What is a Medical Review Officer and When is it Important in a Legal Case?

A Medical Review Officer (MRO) is a licensed physician responsible for receiving and reviewing laboratory results generated by a testing protocol. All physicians order and interpret lab results to better treat a patient. An MRO has received specific training and passed Certification requirements. The Medical Review Officer is qualified to evaluate medical explanations for certain drug test results. Usually, there is a forensic element if associated with employment like a mandatory drug test or DUI.

“An MRO acts “as an independent and impartial “gatekeeper” and advocates for the accuracy and integrity of the drug testing process. You provide quality assurance review of the drug testing process for the specimens under your purview, determine if there is a legitimate medical explanation for laboratory-confirmed positive, adulterated, substituted and invalid drug test results, ensure the timely flow of test result and other information to employers and protect the confidentiality of the drug testing information.”

—U.S. Department of Transportation (Dept. of Health and Human Services and other regulatory agencies are discussed below)

Note that prescription medications and markers for physical conditions are also revealed in lab tests, though we tend to think of illegal drugs and alcohol when we hear “drug testing.”

Who Can be a Medical Review Officer?
The MRO Certificate is granted only to physicians licensed to practice medicine.
After a physician completes MRO-approved training and passes a rigorous examination, they are issued an MRO Certificate and are now qualified to serve as a Medical Review Officer. Certification is granted by the Medical Review Officer Certification Council (MROCC) or the American Association of Medical Review Officers (AAMRO). Courses are sponsored by three approved organizations: AAMRO, the American College of Occupational and Employment Medicine (ACOEM), or AOCOPM.

MRO Certification is renewed every 5 years. Recertification is as rigorous as initial certification and requires completing updated retraining and passing the recertification examination.

MRO: Drug Testing

How is drug-testing administered?
Urinalysis (a urine test), and/or blood tests are the most common type of testing. Hair follicle testing is another method, but due to a higher chance of false positives, their admissibility in court is still an open question.

When is drug testing required?
Drug testing can be “required” or “indicated.” It is required if mandated by law or regulation, such as the FAA, Department of Transportation, Health and Human Services and Private Government Contractor employees. Drug testing is “indicated” when an index of suspicion arises that drug use is an impairment or contributing factor to circumstances that end up in court.

Not just illegal drugs

A Medical Review Officer is qualified to interpret all laboratory results, not just tox screening for the presence of illicit drugs. For example, I may find that prescription drugs are present which could include addictive prescription pain drugs.  Fentanyl is both a prescription medication and a “street drug.” The presence of Fentanyl in a test isn’t illegal if it is prescribed by a doctor but it might be relevant, even central.  I review medical records in civil and criminal cases. But as a physician, I am also mindful if labs show markers of a serious disease that has a medical and medical-legal implication. For example, blood testing may raise questions about a brain disease.

The interaction of drugs, brain function, and behavior can be compelling and relevant. It is one reason I pursued the combination of credentials in Forensic Psychiatry, Brain Injury Medicine, Psychiatry and MRO Certification.

Employment and the Findings of an MRO

Employers might require drug testing as a condition of employment in the private sector, even if they are not obligated to do so under the law.

Fitness for Duty. Drug or alcohol abuse can interfere with an employee’s ability to do their job. For that reason, drug testing might accompany a Fitness for Duty evaluation. Informed consent is required for a FFD and required testing. Termination or being placed on administrative leave can be a consequence if the employee will not agree to be tested. Rules are set by each employer independently and vary.

As a Forensic Psychiatrist, I have conducted Fitness for Duty evaluations with a high risk of employment litigation in the event of termination. Ironically, in one case it was necessary to the job to carry firearms though no drug testing was required as part of the FFD I conducted.

The MRO and Law
A Medical Review Officer is a logical consultant or testifying expert in jurisdictions where the case involves any toxicology or laboratory testing with a forensic implication.

Crime
An MRO is qualified, even preferred, to opine whenever drug testing is conducted in association with an alleged crime.

