National Academies Press: OpenBook

Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements (2011)

Chapter: Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers

« Previous: Chapter Five - Supplements: Nutritional, Herbal, Energy Boosters, Dietary, and Health Foods
Page 50
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 50
Page 51
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 51
Page 52
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 52
Page 53
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 53
Page 54
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 54
Page 55
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 55
Page 56
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 56
Page 57
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 57
Page 58
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 58
Page 59
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 59
Page 60
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 60
Page 61
Suggested Citation:"Chapter Six - Medications and Commercial Driver Medical Certification: Report on a Survey of Medical Examiners of Commercial Drivers." National Academies of Sciences, Engineering, and Medicine. 2011. Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements. Washington, DC: The National Academies Press. doi: 10.17226/14534.
×
Page 61

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

50 INTRODUCTION Both prescribed medications and self-administered “over- the-counter” drugs may affect driver alertness, the onset of driver fatigue, and overall driver performance. Concerns have been raised about the association between drugs and medica- tions as contributing factors to the cause of highway crashes. The significant involvement of medications in accidents is demonstrated in FMCSA’s Large Truck Crash Causation Study (Craft et al. 2007). In that study, prescription and OTC drug use were considered “accident associated factors” in 26% and 17%, respectively, of the 967 accidents. (An accident associated factor was defined by the study authors as a “factor that could be important,” not the “critical reason” or “event” causing the crash.) Further importance of the involvement of medications in highway accidents is provided by research conducted on Australian truck drivers in a volunteer study published in 2004 (Howard et al. 2004). In this study, drivers who con- sumed benzodiazepine-type medications were found to be 1.91 times more likely to have had a crash in the previous 3 years, 3.44 times more likely to have crashed with use of antihistamines, 2.4 times more likely to have crashed with use of narcotic analgesics, and after consuming alcoholic drinks, only 1.09 times more likely to crash. They were no more or less likely to have crashed if they consumed stimulant drugs such as caffeine (Howard et al. 2004). Commercial truck and bus/motorcoach drivers are required by law to undergo medical evaluation on a periodic basis (with no longer than 2 years between examinations) to be permitted to drive or to continue driving commercial vehicles (49 CFR 391.11). The public and drivers’ employers rely on med- ical practitioners in the conduct of Commercial Driver Medical Examinations (CDMEs) to ascertain whether an individual driver meets the standards of applicable federal safety rules (49 CFR 391.41) . . . that the driver has no “established med- ical history of clinical diagnosis of” . . . a medical condition . . . “likely to interfere with the safe operation of a commercial motor vehicle.” The medical examiner role in evaluating and advising drivers on use of medications was detailed in the FMSCA- sponsored “Role Delineation Study.” This was a methodolog- ically and statistically robust detailed study of the medical examiner role in providing CDMEs. The study was conducted between 2005 and 2007 and it reported on 2,297 surveyed medical examiners of commercial drivers within each of the designated professions performing these examinations (medical doctors, doctors of osteopathy, chiropractors, physi- cian’s assistants, and advanced practice nurses.) Tasks associated with the performance of CDMEs were identified and their importance was assessed; the knowledge, skills, and abilities required to perform those tasks were also identified so as to facilitate examiner training and testing in connection with the development of a proposed National Registry of Certified Medical Examiners (NRCME). Of the 146 tasks performed by medical examiners during the exam- inations of commercial drivers, five medication-related tasks were identified. Each was given high importance by the exam- iners (3.71–3.91/4), and study participants (89%–98%) indi- cated they performed those tasks for almost all commercial driver examinations completed. A number of sources for medical examiner guidance on the potential effect of medications on commercial driver safety have been published by the FMCSA. These include rules prohibiting use of insulin [391.41(b) 3] and controlled substances [391.41(b)12] and advisory guidelines includ- ing frequently asked questions (FAQs) on the FMCSA Med- ical Program Web Page, medical conference reports, evi- dence guidelines, and medical expert panel reports, as well as the NRCME Medical Examiner Handbook. In addition, the Medical Review Board of the FMCSA commented exten- sively on medication use and made recommendations to the FMCSA. All of these documents have been published by the FMCSA, are available for public access on the FMCSA website, and can be used to assist medical examiners in deter- mining whether drivers who admitted taking certain med- ications would be able to drive safely. Each of these sources are in separate web locations, are organized by disease entity, and, for the most part, cover medications in the context of the specific diseases. This information is rapidly changing, with many of these sources being published during the devel- opment of this synthesis report. See the FMCSA website for details and the status of each. Review of these sources of information for the medical examiner is beyond the scope of this synthesis. CHAPTER SIX MEDICATIONS AND COMMERCIAL DRIVER MEDICAL CERTIFICATION: REPORT ON A SURVEY OF MEDICAL EXAMINERS OF COMMERCIAL DRIVERS

