-chance agreement. The last-chance agreement requires the employee to enroll in an EAP and pass a return-to-duty test and a series of follow-up tests. The last-chance agreement may be offered on the basis of the employee’s history with the company, rou- tine evaluation results, work ethic, potential drug or alcohol problem, and the professional opinion of the MRO. BNSF Rail Company links 28 states and two Canadian provinces with a network of railways, covering two-thirds of the United States. BNSF does not guarantee second chances following the first confirmed positive drug and/or alcohol violation. If any employee tests positive, then the violation can lead to dismissal. Refusals to test are also not tolerated, and the employee can be disqualified for 9 months and may also be subject to termination. Likewise, extended shy-lung and shy-bladder incidents, where the subsequent medical evaluation does not confirm an underlying medical cause, will be considered refusals to test and the employee can be disqualified for 9 months and may also be subject to termi-

31 nation. Zero-tolerance policies may increase compliance with drug and alcohol regulations by establishing stricter and immediate consequences after a single violation. They also limit the need for return-to-duty and follow-up testing, providing more time, effort, and funding for random testing. These policies, however, appear to violate the spirit of the original intent of the policy, which is to provide a “helping hand” to violators. PRE-EMPLOYMENT ALCOHOL SCREENING As previously discussed, pre-employment alcohol screening is optional, rather than mandated by DOT, because alcohol is not an illegal substance and no illegal act is performed if the applicant has not yet been involved in safety-sensitive duties. One of the seven surveyed companies uses pre-employment alcohol testing. Trailways, an independent group of more than 80 privately owned motor coach companies, imple- ments alcohol tests as part of its pre-employment screening. Pre-employment alcohol tests are an inexpensive way to identify applicants who most likely have alcohol addiction and cannot abstain from drinking. PRE-EMPLOYMENT BACKGROUND CHECK Companies may choose to investigate an applicant’s drug- and alcohol-testing history for more than the required mini- mum of 2 to 3 years. Trailways, for example, checks past test records for up to 5 prior years for potential employees in safety-sensitive functions. ALTERNATIVE SPECIMENS Although the FRA requires both urine and blood tests fol- lowing an accident, urinalysis is the basis of the DOT drug- testing program. Use of alternative specimens, however, has been gaining momentum, with several companies using hair, oral fluids, and sweat testing in addition to testing urine and blood. Among the companies sampled for this project, J.B. Hunt, Continental Airlines, Trailways, and BNSF reported making use of alternative specimens. Note that alternative specimens are collected based on company-only policies, not DOT-regulated testing. As one of the largest transportation logistics companies in North America, J.B. Hunt oversees thousands of employ- ees, many with safety-sensitive functions. J.B. Hunt has been using hair testing since May 2006, and it is now used for all pre-employment tests for all employees, not just the safety- sensitive population. Approximately over 80% of J.B. Hunt’s drivers had a hair test by September 2010 for that year, and the company had observed a decrease in the rate of positive urine tests by about 75%. They attribute this to the deterrent effect of hair testing, which can detect prior drug use for up to 90 days. J.B. Hunt also tests oral fluids following some accidents. Continental Airlines may use blood for follow-up tests. Trailways may use blood for postaccident tests and for some confirmation tests. BNSF uses hair testing for pre-employment drug screening for job applicants. Hair testing occurs in addi- tion to the FRA- and FMCSA-mandated pre-employment urine drug test at the job candidate’s medical examina- tion. BNSF company requirements may also vary by state. In Minnesota, BNSF requires a blood specimen when an employee has a BAC of 0.020 and higher on a company- mandated (non-DOT) breath alcohol test. Nebraska law requires that the railway company obtain a blood sample from the employee on a positive company authority test 0.020 and above if requested by the employee at the time of the test. BNSF may also use DOT-approved saliva tests for ini- tial alcohol screening. If positive, then the employee must be screened and confirmed using an Evidential Breath Testing (EBT) device. Oral fluid tests were noted to be beneficial for screening employees with complex pulmonary medical histories contributing to inadequate breath supply. The use of alternative specimens has elicited consider- able controversy because of many unresolved scientific, logistical, and legal issues. A summary of some of the main scientific and technical issues is presented in the following sections, which are based in large part on the following pub- lications: Baselt and Cravey (1995), Verstraete (2004), Cone et al. (2007), Kintz et al. (2007), Bush (2008), Gallardo and Queiroz (2008), and Drummer (2010). The reader is encour- aged to refer to them for additional material. Since DHHS proposed in 2004 to establish scientific and technical guidelines for the testing of hair, sweat, and oral fluid in addition to urine, considerable efforts have been made in this area of research. Table 24 shows the DHHS pro- posed initial screening and confirmatory cutoffs for alterna- tive specimens, as reported by Bush (2008). It can be noted that decisions about what testing methods to authorize are the province of DHHS, not DOT, and that DOT has no legal authority under the Omnibus Act to permit or require types of testing that DHHS has not incorporated into its manda- tory guidelines. Blood Blood drawing is an intrusive procedure and is not often per- formed for the purposes of workplace drug testing. Blood, however, is the primary mode of entry of drugs and metab- olites into hair, sweat, and oral fluid. It provides the most direct evidence of the presence of a drug in the system and allows estimation of its likely behavioral effects.