• Commission of a Crime.  An MRO may be asked to testify if drug testing suggests an alleged perpetrator was under the influence of a medication or illicit drug.
• Criminal charges of illegal use or distribution of drugs can accompany drug testing. Evaluating a particular test’s rate of false positives or negatives is part of an MRO’s training, as is providing a trier of fact about the test results.
• Collateral charges may include drug possession or distribution including smuggling drugs.
• Accessories (alleged) to the commission of the crime may also be tested.
• DUI. When a driver is pulled over and DUI is suspected, the results of a Field Sobriety Test or officer observations can raise an index of suspicion such that lab tests are indicated to confirm if drugs or alcohol are present. (If charges have not been brought, drug testing can only be administered with the consent of the person being tested.)
• Victim testing. When rape is reported to the police and the victim may have been drugged, police protocol generally indicates labs be drawn. Drug Facilitated Sexual Assault, for example, is where a perpetrator uses drugs to render a victim incapacitated (GBH or other date rape drugs.) Read more.
• Competency to stand trial. Voluntary drug use does not render someone incompetent to stand trial. An MRO is qualified, however, to review laboratory results and report on his or her findings.
• NGRI. Claims of Not Guilty by Reason of Insanity (NGRI or the “insanity defense”) associated with drug use (but not caused by drug use) is addressed by a Forensic Psychiatrist. In my case, as an MRO, I am able to add depth to my opinions with the added interpretation of drug testing.
• Drugs and “Insanity.” Some drugs can induce or worsen psychosis. Psychosis can include hallucinations and delusions. If, for example, a person with Schizophrenia takes a drug that escalates to “Command Hallucinations,” they may believe they are compelled to commit a crime. At what point does Intoxication end and Psychosis begins? Voluntary Intoxication by itself does not qualify for an Insanity defense. The results of drug testing at the time of being charged can be reviewed by an MRO.
• Probation status requires routine drug testing. In other words, failing drug testing may result in a change or revocation of probation and return to prison.

Civil Law
In litigated events there may be features involving good judgment and clarity of thought. If this is compromised by the possibility of medication or illegal drugs, expert testimony by a qualified Expert Witness is indicated.

A Medical Review Officer’s involvement as a consultant or Expert Witness can be helpful to the trier of fact.

From Fraud to testamentary capacity, civil litigation is one remedy. Civil cases even follow criminal cases where financial recompense is sought by victims and their families. Events associated with drug or alcohol use are always considered. This is equally applicable to plaintiff and defense.

Medical Malpractice

Claims about the administration and medical management of prescription drugs can benefit from an MRO’s review of testing. Before I became an MRO, I conducted several Forensic Psychiatric evaluations in civil cases where drug testing results were pivotal.

DUI, Date Rape Drugs and a Tox Screen

I wanted to become an MRO especially after a case that wasn’t as simple as a DUI. Defense argued a date rape drug was given the woman and it caused her to drink excessively (leading to the DUI). The ER physician raised more questions. I was an Expert Witness. Read more about the case “Did Date Rape Drugs Lead to her drinking?”

Probate, Testamentary Capacity and Undue Influence

Is a person incompetent to sign a Will or Trust in some part due to medications or drugs altering their ability to act of their own free will?

Vulnerability. If a person is taking a medication that causes confusion, for example, lab reports become relevant if the medication impairs testamentary capacity. Physicians are trained to order relevant testing, and read results with meaning but the purpose is diagnosis and treatment, not regulatory compliance or relevance to litigation.  MRO Certification was established to comply with Federally Mandated regulations. An MRO’s training, however, is helpful in any medical-legal controversy where proper interpretation of test results is relevant.  A Forensic Psychiatrist adds qualifications to consider mental state that raises to the level of medical-legal implication. An MRO does not define testamentary capacity, but they are qualified to hone in on drug-associated risk factors. In my assessment in a testamentary capacity case I apply my training both as a Forensic Psychiatrist and MRO.

Undue Influence. Undue Influence is a term used in Probate and Trust Administration cases and occurs when one person imposes control over another, usually for financial benefit. Taking advantage of someone may be easier if the person being manipulated is more compliant or dependent. Drugs can have that effect. In some cases, the “influencer” will ply the “influenced” person with drugs to render them less able to self-advocate or stand up to undue influence.  Prescription and certain illegal drugs can promote compliance and vulnerability; sedatives are noteworthy culprits.