51 Medications rather than medical conditions were chosen to be queried for this synthesis survey, because the common uses of many of the medications are “off-label,” which means being prescribed for reasons not approved by the FDA for use in treating a specific disease. Once a medication is on the market for one indication (disease), “the FDA has a lim- ited role in governing use of that medication for other clin- ical indications.” It is both legal and common for medical providers to prescribe medication for off-label uses based on their judgment that the patient will benefit. According to published reports, up to 21% of prescriptions in the United States are written for off-label use (Stafford 2008). Common examples include the use of trazodone, an antidepressant, for insomnia, wherein it is approved for use only as an anti- depressant; or gabapentin, a seizure medication, which is also commonly prescribed for diabetic neuropathy and for the movement disorder of restless legs syndrome (Stafford 2008; Krystal 2009). The examiner must rely on the driver to accurately and completely list his or her medications, and may rely on report- ing by the driver’s prescribing physician on medication effect, make his or her own assessment of medications reported, or do both (FMCSA FAQ #77 “What medications disqualify a CMV Driver”). MEDICAL EXAMINER SURVEY REGARDING MEDICATIONS USED BY COMMERCIAL VEHICLE DRIVERS Aims of the Survey of Medical Examiners In light of the availability of information from the FMCSA regarding the specific medications, and the recognized role and importance of medical examiner efforts in evaluating driver medication use, in this convenience sample survey an attempt was made to characterize what decisions CDMEs anticipate they would make when faced with the decision of whether to “qualify or not to qualify” a commercial driver for their required medical examiners certificate based on issues concerning medications the driver may be taking. In this survey, the synthesis team aimed to answer the fol- lowing questions: 1. What are medical examiners’ knowledge, understand- ing, and actions in qualifying commercial drivers with admitted Schedule II medication use under the FMCSA rules and guidelines? 2. Are examiners providing certification in accordance with published FMCSA rules and guidelines with respect to Schedule II medications? To what extent do they vary from those rules and guidelines? 3. Is there awareness of potential hazards of medications such that examiners require additional steps for the driver to qualify? 4. Is there agreement among medical examiners about which medications drivers would admit taking that would still permit them to be medically certified to continue driving? 5. To what extent are medical examiners providing drivers with guidance on the safe use of medications? 6. To what extent are medical examiners routinely pro- viding employers with Department of Transportation DOT Long Form (Form 649-F-6045): Medical Exam- ination Report for Commercial Driver Fitness Deter- mination? To what extent are they communicating (with or without the driver’s granted release of personal information) regarding specific certification issues or medications in commercial drivers examined at their behest, or do they provide employers with lists of prohibited drugs/medications? Medical Examiner Survey Participants In 2008, a questionnaire was administered to two small groups of medical examiners of commercial drivers. Twenty-three examiners were surveyed at two educational meetings of prac- ticing occupational medicine specialists in two locations: 8 in Reno, Nevada, and 15 in Salt Lake City, Utah. Of the 16 forms distributed on September 11, 2008, to a Salt Lake City group of occupational medicine clinic providers, 15 were completed and returned. This first survey group included 12 practicing occupational medicine physicians, including 3 occupational medicine residents, and 3 mid-level practitioners (Advanced Practice Registered Nurses), who were primarily working in occupational health clinics in Utah. A number of additional questionnaires were sent by e-mail to those who could not attend, but no additional completed surveys were received. Completed survey forms were scored in paper form. Eight questionnaires were distributed and returned by physicians who attended a lecture given by Dr. Howard Leaman at Reno, Nevada, on November 12, 2008. The surveys were all returned before the talk began. Four physicians were employed in private practice and reported seeing commercial drivers in their practice, two practiced in occupational medi- cine clinics, one was an urgent care physician, and one was a corporate physician. Five of the 8 physicians were certified in a medical specialty: family practice or cardiovascular disease. None were certified in occupational medicine. The average number of department of transportation (DOT) exams (CDME) per week was 4, with a range from 0 to 20 exams per medical provider. Some demographic information about the respon- dents in the two groups is depicted in Table 5. Surveys were conducted anonymously so that responses were protected and treated confidentially, and the responses could not be identified with any particular respondent. The responses on the completed questionnaires were hand-scored and entered into an Excel spreadsheet for tabulation of the results. Only statistical measures of central tendency are

Response options to medications listed in the Medical Examiner survey: Option 1: Never approve Option 2: Approve (only with note from treating MD) Option 3: Approve with objective testing Option 4: Approve with detailed history from driver Option 5: Approve only if prescription meds are taken 8 hours or more before driving Option 6: Usually/always approve Option 7: I do not ever see this drug Option 8: I am not familiar with this drug 52 TABLE 5 PARTICIPANTS IN SURVEY QUESTIONNAIRE ASKED OF MEDICAL PROVIDERS OF COMMERCIAL DRIVER MEDICAL EXAMINATIONS Survey Participants on Commercial Driver Examinations Variables Reno, Nevada Salt Lake City, Utah Group Number of Participants 8 15 23 Average Age 49 48 48.5 Male/Female 0.80 0.63 0.71 MD/Mid-level Practitioner (APRN) 1.00 0.80 0.90 Percent MD Board Certified 0.38 1.00 0.62 CDME Average (number per week) 4.00 17.00 10.00 Range 0–20 0–35 <0–35 Providers Reporting Their Practice Is Primarily Occupational Medicine 0.25 0.80 reported here; no particular parametric statistical analyses are provided because of the limited group size. Because of the small number of respondents, one cannot infer that the responses of those surveyed are representative of the opinions of all medical examiners of commercial drivers. That is particularly relevant in view of the coming require- ment that examiners must be qualified by examination and registered to perform medical certification examinations for drivers. Nonetheless, the survey responses here provide insight into the decision-making process in two groups of individual CDMEs responsible for the medical qualification of com- mercial drivers. These survey data represent an initial look at medical provider decision making regarding driver medications in the CDME certification process. The survey results may prompt further investigation using larger groups, better selected medication lists, and statistical methods for improving validity and inference to the larger population of medical examiners. In the several literature searches performed for this syn- thesis study, including that of the PubMed National Library of Medicine Search Engine, no published reports were identified that provided this specific information. MEDICATIONS AND MEDICATION CLASSES Introduction The medications chosen for survey were identified by synthe- sis co-author (Leaman) based on NTSB accident reports and on personal experience performing commercial driver certi- fication examinations over a 25-year career in occupational medicine. The first group of medical providers, surveyed at Salt Lake City, Utah, was presented with a list of 69 drugs and medications, grouped into 12 categories. Some of the more commonly available pharmaceuticals were identified by their trade name so as to ensure that the respondents knew the medications by their recognizable names. However, in review- ing responses from the Salt Lake City group, it became apparent that several medical providers lacked familiarity with some of the 69 medications listed. Consequently, the number of medications queried of the Reno, Nevada, group was reduced to 52 medications in 10 categories, which helped limit the amount of time required to respond to the lengthy questionnaire. The complete list of 69 drugs is described in subsequent sections, with annotations to indicate which 17 were deleted from the second set of questionnaires before administration to the Reno group. The average medical pro- vider took 20 to 25 min to complete the questionnaire in both locations (Salt Lake City and Reno). The medical examiners were asked to classify each medication by the actions they would normally take when presented with that medication by a commercial driver at the time of his/her CDME. On the examiner survey, the medications were grouped into functional categories. Results were expressed as proportions rather than percentages to avoid the appearance of statistical validity or inference that this group represents all medical examiners. This was a very small sample size (n = 23), and the results cannot be said to represent all CDM examiners. For each medication listed, survey participants were given the opportunity to choose one or multiple options to indicate either how they have previously handled such questions, or would handle them now, at the time of the survey administra- tion (2008):