32 Each drug has specific absorption, distribution, metabo- lism, and excretion characteristics. Absorption refers to the rate at which a drug enters the bloodstream, which can be affected by the route of administration (i.e., oral inges- tion, inhalation, insufflations, and injection). After a drug is absorbed into the bloodstream, it circulates through the body and is distributed in various body tissues. Equilibrium is reached when the drug concentration in plasma is equal to the drug concentration in tissues. After equilibrium is reached, the blood drug concentration diminishes because of metabolism and elimination. The liver is the major site of drug metabolism. In the body, drugs are metabolized into other compounds—some psychoactive, some not—that can have different properties than the parent drug. Drugs and their metabolites can be excreted through urine, feces, bile, saliva, sweat, hair, and other pathways. Blood is composed of plasma and several kinds of cells (red blood cells, white blood cells, and platelets). The serum half-life is the amount of time required for a drug concentra- tion to decrease by one-half. Table 25 reports the half-lives of various illegal drugs. In this document, detection time is defined as the time a product can be detected after it was taken. The detection time for a specific drug depends on several factors: the route of administration, the pharmacokinetic properties of the drug, the metabolism of the individual, the drug dose, and the drug test cutoff selection. Table 26 reports typical detec- tion times of selected drugs in blood, serum, or plasma. Urine As the blood is pumped by the heart through the system, it goes through the kidneys at a rate of 1,200 ml per minute. As blood goes through the kidneys, electrolytes, nutrients, and water are returned to the bloodstream, whereas excess water, waste products, and drugs and their metabolites continue to the tubes that propel urine from the kidneys to the urinary bladder. Because some of the water in the TABLE 24 DHHS PROPOSED INITIAL SCREENING AND CONFIRMATORY CUTOFFS FOR ALTERNATIVE SPECIMENS Drug/Analyte Hair (pg/mg) Oral Fluid (ng/ml) Sweat Patch (ng/patch) Urine (ng/ml) Screen Confirm Screen Confirm Screen Confirm Screen Confirm Marijuana metabolites 1 50 Marijuana (parent) THC (parent drug) THCA (metabolite) .05 4 2 4 1 15 Cocaine Cocaine metabolites Cocaine Benzoylecgonine Cocaethylene Norcocaine 500 500a 50 50 50 20 8b 8 25 25b 25 150 100 Opiate Metabolitesc Morphine Codeine 6-Acetylmorphine 200 200 200 200d 40 40 40 4 25 25 25 25 2,000 2,000 2,000 10 Phencyclidine Phencyclidine 300 300 10 10 20 20 25 25 Amphetaminese 500 50 25 500 MDMA Amphetamine Methamphetamine MDMA MDA MDEA 500 300 300f 300 300 300 50 50 50g 50 50 50 25 25 25g 25 25 25 500 250 250h 250 250 250 a Laboratories are permitted to initially test all specimens for 6-acetylmorphine (6-AM) using the appropriate cutoff for each matrix. b Methamphetamine is the target analyte. c BZE/cocaine ratio  0.005 or cocaethylene  50 pg/ml or norcocaine  50 pg/ml. d Specimen must also contain morphine at concentration  200 pg/mg. e Must contain amphetamine  50 pg/mg. f A confirmatory test must be performed for either cocaine or BZE. g Must contain amphetamine  LOD. h Must contain amphetamine  100 ng/ml.

33 blood is reabsorbed by the kidneys, the concentration of drugs and their metabolites is higher in urine than in the kidneys. A healthy adult produces from 1 to 2 L of urine per day. TABLE 25 HALF-LIVES OF SELECTED DRUGS AND THEIR METABOLITES Drug Analyte Half-Life Marijuana Tetrahydrocannabinol 30 min Delta-9-tetrahydrocan- nabinol-9-carboxylic acid Infrequent users: 20–57 h Frequent users: 3–13 days Cocaine Cocaine Intravenous: 37–41 min Smoked: 58–89 min Intranasal: 73–207 min Benzoylecgonine 6 h Opiates Morphine 2–3 h 6-Acetylmorphine 6–25 min Phencyclidine Phencyclidine 7–46 h Amphetamines Amphetamine 7–34 h Methamphetamine Oral: 10.1 h Intravenous: 12.2 h MDMA Methylenedioxymetham- phetamine (MDMA) 7.6 h Methylenedioxyamphet- amine (MDA) 16–18 h Methylenedioxyethylam- phetamine (MDEA) N/A Note. Half-life rates obtained from Baselt and Cravey (1995), Burns et al. (1998), Mas et al. (1999), Couper and Logan (2004), and Verstraete (2004). N/A = not available. Urine drug levels vary as a function of the pharmacoki- netic properties of the drug, the metabolism of the individual, the drug dose, the drug test cutoff selection, and the quantity and frequency of the voids before collecting the specimen. Detection times in the scientific literature, therefore, can vary from study to study, depending on the experimental proto- col. Table 27 shows urine drug detection times as reported by Verstraete (2004). Note the distinction between detection time and maximal detection time. Table 28 shows urine drug detection times as reported by Moeller et al. (2008). In gen- eral, the window of detection for most drugs is 2 to 3 days. A positive urine drug test indicates only that the person has used the drug and cannot be used to determine whether the person is under the influence of the drug. One of the advantages of urine drug testing is that it has been examined extensively, is scientifically proven, and is forensically defensible. Entering the keywords “urine drug testing” in PubMed and limiting the search to humans yielded 3,575 results. It is a mature technology that is toxico- logically accurate and reliable. Oral Fluid Oral fluid consists of saliva, gingival fluid, and cellular debris. Saliva is produced by the salivary glands, which are highly vascularized. Therefore, drugs in plasma are rapidly distributed to the salivary glands. Relative to plasma con- centrations, drug concentrations in oral fluids depend on the water and lipid solubility of the drugs and their metabo- lites. Table 29 shows drug detection times in oral fluids as reported by Verstraete (2004). Note that the drug detection window in oral fluid is similar to that of blood. Entering the keywords “saliva drug testing” and “oral fluid drug testing” in PubMed yielded 558 and 396 results, respectively. One of the advantages of oral fluid drug test- ing is that drug concentrations can be related to plasma-free drug concentrations and to the pharmacological effects of the drugs (Gallardo and Queiroz 2008). Also, oral fluid can be easily collected in a fairly noninvasive fashion, under direct observation, which reduces the probability of adul- teration and substitution. TABLE 26 DETECTION TIMES FOR SELECTED DRUGS IN BLOOD, SERUM, OR PLASMA Drug Dose (mg) Route of Administration Analyte Cutoff (ng/ml) Detection Time (h) Marijuana 34 Smoked Tetrahydrocannabinol (THC) 10 5 Delta-9-tetrahydrocannabinol-9-carboxylic acid (THCA) 10 36 Cocaine 100 Intranasal Cocaine 10 12 Benzoylecgonine 10 48 Heroin 12–20 Smoked Morphine 1 20 Amphetamine 6 Oral Amphetamine 4 46 Methamphetamine 22 Smoked Methamphetamine 3 48 MDMA 100 Oral MDMA 20 24 Note. Adapted from Verstraete (2004).

