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Qualifications of Medical Review Officers (MROs) in Regulated and Nonregulated Drug Testing

Journal of Occupational and Environmental Medicine: January 2003 - Volume 45 - Issue 1 - p 102-103
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The medical review officer (MRO) concept was first introduced in 1988 with the announcement of the federal Department of Transportation drug testing regulations. The MRO’s primary role is to determine whether a medical explanation exists for a laboratory-verified positive controlled substance test. The MRO was defined as “a licensed physician (MD or DO) who has knowledge of substance abuse disorders and has appropriate medical training to interpret and evaluate an individual’s positive test result together with his or her medical history and any other relevant biomedical information.” Neither official training nor certification were required.

In the original 1990 American College of Occupational and Environmental Medicine (ACOEM) position paper on MRO qualification, it was recommended that an MRO be “certified as having received at least 14 hours of [continuing medical education] CME credit for instruction as medical review officers, including the pharmacology of substance abuse, laboratory testing methodology and quality control, forensic toxicology, federal regulations, legal and ethical requirements, chemical dependency illness, employee assistance programs and rehabilitation.…”

As testing for controlled substance expanded in the nonregulated arena, several states began to develop laws concerning protocols and procedures to be followed. Although testing performed under federal standards required the reviewing MRO to be a physician, some states passed legislation that would allow a nonphysician to provide MRO services in state regulated situations.

Extensive changes to the Procedures for Transportation Workplace Drug and Alcohol Testing programs were published in the December 19, 2000, Final Rule. Among the changes were training and certification requirements for MROs.

As a result of this change and upon recommendation of the Medical Review Office Section, ACOEM updated its position paper on the Qualifications of Medical Review Officers (MROs) to include both regulated and non-regulated drug testing. This updated position paper was passed by the ACOEM Board of Directors on July 28, 2001. It reflects the new MRO requirements and supports that MRO services in nonregulated drug testing should be provided by a licensed physician consistent with the requirement for federal testing.

Qualifications of MROs in Regulated and Nonregulated Drug Testing

ACOEM commends the Department of Health and Human Services (DHHS) and the Department of Transportation (DOT) for their ongoing commitment to ensure the integrity of workplace drug testing programs. The recently revised “Procedures for Transportation Drug and Alcohol Testing Programs” updates the regulations based on current science and technology.

An integral part of these programs is the regulation’s definition of an MRO as a “licensed physician who is responsible for receiving and reviewing laboratory results generated by an employer’s drug testing program and evaluating medical explanations for certain drug test results.” The MRO function in the process serves to alleviate fears among employees who are not using drugs illegally that they will be accused of being drug users. With these changes, ACOEM is updating its position on the qualifications required to perform services as an MRO.

The College agrees that MROs must be licensed physicians with the following:

  • knowledge and clinical training in controlled substance-abuse disorders, including detailed knowledge of alternative medical explanations for laboratory-confirmed drug test results;
  • knowledge of issues relating to adulterated and substituted specimens and possible medical causes of an invalid result;
  • knowledge of the “Procedures for Transportation Drug and Alcohol Testing Programs,” the DOT “MRO Guidelines,” and DOT agency rules applicable for any employer for which the MRO provides services.

In addition, ACOEM feels that the MRO must also have knowledge of:

  • the pharmacology of drugs of abuse;
  • accepted pharmacological treatment and standard prescribing practices for specific disease process;
  • use and authorization to prescribe controlled substances consistent with Drug Enforcement Agency (DEA) rules and regulations;
  • ethical considerations in workplace drug testing programs;
  • laboratory testing methodology and quality control;
  • laws and regulations related to the use of illicit and licit substances;
  • chemical dependence and addiction behavior;
  • employee assistance programs and rehabilitation.

MROs must be able to demonstrate that they have completed training in the proper performance of MRO services by successfully completing an examination administered by a nationally recognized MRO certification board. With the ongoing advances in the drug testing arena and regulatory changes, MROs must be required to stay current with these changes by participating in at least 12 hours of CME pertaining to MRO functions during each 3-year period. This CME activity must include an assessment tool to ensure that the material has been adequately learned.

ACOEM also recognizes that the use of MROs may be addressed in state laws and regulations. ACOEM supports the same requirements for MROs who provide services in the nonregulated sector as in regulated. This should include a provision that, as in the regulated testing, the MRO interviews donors with laboratory positive tests so as to insure investigation into possible reasonable medical explanations for the result.

Furthermore, ACOEM supports the adoption of the standards in these regulations for all employment-related drug-testing programs. Adoption of these guidelines and in accordance with DHHS Guidelines for Workplace Drug Testing which include the requirements that an MRO be a licensed doctor of medicine or osteopathy, will ensure uniformity of standards and quality of benefit for both employers and employees.


This ACOEM statement was prepared by Natalie P. Hartenbaum, MD, MPH, and Douglas W. Martin, MD, under the auspices of the ACOEM Medical Review Officer Section. It was approved by the ACOEM Board of Directors on July 28, 2001.

©2003The American College of Occupational and Environmental Medicine