53 Definitions: Issuance: Granting of a medical certificate to a commer- cial driver from an appropriately designated medical examiner for any period of time. Conditional issuance: Granting of a certificate to a commercial driver by an appropriately designated medical examiner, pending the driver’s agreeing to comply with a condition of issuance such as provid- ing the examiner with a note from the prescribing prac- titioner, providing additional detailed medical history at the time of the examination, additional objective testing, and/or medical certification with the stipulation that the medication in question be taken 8 h or more before driving. No issuance: Driver is not issued a medical certificate at the time of the examination. Pain Medications Tramadol (Ultram®) Oxycodone (Oxycontin®) Oxycodone (Percocet®, Lortab®) Codeine (Tylenol with Codeine) Morphine (Kadian®) Methadone (Dolophine®) Applicable FMCSA Regulation and Guidance regarding con- trolled substances: Federal Rule 391.41(b)(12): A person is physically qualified to drive a commercial vehicle if that person: Does not use a controlled substance identified in 21 CFR 1308.11, Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who is familiar with the driver’s medical history and assigned duties; and has advised the driver that the prescribed substance or drug will not adversely affect the driver’s ability to safely oper- ate a commercial motor vehicle. This exception does not apply to the use of methadone. The intent of the medical certification process is to medically evaluate a driver to ensure that he or she has no medical condition that interferes with the safe per- formance of driving tasks on a public road. If a driver uses a Schedule I drug or other substance, an amphet- amine, a narcotic, or any other habit-forming drug, it may be cause for the driver to be found medically unqualified. Motor carriers are encouraged to obtain a medical practitioner’s written statement about the effects on transportation safety of the use of a particu- lar drug. A test for controlled substances is not required as part of this biennial medical certification process. The FMCSA or the driver’s employer should be contacted directly for information on controlled substances and alcohol testing under Part 382 of the Federal Motor Carrier Safety Regulations. The term “uses” is meant to encompass instances of prohibited drug use determined by a physician through established medical means, which may or may not involve body fluid testing. If body fluid test- ing takes place, positive test results should be con- firmed by a second test of greater specificity. The term “habit forming” is intended to include any drug or medication generally recognized as capable of becoming habitual, and that may impair the user’s ability to operate a CMV safely. The driver is medically unqualified for the duration of the prohibited drug(s) use and until a second examination shows the driver is free from the prohibited drug(s) use. Re-certification may involve a substance abuse evaluation, the success- ful completion of a drug rehabilitation program, and a negative drug test result. Additionally, given that the certification period is normally two years, the medical examiner has the option to certify for a period of less than two years if this examiner determines more fre- quent monitoring is required. (See Conference on Neurological Disorders and Commercial Drivers and Conference on Psychiatric Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/facts-research/ research-technology/publications/medreports.htm.) Survey Results (Pain Medications) Methadone Commercial drivers are prohibited from driving while taking methadone, and medical certification for com- mercial driving is also not permitted [391.41(b)(12)]. Thirteen of the 23 medical examiners surveyed correctly identified this rule in the questionnaire and indicated the driver would “Never” be issued a certificate while taking that medication. Unfortunately, eight medical examiners did not, with five indicating they would provide medical certification when presented with a note from the driver’s prescribing physician; two would approve if provided with a detailed history taken in the clinic; and one if the driver took the medication 8 h or more before driving. There were differences between locations, with only one of the eight Reno providers surveyed indicating “no certificate” would be issued; the others would provide certification conditioned on receipt of the prescribing physician’s note, completion of a detailed history in the clinic, or results of some objective testing. Other opiates There appeared to be regional differences in conditional approvals for opiates, most notably methadone, fol- lowed by oxycodone (Oxycontin®) and morphine (Kadian®). These are potent opiate medications usually prescribed for severe chronic pain. For oxycodone (Oxycontin®), 8 of the 23 surveyed providers would not anticipate providing a med- ical certificate to a driver who admitted taking this medica- tion; 7 would require a physician’s note; and 5 would instruct