34 One disadvantage of oral fluid drug testing is that recently consumed drugs can leave residual amounts in the mouth. The effect and duration of oral contamination have not been established, and it is unknown whether this can be overcome by a realistic observed wait period. Furthermore, possibly a second disadvantage is that people are sometimes unable to produce enough oral fluid for analysis (Gallardo and Queiroz 2008). Oral fluid, however, has been gaining prominence as an alternative matrix for monitoring drugs of abuse in law enforcement and criminal justice purposes, driving under the influence of drugs programs, and treatment settings (Schwope et al. 2010; Vindenes et al. 2011). Its role in traffic safety is likely to increase in the coming years. Hair Hair follicles are highly vascularized, and as the blood circu- lates, drugs are absorbed into the growing hair. The growing phase, the antegen phase, lasts 2 to 6 years. Blood supply to the hair shaft stops during the catagen phase, which lasts 1 to 2 weeks. The final stage when the separation from the blood supply is complete is known as the telogen stage or the resting phase. Approximately 2% to 3% of head hair is TABLE 27 DETECTION TIMES FOR SELECTED DRUGS IN URINE Drug Dose (mg or THC) Route of Administration Analyte Cutoff (ng/ml) Detection Time (h) Maximal Detection Time (days) Marijuana 1.75 Smoked Delta-9-tetrahydrocannabinol-9- carboxylic acid (THCA) 15 34 95 3.50 Smoked Delta-9-tetrahydrocannabinol-9- carboxylic acid (THCA) 15 87 Cocaine 100 Intranasal Benzoylecgonine 1,000 48–72 22 Heroin 10–15 Intravenous, Smoked Morphine 11–54 11.3 Amphetamine 9 Methamphetamine 10 Oral Methamphetamine 2.5 87 ± 51 6 MDMA 100 Oral MDMA 20 48 Source: Verstraete (2004). TABLE 28 DETECTION TIMES FOR SELECTED DRUGS IN URINE Drug Time Marijuana Single use 3 days Marijuana Moderate use, 4 times per week 5–7 days Marijuana Daily use 10–15 days Marijuana Long-term heavy smoker More than 30 days Cocaine Metabolites 2–4 days Opioids Codeine 48 h Heroin (morphine) 48 h Hydromorphone 2–4 days Methadone 3 days Morphine 48–72 h Oxycodone 2–4 days Propoxyphene 6–48 h Amphetamines Amphetamine/ Methamphetamine 48 h Phencyclidine 8 days Source: Moeller et al. (2008). TABLE 29 DETECTION TIMES FOR SELECTED DRUGS IN ORAL FLUID Drug Dose (mg) Route of Administration Analyte Cutoff (ng/ml) Detection Time (h) Marijuana 20–25 Smoked Tetrahydrocannabinol 0.5 34 Cocaine 25–42 Intravenous, intranasal, smoked Cocaine 1 5–12 Benzoylecgonine 1 12–24 Heroin 20 Intravenous 6-Acetylmorphine 1 0.5–8 Amphetamine Oral Amphetamine 10 20–50 Methamphetamine 10 Sustained release, oral Methamphetamine 2.5 24 MDMA 100 Oral MDMA 126 24 Source: Verstraete (2004).