Decedent Medical Records.  Probate cases usually arise after a person’s death. This invariably involves reviewing the Decedent’s medical records. In fact, they may be the only available information on which to base a forensic opinion. I am almost always asked to review medical records as part of a Forensic Psychiatric assessment. If a person is deceased and was being treated for a medical condition at the time of their death, medical records usually include laboratory results. Interpreting results present at the time a testamentary document was changed is a prime example of when a physician with Medical Review Officer status is helpful.

Occupation

Public Safety / Regulatory

Federal and State regulatory agencies may require routine or one-time drug testing in high-risk professions. Compliance and “clean” results are often necessary to maintain a license or certification.

Most federal safety-sensitive jobs require drug testing. Regulating agencies include SAMHSA (Health and Human Services), Department of Homeland Security, Department of Transportation, Department of Defense and the FAA.

Police officers and other public servants who are authorized to carry firearms require routine drug testing.

A commercial pilot’s license can be revoked by the FAA if a pilot will not comply with testing or the test results show drug use.

The U.S. Department of Transportation has extensive regulations about mandatory drug testing. Private commercial trucking companies must also require of their employees extensive driver safety training regarding alcohol and drug abuse. In some cases the trucking company must, by DoT regulations, conduct drug testing.

HHS, the U.S. Department of Health and Human Services, governs SAMHSA (Substance Abuse and Mental Health Services Agency.) SAMHSA is a Federal Agency that regulate drug testing of federal employees under specific conditions.

The Departments of Defense and Homeland Security also regulate drug testing in jobs involving public safety.

“Regulations require a Federal employee who works in a safety-sensitive position to be subject to drug, and in some cases, alcohol testing. This type of position is referred to as Testing Designated Position (TDP). Additionally, any position that is occupied by an individual requiring a Secret, Top Secret or higher security clearance is a TDP for drug testing only. A position requiring a Commercial Driver’s License is designated for drugs and alcohol testing. A list of covered positions can be found at in the Appendix of COMDTINST 12792.4.“

–U.S. Department of Homeland Defense, Coast Guard

Department of Defense private contractors subject to the Defense Base Act may operate in active military zones in designated safety-sensitive jobs. Private contractors and Federal civilian employees should be prepared for drug testing under these circumstances. Construction under combat conditions, for example, may be conducted by a private contractor and not military personnel.

Private Sector Employment
Drug and alcohol testing may not be mandatory by law for private employers who are not government contractors. If security, workplace or public safety, or on-the-job performance are a concern, employers may require drug testing.

Pre-Employment Drug Testing and Psychological Evaluations
An employer may require an applicant pass drug screening before being hired, or even before an interview. An MRO is qualified to assess the test results. Interestingly, a “psych eval” may also be required in pre-employment screening. An MRO who is also a Forensic Psychiatrist is qualified to conduct both the interpretation of drug testing results and a Pre-Employment Psychological Evaluation.

Random Drug Testing: Staying Employed

• Random Drug Testing is standard protocol by some employers. Failure to cooperate with the test (let alone “pass” it) can lead to termination or being placed on administrative leave (with or without pay).
• Fitness for Duty. Even when there is no security or safety issue, employers may need to know if a physical or drug abuse condition is impairing the employee’s ability to do their job. An MRO may be brought in. A Forensic Psychiatrist usually conducts FFD evaluations when mental health is a concern. Drug use and mental illness are known to be associated and an evaluator skilled in both can produce a report with both conclusions and cross-analysis.[1]

Athletes
Drug testing is required prior to many professional and amateur sports events, like the Olympics, Tour de France, National and International competitions in a broad range of sports. At the Olympics, “doping” or use of a banned substance, has resulted in entire teams losing a medal as a result of one team member’s failure of drug testing. To make matters more complicated, false negatives and false positives plague testing in sports. A Medical Review Officer is an appropriate evaluator, though the International Olympics Committee has not set requirements for the proper professional to interpret drug screening, mindful of all participating countries and a myriad of drug testing protocol.

[1] “Why is There Comorbidity Between Substance Use Disorders and Mental Illness?” National Institute on Drug Abuse.

Sanjay Adhia, M.D., Forensic Psychiatrist