8 of 15; Reno: 3 of 4 respondents who answered) and issu- ing a certificate for a driver who admitted taking morphine (Kadian®) (Salt Lake City: 7 of 15 respondents; Reno: 4 of 6 who responded). Stimulant Medications d-Amphetamine (Adderall®) Methylphenidate (Ritalin®, Concerta®) Modafinil (Provigil®) Caffeine (No Doze®, Vivarin®, etc.) Energy drinks (Red Bull®, etc.) Survey Results (Stimulant Medications) D-Amphetamine Conditional medical certification was anticipated by 14 of 23 surveyed examiners when presented with a driver who admits taking amphetamine, most often conditioned on receiving a treating physician’s note (7 of 23) and in 3 of 23 instances a detailed medical history in the clinic. Six of the 23 examiners indicated that they would never medically qualify a driver who admits to taking amphetamine, and 2 of 23 marked “Usually always” qualifying such a driver. Several of the examiners indicated they never see this medica- tion in their practice with commercial drivers. Compliance with 391.41(b)(12) was similar between regions for those who would issue the certificate [Salt Lake City (6 of 11); Reno (3 of 6)]. For the other prescription stimulants such as methyl- phenidate (e.g., Ritalin®), the majority of the medical providers would certify drivers using these medications if a detailed history in clinic and a physician prescriber’s written statement were provided. No providers indicated they would “Never” qualify a driver using methylphenidate, 13 of 23 would require the prescriber’s written statement, and 7 of 23 would require additional detailed history in the clinic. Modafinil (Provigil®) was “Usually/Always” approved by 4 of the 23 medical pro- viders surveyed, with an additional 8 of the 23 providers indi- cating they would require a prescriber’s written statement, and 8 requiring a detailed history in the clinic. A question concerning drivers admitting to the use of caffeine and energy drinks was marked “Usually/Always” permitted certification in 6 and 7 of the providers, respectively, with the majority, 9 and 10 of 23 providers, indicating they would require a detailed history in the clinic for these drivers. Curiously, two providers indicated they would “Never” issue a medical certificate to drivers ingesting these substances. In summary, for the small group surveyed, there were regional differences (Reno vs. Salt Lake City) and variation in anticipated practice among providers. The source of this variation was not identified in the data; however, data from another part of the questionnaire may be relevant. 54 the driver to take the medicine 8 h before driving. For mor- phine (Kadian®), 8 of 23 surveyed providers indicated they would never qualify a commercial driver admitting to use of this drug. Of the others who would conditionally allow med- ical certification, 6 of 23 would require a physician’s note, 4 of 23 a detailed history in clinic, and 4 of 23 indicated advising the driver to take the medication no sooner than 8 h before driving. For Tylenol with codeine, most indicated they would qualify a driver with a note from their prescriber in 6 of 23 examiners, detailed history in 10 of 23 surveyed examiners, and instructions by 11 of 23 examiners to take the medication no sooner than 8 h before driving. Tramadol Drivers admitting use of this medication were anticipated to be in a medically certified condition on provid- ing a detailed medical history to the examiner in the clinic by 13 of the 23 examiners. Six of 23 examiners indicated the dri- ver would be qualified, and the driver was instructed to take the medication no sooner than 8 h before driving. Summary (Pain Medications) Methadone Substantial variation existed between the two groups of medical providers surveyed (Reno and Salt Lake City groups) in terms of providing medical certification to drivers who admit taking the drug methadone, which is specif- ically regulated (prohibited) in FMCSA rules 391.41(b)(12). Some providers of CDMEs are apparently unaware, or for some reason do not comply with the DOT regulation stating that this medication is prohibited for use in commercial driving. Regional differences appeared with respect to permitting drivers to be certified when taking methadone: most of the Reno group of providers reported they would issue conditional certificates to drivers, whereas in the Salt Lake City group only 3 of 15 medical examiners would permit conditional certification for drivers who admit to methadone use. Other Opiate/Pain Medications (not methadone) Question- naire responses showed consistency for the opiates/pain medications, particularly regarding tramadol, where all of the medical providers responded they would permit con- ditional or full certificate issuance to drivers who admitted taking it. Of the 23 providers surveyed, only 3 would require a driver’s prescribing physician statement in compliance with 391.41(b)(12) before issuing a certificate for a driver taking tramadol (Ultram®). Over all the pain medications, only 6 of 17 respondents who would allow certification stated they would require the prescribing physician’s written statement before issuing a medical certificate to a commercial driver. There was uniform response on “would issue” a certificate (conditional or “usually always”) for oxycodone (Percocet®, Lortab®) (21 of 23) and codeine (Tylenol with codeine) (22 of 23). There were substantial inter-group or regional differences in the willingness to issue a certificate to a driver who admitted taking oxycodone (Oxycontin®) (Salt Lake City:

55 Antidepressants and Other Psychiatric Medications Psychotropic Medications Selective Serotonin Reuptake Inhibitors (SSRIs) Venlafaxine (Effexor®) Fluoxetine (Prozac®) Sertraline (Zoloft®, etc.) Atomoxetine (Straterra®) Bupropion (Wellbutrin®) Mirtazapine (Remeron® and other heterocyclic antidepressants) Tranylcypromine [Parnate® (MAO Inhibitor)] Amitriptyline (Elavil®) Lithium (Eskalith®) Quetiapine (Seroquel®) Abilify/Geodon (deleted for the 2nd round of questionnaires) Survey Results (Psychotropic Medications) For SSRI-type antidepressants, 14 of 23 surveyed medical examiners would qualify drivers with additional history in clinic; only 2 of 23 indicated that they would require a written statement from the provider who prescribed the driver’s antidepressant. In the surveyed group, no examiners indicated they would “Never” qualify a driver who admitted taking any of the medications queried. Other than lithium, conditional approval was the most common response, with detailed history in clinic required for most medications queried. In the case of lithium, 13 of 23 medical examiners would require the driver to provide a written statement from their pre- scribing physician. Quetiapine (Seroquel®—a member of a class of medications known as atypical antipsychotics) and amitriptyline (Elavil®) and mirtazapine (Remeron®) (sedating antidepressants), were the only medications in this class where examiners anticipated advising the driver to take the medication no sooner than 8 h before driving. Unfortunately, this was not prevalent, and only 3 of 23 examiners indicated no driving sooner than 8 h after use of amitriptyline medication, and 2 of 23 indicated this for mirtazapine (Remeron®) or Quetiapine (Seroquel®). Antihistamines Diphenhydramine (Benadryl®) Hydroxyzine (Atarax®) Loratadine (Claritin®) Monoleukast (Singulair®) Astemizole (Hismanal®) Cetirizine (Zyrtec®) Survey Results (Antihistamines) The most commonly occurring response from the medical examiners in this drug category was “Approve only if med- ication taken 8 h or more prior to driving.” The number of the examiners indicating no medication use within 8 h of driving included: diphenhydramine (Benadryl®) 17 of 23; hydrox- yzine (Atarax) 12 of 23; and certirizine (Zyrtec) 10 of 23. There appeared to be little regional variation in these recom- mendations. Of those surveyed, only one provider of the 23 indicated that he/she would “Never” certify a driver taking diphenhydramine (Benadryl®) or hydroxyzine (Atarax). Neuroleptic Medications Gabapentin (Neurontin®) Pregabalin (Lyrica®) Dilantin Phenobarbital Lamotrigine (Lamictal®) (Keppra®) (deleted in 2nd questionnaire) Survey Results (Neuroleptic Medications) The surveyed examiners consistently indicated conditional approval for gabapentin (Neurontin®) and pregabalin (Lyrica®). For gabapentin (Neurontin®), 18 of the 23 sur- veyed examiners would provide conditional approval, with 11 requiring that the driver provide additional detailed history in clinic, 4 requiring that the driver provide a note from the prescribing physician, and 2 would instruct the driver to take the medication 8 or more hours before driving. For dilan- tin, typically used for seizure control and sometimes periph- eral neuropathy, the response was different, and varied by location. Eight of the 23 examiners indicated they would “Never” medically qualify a driver taking this medication; most of these examiners were in Salt Lake City. In Reno, four of the eight surveyed practitioners indicated they would require a physician’s note. To either effect, the examiners appear to be further inquiring why the medication is being used (seizures, neuropathy, or some other reason). The FMCSA specifically states that, “Use of medication to prevent seizures is dis- qualifying” (FAQ #77). Similar to their responses to dilantin, medical examiners evaluating drivers admitting use of pheno- barbital either would never qualify the driver (8 of 23) or would require the driver to present a prescribing physician note (6 of 23). Lamotrigine (Lamictal®) is a neuroleptic agent, typically used as a mood stabilizer in bipolar disorder. Twelve of the 23 medical providers either would never qualify a driver who admitted to taking this medication or would require the driver to present a medical note before consider- ing qualification for a commercial driver medical certificate. Four of the 23 surveyed would “approve,” conditioned on a detailed history in the clinic, and five examiners indicated that they never see this medication.

Pramipexole (Mirapex®) Ropinirole (Requip®) Levodopa–Carbidopa (Synemet®) Levodopa–Carbidopa–Entacapone (Stalevo®) (deleted in 2nd questionnaire) Dobutamine (Dobutrex®) Amiodarone (Cordarone®) Digitalis Survey Results (Cardiac and Heart Medications) The medical examiners response to dobutamine (Dobutrex®) indicated that this medication is not commonly observed. Six of 23 medical examiners reported they “Never” see this medication in commercial driver certification examinations. Sixteen medical examiners indicated they would conditionally approve a driver if they were to submit a prescribing physi- cian note, provide a detailed medical history, and undergo objective testing. Only two medical providers indicated they would “Never qualify” an individual who admitted to using dobutamine. Three of 23 examiners indicated they would “Never” qualify a driver who admitted taking amidarone (Cordarone®); 4 would require a detailed history in the clinic, 2 objective testing, and 11 of 23 would require a note from the treating physician. For digitalis, 17 of the 23 surveyed examiners indicated they would conditionally approve drivers taking this medication, with 4 of 23 indicating “Usually/Always.” A physician note (11 of 23), detailed medical history in the clinic (4 of 23), and requiring objective testing (2 of 23) were the conditions spec- ified for certification of drivers admitting taking digitalis. Other Medications and Commercial Drivers Varenicline (Chantix®) Theophylline (deleted in 2nd questionnaire) Prochlorperazine (Compazine®) (deleted in 2nd questionnaire) Diphenoxylate and atropine (Lomotil ®) (deleted in 2nd questionnaire) 56 Sedatives and Hypnotics instructions to take the medication no sooner than 8 h before driving were the conditions of certification. Two of 23 exam- iners indicated they would “Never” qualify, and 2 others indicated they “Usually/always” qualify commercial drivers who admitted taking these medications. Six of the 23 indicated they “Never see” these medications. Levodopa/carbidopa (Synemet®) provoked 10 of the 23 examiners to mark “request a prescribing physicians note”; 4 of 23 indicated they would “Never” qualify a commercial driver taking this medication; and 2 of 23 indicated that they “Usually/always” qualify a commercial driver who admits to using this medication. Cardiac Medications and Drugs for Heart Conditions Lorazepam (Ativan®) Clonazepam (Klonopin®) Diazepam (Valium®) Temazepam (Restoril®) Flurazepam (Dalmane®) Buspirone (Buspar®) Zolpidem (Ambien®) Eszopiclone (Lunesta®) Trazodone (Desyrel®) Melatonin Survey Results (Sedatives and Hypnotics) Lorazepam (Ativan®), clonazepam (Klonopin®), and diazepam (Valium®) have significantly different half-lives affecting the time impairment may potentially last after a dose is taken. These were deliberately placed side-by-side in the question- naire to identify whether half-lives were a consideration in medical examiner decision making. Similarly, the hypnotic medications, also of widely varying half-lives, were placed side-by-side to identify differences in examiner anticipated actions. In the group surveyed, examiners indicated they would conditionally certify, and not automatically qualify or dis- qualify, drivers who admitted taking these medications. This was consistent between both groups of examiners (Salt Lake City and Reno). The majority of the responses indicated examiners instructing drivers not to drive within 8 h of taking the medication (9 to 14 of 23). Fewer examiners would insist on a note from the driver’s prescriber (4 to 7 of 23). Hypnotics zolpidem (Ambien®) and eszopiclone (Lunesta®) had the most providers advising taking the medication at least 8 h before driving (14 of 23 for both); temazepam (Restoril®) the next highest (12 of 23); and, lorazepam (Ati- van®), clonazepam (Klonpin®), and diazepam (Valium®) and flurazepam (Dalmane®) had similar numbers of examiners indicating they would qualify the driver if he/she took their medication no sooner than 8 h before driving (9 to 10 of 23). Dopamine Agonists Survey Results (Dopamine Agonists) The medical examiners were also asked about pramipexole (Mirapex®) and ropinirole (Requip®). Twelve and 13 of the 23 respondents indicated they would approve a driver pre- senting for certification with either of these medications. A prescribing physician’s note, detailed history in clinic, and