35 in the catagen stage and 10% to 15% in the telogen stage at any point in time. Therefore, drug concentrations will dif- fer between hairs within one location and between locations such as scalp hair, pubic hair, and arm or leg hair (Cone et al. 2007: Gallardo and Queiroz 2008). For hair drug testing, however, specimens are typically collected from the back of the head. Hair testing has received considerable attention in recent years. Entering the keywords “hair drug testing” in PubMed and limiting the search to humans yielded 834 results. Because of the nature of hair growth, and the fact that hair is typically exposed to the environment, hair drug testing has unique sets of advantages and disadvantages. The main advantage of hair drug testing is the long win- dow of detection of drugs, which can extend from weeks to months, depending on the rate of hair growth and the length of hair available for sampling. Another advantage is that hair collection is relatively easy and noninvasive, with the oppor- tunity to obtain additional specimens. One disadvantage is contamination from the environ- ment. There are three known mechanisms for incorporating drugs into the hair shaft. The first is from blood. The second is from sweat in the tissues surrounding the follicle, usually after the hair emerges from the skin. The third is from envi- ronmental exposure to the drug. Detection of a drug is not sufficient to identify drug use because hair may be contaminated by exposure to the smoked drug and by powder residue from surfaces where use occurred (Ropero-Miller and Stout 2008). Contami- nation is an issue for drugs that may be smoked, such as marijuana, cocaine, amphetamine, methamphetamine, and heroin (Stout 2007). Several studies have shown that being in contact with a drug can result in the accumulation of the drug in the hair and result in a false positive. Mieczkowski (1995) found that undercover narcotics officers who had chronic envi- ronmental exposure to cocaine had detectable amounts of the drug in the hair; Koren et al. (1992) found concentra- tions of both cocaine and benzoylecgonine in hair exposed to varying quantities of crack smoke in a small, unventi- lated room; and Thorspecken et al. (2004) found that in vitro hair exposed to marijuana smoke tested positive for the drug, depending on concentrations in the air, hair care habits, and cosmetic treatment. Thus, the issue is not whether contamination can occur, for which there is broad consensus, but whether there are ways of discriminating between active use and passive con- tamination. Currently, laboratories use two complementary procedures to minimize the possibility of passive contamina- tion. The first is decontamination of hair samples by washing the hair before analysis. Several decontamination—or wash- ing—procedures are described in the literature, but there is no agreement on which procedure must be used (Pragst and Balikova 2006), whether washing the hair is able to remove all potential risks from external contamination (Romano et al. 2001; Stout 2007; Ropero-Miller and Stout 2008), and whether variations in washing techniques produce analyti- cal variability (Stout 2007). Washing procedures include organic solvents, aqueous buffers, water, and a combination of these (Gallardo and Queiroz 2008). Some laboratories have included analysis of the wash solu- tion as a crucial step in the decontamination procedure. After several washes, measurement of a drug in the solution is com- pared with the measurement of the drug in the hair. In general, if the drug is detected in the hair and not in the solution, it is an indication of active drug use, whereas if the drug levels in the solution vis-à-vis the hair exceed a given criterion, it is an indication of passive contamination. A summary of those pro- cedures is beyond the scope of this project, but the reader is encouraged to read the following articles for details: DuPont and Baumgartner (1995), Romano et al. (2001), Schaffer et al. (2002), Cairns et al. (2004a,b), Schaffer et al. (2005); Kintz et al. (2007), Stout (2007), Hill et al. (2008), Ropero-Miller and Stout (2008), and Tsanaclis and Wicks (2008). The second step is detection of drug metabolites, specifi- cally those that are unambiguously related to endogenous processing of the drugs. In some cases, ratios of the metabo- lite to the parent drug must be interpreted to report results (DHHS Proposed Revisions to Mandatory Guidelines for Federal Workplace Drug Testing, 69 Fed. Reg. 19,644). The metabolites may be present in much lower concentrations than the parent drug (Pragst and Balikova 2006), and their detection requires highly sensitive and specific analytical techniques (Gallardo and Queiroz 2008). Recent develop- ments in immunochemical, GC/MS, and especially LC/MS, which have allowed lower LODs and LOQs, have made this possible (Barroso et al. 2011; Wada et al. 2010). Note, however, that some metabolites are not unambigu- ously related to endogenous processing of the drugs. Some metabolites (e.g., MDA) are used as a drug themselves (Pragst and Balikova 2006), some may appear as congeners in the parent drug, and some may be formed by degradation during processing (Hoelzle et al. 2008). The latter is espe- cially true for some extraction methods (Barroso et al. 2011). Thus, criteria for interpretation need to be adjusted for the specific analytical conditions (Hoelzle et al. 2008). Because of the issue of contamination, the Federal Bureau of Investigation laboratory no longer conducts cocaine analy- ses in hair for most cases involving subjects who have a legiti- mate reason to be in contact with cocaine, such as attorneys involved in drug cases, law enforcement officers handling drug evidence, and crime laboratory employees (LeBeau

