Drug and alcohol disorders can occur in any patient seen in family practice, and they are present in many more patients than are diagnosed. Physician awareness of the potential for such problems is the first step in detecting, evaluating and treating patients who are substance abusers. In some cases, treatment is possible in the office setting. In others, the physician oversees inpatient treatment or makes referrals and provides long-term collaborative follow-up, all of which are essential if the patient is to avoid a relapse. Treatment should be considered part of an ongoing process designed first to help the patient discontinue the self-destructive behavior and then to maintain abstinence from illegal or problematic drug use.

Another role for physicians is that of medical review officer (MRO) for a drug testing program. Screening employees for drugs is required in some regulated industries such as interstate trucking, air transportation, nuclear energy plants and maritime and railroad industries. Drug testing programs regulated by the Department of Transportation and other federal programs are required to employ MROs, who must be licensed physicians with a knowledge of substance abuse disorders and of possible alternative medical explanations for positive urine drug test results. It is likewise recommended that non-federally regulated drug testing programs employ an MRO.

The MRO generally functions as a safeguard against wrongful accusations; therefore, the MRO must thoroughly investigate each positive screen [46]. If a prospective or current employee has an acceptable medical explanation for a positive result, the MRO would report to the employer that the result was negative. Other issues involved in the duties of the MRO include documenting the chain of evidence of clinical samples, reporting verified positive test results and recommending a rehabilitation program for the employee. The duties of an MRO are outlined in booklets published by SAMHSA and the U.S. Department of Transportation.

Before becoming an MRO, a family physician should carefully weigh practical and personal issues [47]. Charting and office policies may need to be modified to meet legal requirements. Because the MRO serves as an adviser to the employer, the physician-patient relationship differs from that in conventional patient care. Moreover, the MRO may be sued by a patient who loses a job or experiences employment problems because of a positive test result. Therefore, becoming certified by one of the organizations that offers courses in this area is highly recommended. Nevertheless, family physicians may find interesting opportunities in the field of occupational drug testing.

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