57 Survey Results (Other Medications) For varinicline (Chantix®), 8 of 23 medical examiners indicated they would “Never” medically certify a driver of commercial vehicles who admitted taking this medication. Four of the 23 indicated conditional approval pending the receipt of a detailed medical history, and one respondent, “only if the driver took the medication no sooner than 8 h prior to driving.” There were significant regional differ- ences, with 5 of 8 examiners in Reno indicating they would “Usually/Always” certify and only 1 of the 15 Salt Lake examiners indicating so. Educating Drivers About Medications The medical examiner survey participants were asked whether or not they engaged the commercial drivers they were exam- ining in discussions to “educate them” about medications or drugs of any kind, or even to discuss nutritional supplements and their possible effects on driving performance. Q: What “education or training” (guidance, infor- mation pamphlets, etc.) do you usually give to commercial drivers regarding any medications? Please answer the question above whether the driver admits to self-medicating, or regarding the drug pre- scriptions you are giving them as a part of treatment you recommend or monitor with your patient? __ None, __ “Driving caution” on prescription written for driver, __ Other material: list below Responses: Driver Education on Medications by Medical Providers during the Commercial Driver Medical Evaluation Salt Lake Reno Combined No Education 1/15 1/8 2/23 Driving Caution 9/15 4/8 13/23 Other 2/15 1/8 3/23 Verbatim responses (other material): “Verbal guidance,” three examiners, one each: “Never use sedating meds within 8 hours of driving”; “No driving on narcotics, sleeping meds”; and “Can’t use benzodiazepines within 8 hours of driving.” Conclusion on advice to drivers on safe medication use: In this small survey, the education of commercial drivers about medications is most often limited to “Driving caution” on prescriptions written by only some medical examiners who as part of their own medical practice are also providing medical care to commercial drivers (8 of 23). “Verbal guidance” is given by very few providers regarding medication use (8 of 23). Driver guidance appears to be limited to the restriction of medication use to 8 h before working (driving). Interactions with Drivers’ Employers (e.g., carriers) Q: Do you provide a list of prohibited drugs for commercial drivers to employers? ___ Yes ___ No If Yes, what is the source of the list? ________________________________________ No medical examiners surveyed indicated that they provide any list of medications to employers with whom they work. The only published list of medications mentioned by the providers was that by Airline Owners and Pilots Association (AOPA). Q: Do employers require the “long form” medical examiners report? ____ yes, most of the time _____ no, not usually Percent of Medical Examiners Reporting Employers Require the DOT “Long Form” from them after Medical Examination of Commercial Drivers Salt Lake Reno Combined Long Form 10/15 2/8 12/23 Required Long Form 5/15 6/8 11/23 Not Required Summary of employers requiring DOT Long Form. The “DOT Long Form” (Form 649-F-6045) containing a driver’s personal medical history, physical examination, and examiner’s certification decision is required by employers in some but not all geographic regions. Factors influencing this are not clear, and there was considerable variability within the two regions surveyed (Salt Lake City and Reno). Q: What interactions do you usually have with drivers’ employer over issues of prescribed medications for their drivers? Medical Examiners reporting Employer Communication on Driver’s Specific Medication Salt Lake Reno Combined Employer 6/15 0/8 6/23 Interaction No Employer 9/15 8/8 17/23 Interaction Responses: Salt Lake City—Verbatim responses given by medical examiners: “usually none, if concerned will call and talk to employer about driving on meds” “inform them if disqualified” “very limited” “hardly have any, but if [we] do, usually [it’s] about narcotics” “phone call” “usually I am justifying to the employer why I am concerned about a driver’s meds and educating them on safety issues.”