36 and Montgomery 2009). As Pragst et al. (2010) point out, however, it is unlikely that innocent citizens in their daily environment might contaminate their hair to such an extent that it could lead to cocaine-positive results with the current criteria. When contamination is suspected, they suggest that additional investigation be conducted of nonhead hair, which is much less prone to external contamination, and that hair analysis continues to be a suitable tool in the majority of appli- cation fields, including testing for cocaine exposure. The Fed- eral Bureau of Investigation laboratory is actively researching this issue of contamination, and it has expressed the belief that it can be resolved by identifying a truly unique metabolite that does not exist in street cocaine and/or through additional wash kinetic studies (LeBeau and Montgomery 2010). A second disadvantage is that hair drug testing cannot detect recent drug use. Three to 5 days of hair growth are typi- cally required for the hair to emerge from the skin surface. Dur- ing that time, the drug may be detected in the sweat bathing the hair, but washing procedures can make detection unlikely. A third disadvantage is that incorporation of the drugs into the hair is affected by melanin. Studies have shown that mel- anin content increases with hair “darkness” (Baumgartner and Hill 2001) and that the drug concentration in pigmented hair can be significantly higher than in nonpigmented hair (Kidwell and Smith 2007). Some researchers have further suggested that because minority groups tend to have dark hair, the melanin bias is in effect a race bias. Others have suggested that differences in hair structures, permeability of the hair, use of cosmetic hair treatment, personal hygiene, and artificial hair color may also affect the drug analyses (Kidwell et al. 2000; Wennig 2000). Entering in PubMed the keywords “melanin bias in hair drug testing,” “race bias in hair drug testing,” and various combinations of these yielded 32 articles. Of those, seven could not be retrieved and 10 were outside the narrow focus of interest. Of the 15 articles that were reviewed, some found that drug levels were higher in darker color hair (Kelly et al. 2000; Mieczkowski and Newel 2000; Mieczkowski et al. 2002; Hill et al. 2005; and Mieczkowski and Kruger 2007), but none of the reviewed articles found direct support for the race bias hypothesis (Mieczkowski and Newel 1993; DuPont and Baumgartner 1995; Hoffman 1999; Kelly et al. 2000; Mieczkowski et al. 2002; Tassiopoulos et al. 2004; Bern- stein et al. 2005; Hill et al. 2005; Mieczkowski and Kruger 2007; Mieczkowski et al. 2007). The apparent inconsistency may be explained by the fact that different ethnic groups have different patterns of drug use (Kelly et al. 2000) and that some analytical procedures remove the melanin by cen- trifugation prior to the analysis of keratin, another compo- nent of human hair (Baumgartner and Hill 2001). It can be noted, however, that because of the logistical and ethical difficulties in studying the pharmacokinetics and pharmacodynamics of illicit drugs under controlled conditions, most of the studies cited previously compared the results of hair drug tests of subjects of varying hair color without an accurate and dependable reference stan- dard against which the sensitivity and specificity of the hair drug tests could be calculated. Because of this difficulty, researchers have resorted to less direct analytical strategies, comparing hair drug test results with urine drug test results and/or self-report measures. Mieczkowski and Newel (1993), for example, compared the outcome of hair and urine drug tests for cocaine in White and Black arrestees. Urine tests indicated that 35.9% of Blacks and 16.5% of Whites were positive for cocaine, for a ratio of 2.18 (35.9/16.5 = 2.18, Blacks were 2.18 times more likely to test positive than Whites). Hair tests indicated that 62.5% of Black and 36.1% of Whites were positive for cocaine, for a ratio of 1.73 (62.5/36.1 = 1.73, Blacks were 1.73 times more likely to test positives than Whites). Relative to Whites, therefore, pos- itive cocaine tests for Blacks were more likely with urine tests than with hair tests. Thus, no evidence of a race bias in hair testing was found. Similar results were obtained by Hoffman (1999) with Black and White applicants for employment with a large metropolitan police department. A recent report by Ropero-Miller and Stout (2011) further suggests that whereas cocaine analyte concentrations may be significantly higher in dark hair types, including African American individuals, use of benzoylecogonine/cocaine ratios and extensive decon- tamination wash criteria greatly reduce positive hair in vitro testing results in contaminated hair. A fourth disadvantage is the interference of cosmetic treat- ment on the analysis of hair. Because of cultural differences in ethnic grooming, some groups tend to wash their hair less often than others. Some researchers have suggested that the lower frequency of hair washing causes less leaching of the drug out the hair as a result of washing, which results in a potential increase of positive tests. Conversely, because most cosmetic treatment involves oxidation of the hair, it may reduce the availability of drugs for detection in hair testing, which results in a potential increase of negative tests. In summary, although some researchers assert that the inherent drawbacks of hair testing preclude it for use in the workplace, where accuracy and fairness in employment decisions are paramount (Romano et al. 2001; Stout 2007; Ropero-Miller and Stout 2008), others assert that the main analytical problems have been adequately dealt with (Bar- roso et al. 2011), and it is important that hair preferentially be chosen for pre-employment and random tests (Pragst and Balikova 2006). Sweat Sweat is produced by eccrine and apocrine glands in the skin for the purpose of thermal regulation of the body. Drugs are