58 Responses: Reno: None of medical examiners surveyed indicated that they interact with employers regarding specific medications. Summary of medical examiner interaction with employer on driver’s prescribed medication. In this small survey, the medical examiners appeared to vary by region on whether they interacted with drivers’ employers on specific medications taken by their drivers (employees). Verbatim responses indicated that medical examiner interaction with drivers’ employers is very limited, often only to justify rea- sons for disqualification or providing information on a driver related to his or her operating safety and often specifically regarding narcotic medications. Percent of Medical Examiners Reporting Company Official Interaction Regarding Specific Drivers Salt Lake Reno Combined Employer 9/15 1/8 10/23 Interaction No Employer 5/15 7/8 12/23 Interaction Q: Do you interact with company officials regarding specific patients (drivers)? ___ Yes ___No Verbatim responses given by medical examiners included: “inform if not qualified, and give reasons” “pass or no pass” “exam status (pass no pass, awaiting info)” “medical condition likely will not interfere with obtaining medical certification, or inform about outright rejection in general terms if personal” “warn if going elsewhere for medical card” “address driving safety issues, physician follow-up required” “justify concerns regarding medications and safety—educate regarding general DOT policy” “without releasing specific information; e.g., common sedating meds, common side effects are.” Q: What information do you give without a written release of information? ___None, __other, note below: Responses: Salt Lake City Employer interactions: two medical examiners sur- veyed did not give employers information about driver physicals without release of information. Verbatim responses on specific information given by medical examiners included: “always require written release of information” “driving safety issues, inform if not qualified, and reason” “basic information: pass or no pass, if Personal Medical Doctor follow up required” “justify concerns regarding medications and safety—educate about general DOT policy” “without a release, I educate in general terms . . . ; e.g., the DOT policy is . . . Common sedating medications are . . . common side effects of medicine x are . . .” “hardly ever” “reason why card not issued” “1 or 2 responses concerned elderly drivers, only give out information that pertains to driving safety” “if concerned, I will call and talk to employer about driving on medications . . . especially if concerned about circumventing not receiving card by going elsewhere for card” Responses: Reno: No information was reported given without a release form. Summary of medical examiner release of information to driver’s employer: After completing the driver’s med- ical examination (CDME), regional variation on information release to employers was identified in the small group of medical examiners surveyed. This was the case for both med- ication issues as well as examination issues. In Salt Lake City, 6 of the 15 medical examiners did report interacting with the drivers’ employers, whereas in Reno none of med- ical examiners reported interacting with employers. When verbatim responses were examined, it became evident that the medical information reportedly given by 6 of the 15 members of the Salt Lake group related to work fit- ness or issues regarding medications that the employer will likely learn from the Medical Review Officer (MRO) in drug testing notification under 49 CFR Part 40.21 (Provision for “Stand Down”). Q: Do you provide a list of prohibited drugs for commercial drivers to employers? ___ Yes ___No Responses: Salt Lake City and Reno No medical examiners indicated they provide a drug list to employers for the purpose of determin- ing which medications are “safe” or “approved,” although one mentioned the FAA list and the Airline Owners and Pilots Association (AOPA) pamphlets as general guidelines.

59 Questions about Alertness Management Q: Do you routinely advise drivers on how to main- tain alertness and combat fatigue? ___ Yes ___No Responses: Only two of the medical examiners surveyed (at Salt Lake City) reported giving alertness advice to drivers at the time of their examination. One reported discussing sleep hygiene; the other dis- cusses sleep apnea risk and referral. The remaining 21 medical examiners reported that they do not give drivers advice on “remaining alert and combating fatigue.” Q: What do you tell them? (No responses) Examiners’ Comments and Suggestions to Open-Ended Question The end of the questionnaire/survey forms allowed the med- ical providers (examiners) an open-ended opportunity to pro- vide their comments and suggestions. Q: Your Comments and Suggestions here: Here we solicit your comments, suggestions, recommen- dations, etc., concerning the medical examining process and/or the Medical Qualification Standards for CMV drivers. Remember these comments will be held in confidence, so please be frank, but also be specific enough that we can determine precisely what your comments mean in the context of this synthesis study. Verbatim responses to open-ended question: Only a small number of open-ended responses were received, among them the following specific com- ments were proffered: “Indication for Rx [underlying condition being treated] plays a large role in how I handle different cases.” “Priority needs to be national standards/ certification for providers; need a national database for drivers so they cannot MD shop.” “I am not familiar with the Hartenbaum book.” DISCUSSION OF SURVEYS OF MEDICAL EXAMINERS This Survey This survey of a small number of medical examiners (n = 23) of commercial drivers found the following: • There was some variation in responses of the group of medical examiners surveyed on whether their anticipated actions adhered to published federal rules with respect to methadone and Schedule II medications. • There also appeared to be variation in medical examiner anticipated actions regarding medications that had no specific rules associated with their use. The examiners were queried about a large number of medications. Other than methadone, these medical advisors would permit most of these medications for use by commercial drivers on the condition of receiving the prescribing physician’s release notes, or by giving the driver advice to take med- ication no sooner than 8 h before driving, or by comple- tion of a detailed evaluation at the clinic. • The amount of education about medications provided to drivers by their CDME examiners was limited in this small group of surveyed examiners. The most common advice was to avoid the of use of a medication within 8 h before work; advice most commonly given when the medical examiner prescribes medications to the drivers for medical conditions for which they are providing care. • According to the group surveyed, the Medical Exami- nation Report (Form 649-F-6045) is required by some employers in addition to the Medical Certificate. This appears to vary by region. • Medical examiners’ interactions with employers without specific release of information were reported in about half of the Salt Lake City group, and by none of the Reno group. Information released was cited as primarily related to safety concerns, or why the driver did not “pass” the examination. • The group of examiners surveyed reported that they very seldom provided alertness education to drivers they examined. Of the 2 of 23 examiners who indicated they provide such education, one reported discussion of “sleep hygiene” and the other “sleep apnea.” • Medical examiners surveyed were not aware of any “list” of prohibited medications. • Open-ended responses by medical examiners were limited, and emphasized a need for a national medical examiner standard of performance and the need to know underlying conditions (why the medication is being prescribed). One of the examiners indicated that he or she was not familiar with one of the more commonly used privately developed sources of information on the CDME (Hartenbaum 2006). This initial study survey was limited by a number of factors: 1. The size of the surveyed group (23 participants). The U.S.DOT’s FMCSA estimated that there are 317,000 medical providers who might perform driver physical examinations on a regular basis in the United States (FMCSA NPRM, 73FR-73129, 1 Dec. 2008); however, in the synthesis survey work reported here, only 23 of these medical examiners in two western cities were questioned. Therefore, these survey data, on so few medical professionals, cannot provide any infer- ences about the activities of so many other medical examiners. Nonetheless, this survey provides insight into