37 incorporated into sweat by passive diffusion from blood and by transdermal passage across the skin. Entering the keywords “sweat drug testing” in PubMed and limiting the search to humans yielded 147 results. Sweat is typically col- lected with a patch made of transparent film that is attached to skin. While wearing the patch, sweat saturates the pad and the drugs present in sweat are retained. The main advantage of sweat testing is a relatively lon- ger window of detection, which spans the duration the patch is applied to the skin, usually 1 week, plus 24–48 h before the application of the patch. Other advantages are that the patch is noninvasive, relatively tamper-proof, and provides a cumulative measure of drug exposure. Because it is difficult to estimate sweat volume and to eval- uate drug concentrations, sweat testing is primarily a qualita- tive rather than quantitative method of measuring drug use. Disadvantages include low acceptability of patch wearing, the possibility of accidental removal or purposeful removal, and the potential for contamination at the time of removal. Relative Utility of Different Specimen by Type of Drug Test Does the larger detection window of hair analysis—relative to urine analysis—result in higher positivity rates? There is evidence that this may be the case. Sample (2010) examined 193,000 same-donor paired specimens of hair and urine, collected over a 5.5-year period from 2004 to 2009. As shown in Table 30, overall positivity rates for hair were considerably higher than the positivity rates for urine. Hair analyses detected use of amphetamines (particularly methamphetamine) and cocaine to a greater extent than urine analyses. Studies from different donors (independent specimens of urine and hair) also show differences in positivity rates between urine and hair, but only for certain type of drugs (Quest Diagnostics November 2009). Table 31 reports the positivity rates by drug category for urine and hair drug tests for the general U.S. population (Quest Diagnostics Novem- ber 2009). According to these data, hair positivity rates tend to higher than urine for amphetamine/methamphetamine, cocaine, and marijuana, whereas urine positivity rates tend to be higher for opiates and phencyclidine. TABLE 30 SAME-DONOR HAIR AND URINE POSITIVITY RATES (%) Drug Hair Urine Overall 12.6 7.6 Amphetamines 5.9 2.1 Methamphetamine Only 5.9 1.8 Cocaine/Metabolites 4.8 0.65 Opiates 0.23 0.52 Phencyclidine 0.05 0.05 Marijuana Metabolites 3.4 3.4 Source: Sample (2010). Overall, the pattern of higher positivity rates for hair test- ing is robust. Table 32 reports the positivity rates by type of test for urine and hair drug tests for the general U.S. work- force (Quest Diagnostics November 2009). Mieczkowski (2010) examined 11,242 same-donor paired urine and hair specimens for pre-employment tests and 1,458 urine and hair specimen for random tests. Of the pre- employment tests, approximately 2% of the urine specimens and 9% of the hair specimens were positive. Of the random tests, 0.6% of the urine specimens and 3% of the hair speci- mens were positive. An important distinction must be made at this point between drug use and impairment. Drug use can be detected with a drug test by the presence of active or inactive analytes, whereas impairment can only be inferred by the presence of active analytes and/or behavioral signs and symptoms. As shown in the previous sections, active analytes tend to have shorter half-lives than inactive analytes and can, therefore, be detected for shorter periods of time. The suitability of different specimens varies as a function of the type of test that is being performed. Pre-employment tests, for example, are administered to determine whether TABLE 31 POSITIVITY RATES (%) BY DRUG CATEGORY FOR URINE DRUG TESTS AND HAIR DRUG TESTS FOR THE GENERAL U.S. WORKFORCE Year Amphetamines Cocaine Marijuana Opiates Phencyclidine Urine Hair Urine Hair Urine Hair Urine Hair Urine Hair 2005 0.48 2.1 0.70 5.0 2.5 3.0 0.32 0.14 0.020 0.01 2006 0.42 1.1 0.72 4.5 2.4 3.5 0.32 0.14 0.020 0.01 2007 0.44 1.2 0.58 5.3 2.3 3.9 0.35 0.17 0.020 0.01 2008 0.48 0.86 0.41 4.2 2.1 3.4 0.38 0.14 0.020 0.00 2009 (Jan.–June) 0.55 1.1 0.30 3.2 2.0 3.2 0.44 0.15 0.01 0.01

38 an individual is an illegal drug user. These tests benefit from a relatively large detection window, hence the usefulness of hair testing. Postaccident tests, in contrast, may be admin- istered not only to determine whether an individual is an illegal drug user, but also to determine, for forensic and legal purposes, whether the individual was impaired at the time of the accident. These tests require the detection of the active analytes and benefit from a relatively short detection win- dow, which frames the co-occurrence of the accident and of the drug use within a relatively brief period of time. Blood and oral fluids tests are best suited for these needs. TABLE 32 POSITIVITY RATES (%) BY TYPE OF TEST FOR URINE DRUG TESTS AND HAIR DRUG TESTS FOR THE GENERAL U.S. WORKFORCE Year Pre-employment Random Urine Hair Urine Hair 2005 3.9 7.0 6.6 12.7 2006 3.9 7.2 5.5 11.0 2007 3.9 7.4 5.7 15.8 2008 3.6 6.3 5.3 9.6 2009 (Jan.–June) 3.4 4.7 5.4 10.4 The usefulness of additional specimens to the DOT pro- tocol must be weighed against the practical complexity of managing a drug-testing program with different specimens. For each type of specimen, collection methods, analyte cut- offs, and laboratory standards and procedures must be imple- mented. Given the size of the DOT drug-testing program, careful consideration must be given to the logistical and finan- cial burden associated with the use of additional specimens. Although specific types of specimens are best suited for specific types of tests, urine is the only specimen that is ade- quately suited for all types of tests. Table 33 rates the useful- ness of the window of detection of different specimens as a function of type of drug test. If only one type of specimen is to be used for practical and economic reasons, urine is cur- rently the best option. TABLE 33 UTILITY (LOW, MEDIUM, HIGH) OF DIFFERENT SPECIMENS AS A FUNCTION OF TYPE OF DRUG TEST Test Blood Oral Fluids Urine Sweat Hair Random Low Low Medium Low High Pre-employ- ment Low Low Medium Low High Postaccident High High Medium Low Low Reasonable Suspicion High High Medium Low Low Return-to-Duty Low Low Medium Medium Low Follow-up Low Low Medium Medium Low HIGHER RANDOM TESTING RATES Some companies set target rates for the random alcohol and drug tests that exceed the minimum rates established by their regulatory agencies. Of the companies sampled for this project, Greyhound Lines, J.B. Hunt Transport, and BNSF conduct ran- dom alcohol and drug tests above the minimum requirements. Greyhound Lines, Inc., is the largest provider of intercity bus transportation, with 8,500 employees nationwide. Grey- hound’s third-party administrator is HireRight, a global provider of employment drug and background screening. According to HireRight, Greyhound Lines maintains annual random testing rates at 55% for drugs and 15% for alcohol. J.B. Hunt Transport testing rates are 55% for drugs and more than 10% for alcohol. Unannounced, random drug and alcohol tests are spread periodically throughout the year, aiming for completion on a quarterly basis. This method attempts to eliminate the possibility of falling short of the random rates at the end of the year owing to unpredictable circumstances, such as employees leaving the company before being tested. BNSF conducts random testing at a higher frequency than the minimum for both drug and alcohol tests. As of Novem- ber 1, 2010, all FRA and company random testing is admin- istered at 37.5% for both alcohol and drug tests. Exceptions include all FRA random road tests are alcohol tests only for all outbound trains, and FMCSA random tests continue at 50% for alcohol and 50% for drugs. Higher random testing rates are a fair and effective strategy for increasing compliance with alcohol and drug policies. With the exception of costs to the company, this strategy has no adverse effects. LONGER PREDUTY ALCOHOL ABSTINENCE PERIODS Companies can require longer preduty alcohol abstinence periods than the required 4 to 8 h. J.B. Hunt, for example, requires 12 h of alcohol abstinence before initiating safety- sensitive work. CONSEQUENCES FOR BACS 0.020–0.039 There is considerable empirical evidence that alcohol nega- tively affects human performance with any deviation from BAC 0.000 (Moskowitz and Fiorentino 2000). Consistent with this view, DOT rules require that an employee with BACs 0.020–0.039 be immediately removed from all safety-sensi- tive duties. The employee cannot return to safety-sensitive duty until the BAC has dropped below 0.020, and a minimum period of time has elapsed, usually between 8 and 24 h.

39 To deter employees from having BACs in the 0.020–0.039 range, some employers have imposed stricter consequences for those lower BACs. Of the companies sampled for this project, three impose these stricter consequences: Hallibur- ton, Continental Airlines, and BNSF. Halliburton is an energy company with employees and locations worldwide. Its policy allows immediate removal of employees with BACs of 0.020–0.039 from all safety-sen- sitive work. The employees are sent home with safe travel arrangements. The employees are also suspended from all duties and functions and cannot return to work for 2 weeks. Continental Airlines immediately removes employees with BACs in the 0.020–0.039 range from safety-sensitive work. The employees are taken off the future work schedule. Employ- ees are reported to the SAP and enrolled in an EAP. The SAP and EAP, together, decide when the employee is fit to return to work. If the employee is already participating in a last-chance agreement, then this BAC range of 0.020–0.039 counts as a positive, which would violate the terms of the agreement. The employee is then terminated from the company. BNSF considers any alcohol test with BAC of 0.020 or above as a positive test and a violation of the company’s drug and alcohol policy. Employees are immediately removed from performing services and referred to the EAP. The company may extend a waiver of charges agreement on a first-time positive and require that the employee enter an EAP. When released back to work by the SAP and EAP, the employee is subject to a return-to-duty test and follow-up testing as directed by the SAP. Alternatively, if a waiver is not offered, the employee would be subject to a formal investigation and face termination. STRICTER POSTACCIDENT TESTING Postaccident drug and alcohol tests must be conducted within a particular timeframe, typically 8 h for alcohol and 32 h for drugs. Of the companies sampled for this project, four have policies that shorten the postaccident test timeframe: Halli- burton, Continental Airlines, Greyhound Lines, and BNSF. Following an accident, Halliburton’s testing staff and company officials are dispatched to the scene. The objective is to test all employees, for both alcohol and drugs, within 2 h of the accident. If for some reason an unforeseen delay occurs, a 4-h window is accepted. With strict postaccident testing windows, Halliburton has experienced its lowest rates for injury and vehicle incidents in the past 2 years at under 0.75 and 0.50 per 200,000 work-hours, respectively (Halliburton 2010). Continental Airlines aims to test its personnel within 5 h of an accident. Employees are tested for both alcohol and drugs. Greyhound Lines set its postaccident testing window to 2 h, with drug and alcohol tests conducted at the same time. There can be exceptions, however, as if a citation is not issued within 30 min of the accident or if location and/ or weather prevent the employee from reaching the testing facility within the 2-h window. BNSF makes every effort to complete FRA postaccident testing within 4 h following the incident at a medical facility where employees are required to provide urine and blood samples. However, reasonable delays can occur because of railroads in remote locations with limited access points, rug- ged terrain, and, at times, severe weather conditions. STRICTER FOLLOW-UP TESTING Currently, no fewer than six tests in 12 months are allowed for follow-up testing. Companies that elect to exceed those requirements may increase the number of tests, extend the duration of the testing period, or both. Of the companies sampled for this project, two exceed the minimum require- ments: Halliburton and Greyhound. Halliburton employees are given a chance to sign a last- chance agreement and enroll in an EAP after the first con- firmed positive result. If the employee signs the last-chance agreement and passes the return-to-duty tests, the EAP or SAP determines when the employee can return to safety- sensitive duties. In the EAP, the employee is followed over a 2-year period, with no fewer than 12 unannounced follow-up tests per 12-month period (for a total of 24 tests). The tests are conducted at random each month of the program. If at any time the employees test positive, they are expelled from the EAP and removed from the company entirely. Likewise, after the EAP is complete, if the employees ever test positive again, they are terminated with no chance of rehire. Greyhound follows a similar pattern. Following a con- firmed positive result, the employee is referred to a SAP in the area and must sign a last-chance agreement to continue with the company. If the agreement is made, the employee is subject to between 6 and 12 unannounced follow-up tests per year for up to 5 years. Currently, Greyhound has fewer than 20 employees participating in follow-up testing pro- grams—0.02% of its total workforce. If any of these employ- ees test positive again on any other drug or alcohol test, they will not be given another chance and will be permanently removed from the company. NATIONAL DATABASE As mentioned earlier, only 48% of all motor carriers have alcohol- and drug-testing programs in place, covering 89% of all commercial drivers (Khan 2010). A 2008 GAO report

40 estimated that fewer than half of commercial drivers who test positive or refuse to take a test complete the return-to- duty process. According to J.B. Hunt Transport, the primary problem of verification of previous drug and alcohol test results is with drivers failing to disclose their own refusals to take the test and with employers that have gone out of business. Those drivers who do not complete the return-to-duty pro- cess continue to drive, primarily by “job hopping.” Job hop- pers test positive with one carrier, stop working for that carrier, do not go through the return-to-duty process, stop using drugs for the necessary period of time to test nega- tive on pre-employment tests, and begin working for another carrier, where they may resume using drugs, and the cycle begins anew. Another category of drivers who are not likely to remove themselves from service after testing positive are owner-oper- ators. Note that DOT regulations require owner-operators to participate in a random testing program, which includes other owner-operators. The random testing pool is typically man- aged by a C/TPA. The exact number of owner-operators is unknown, making measurement of compliance difficult. The 2008 GAO report makes a strong case for the useful- ness of a national database in reducing the number of driv- ers who test positive and continue to drive. Such a national database would maintain drug and alcohol test positives and refusals information. Carriers would be required to search applicants in the database before hiring them. Such an approach depends on the level of compliance of carriers in reporting employees’ testing data, with some owner-opera- tors unlikely to voluntarily provide such data. The FMCSA is in the process of developing rules that would mandate reporting requirements for C/TPAs, MROs, and additional parties who participate in the DOT testing program. These rules would require that carriers access and review the relevant information contained in a database to ensure that only drivers in compliance with the DOT alco- hol- and drug-testing requirements be allowed to perform safety-sensitive functions. The FMCSA plans to implement the national database by the end of 2012. The proposed system will allow authorized FMCSA staff and state law enforcement personnel to access the data and create reports. For purposes of enforcement, the system will likely require the expansion of civil penalty enforcement authority to cover all DOT service agents. Note that some states (Arkansas, New Mexico, Oregon, Texas, California, North Carolina, and Washington) have already enacted reg- ulations mandating the reporting of positive tests and refus- als (GAO 2008). DRIVING RECORD NOTATIONS Some states have enacted regulations that place a notation on the driving record of commercial drivers who have tested positive in a drug or alcohol test. DOT took regulatory action to remove legal barriers allowing states to implement such regulations. We have obtained information from North Car- olina, Washington, and Oregon. In general, those statutes work as follows. The depart- ment responsible for the licensing of commercial drivers must place a notation on the driving record of the driver on receipt of notice of a positive result in an alcohol or drug test. The notation of disqualification is retained on the record of the person for a predetermined period, usu- ally 2 or 3 years. After a positive alcohol or drug test, the driver is noti- fied by the department of the pending disqualification. The driver has a predetermined period of time (usually 20 days) from the day of the notice to request an appeal. If no request is received within the time period, the disqualifica- tion becomes effective. If the driver requests a hearing, the disqualification is stayed pending the outcome of the hear- ing. The hearing is typically limited to issues of testing pro- cedure and protocol.

Next: CHAPTER SEVEN Summary and Research Recommendations »
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TRB’s Commercial Truck and Bus Safety Synthesis Program (CTBSSP) Synthesis 23: Operator Drug- and Alcohol-Testing Across Modes explores practices used to deter drug and alcohol use among operators within the U.S. Department of Transportation’s (DOT’s) regulated community.

The report includes a brief history of the transportation workplace drug- and alcohol-testing program, the general approach, the reasons for testing, some of the issues that impact the validity of the tests, and an outline of the specific regulations by mode.

Some alcohol- and drug-testing statistics are presented in the report to help provide a sense of the scope of the program and of the prevalence of illegal alcohol and drug use among safety-sensitive employees.

The report also highlights alternative strategies aimed at helping to deter illegal alcohol and drug use among employees.

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