60 practices “in-the-field,” and these data help underscore the need to extend such survey work to other groups of CDME examiners. 2. The list of medications queried was not a complete list of all medications used by drivers of CMVs. Medications were chosen by the synthesis co-author (H. Leaman) based on his experience, review of NTSB accident reports, and personal observations made dur- ing a 25-year occupational medicine practice. This survey study could be expanded and strengthened by better methodology, including methods for choosing medications. Observations Made from Survey Results One of the more significant limitations on the process of medical examiners performing evaluations of commercial drivers (CDME) includes the completeness, or incompleteness, of driver self-reporting of their medications to the medical examiner. Although drivers are required to complete their medical history form accurately and completely (or risk invalidating their certificate) there is evidence this does not always happen; numerous medical examiners attest to this from prior experiences with drivers who deliberately disguise the truth on their personal history forms and in interviews at the time of CDME exams. Estimate of Foreseeable Risk One key issue that is implied but not explicit in this survey is that the certification actions of the medical providers rep- resent their “estimation of foreseeable risk” of motor vehicle accidents in the commercial drivers they examine. In the Medical Examiners Handbook (NCRME-FMCSA) the recom- mendation is given to certify the driver “if the examiner believes that the nature and severity of the underlying condi- tion does not interfere with safe driving and the effects of medication use while operating a commercial motor vehicle does not endanger the safety of the driver and the public.” Lack of Common Reference Guidance Two possible sources of CDME certification decision vari- ability regarding safe medication use that were encountered in this study are: (1) the absence of a commonly accepted, single source, up-to-date, medication-based (rather than dis- ease based) reference guideline (“List”) for use by CDME in the certification examination, and (2) absence of a uni- form and specific training and knowledge base for examiner qualification. Need for a Medication List Regarding the topic of a “List,” new guidelines for medication use in commercial drivers (which are contained within specific disease guidelines) are continuously being published, but pre- sent a “moving target” for examiners’ reference. The FMCSA Evidence Reports and Medical Expert Panel Recommen- dations, as referenced earlier, and a new Medical Examiners Handbook (NRCME-FMCSA) are available online. The FMCSA Medical Review Board has also issued new recom- mendations to the FMCSA regarding medications. Knowledge Base and Training Regarding knowledge base and training, the FMCSA Com- mercial Driver Medical Qualification is evolving rapidly. As this synthesis report was being prepared, the FMCSA announced the Notice of Proposed Rule Making to establish a national registry of medical examiners (FMCSA NPRM Federal Register announcement No. 73FR-73129; Docket No. 2008-0363). The Role Delineation Study performed in support of this initiative identified “Knowledge, skills and abilities” that will guide CDME training and testing content, but did not directly identify the source of these attributes. Because evaluating a driver’s use of medication has been associated with at least five essential CDME tasks (see ear- lier discussion) any training developed would be expected to derive from some common understanding of effects of specific medications on driving ability and performance, independent of the underlying medical condition. Resolving the former issue (List) would likely be needed to complete the latter (training and certification). Alertness Education for Drivers Commercial Driver Medical Examiners have not yet been asked to provide drivers with sleep and alertness education, or educational materials, which has already been provided to commercial drivers and their employers through the FMCSA- ATRI-sponsored train-the-trainer courses (O’Neill et al. 1996; Krueger and Brewster 2005). From having discussed this topic with medical examiners in several round table discussions, there appears to be a common opinion among the medical examiners. The medical providers pointed out that it is the driver’s responsibility to manage a suitable sleep/wake sched- ule. Furthermore, they indicated that assigning this fatigue education responsibility to medical examiners would detract from the primary purpose of the examination, and may place the medical examiner in the position of being responsible for driver factors over which he or she has little to no control; they can’t “write a prescription for sleep.” Communication with Employers There are a few generalized findings from the questions asked of the medical examiners about their interactions with the drivers’ employers. In brief, some employers seek too much information from the examination process, and many ask for too little.

61 Employers in one of the two regions surveyed apparently regularly demand the DOT “Long Form” (Form 649-F-6045) from medical examiners performing driver examinations. As a result, in many clinics, before being examined commercial drivers are required to sign an individual release form to permit sharing medical information with their employer. It is unclear what impact this has on the veracity of the answers to the medical examiners’ questions of the driver. Some employers contract with third party administrators to review the commercial driver examinations and to help them ensure compliance with federal rules, providing some oversight for the medical qualification process. A number of other employers permit the drivers to be certified by their primary care physicians, which allows for greater variability in meeting the medical certification standards than either of the two previously mentioned options, but better knowledge of the drivers’ underlying health history. This, as the survey respondents indicated, permits a driver to “doctor shop”; to find a doctor who is friendly to the driver’s particular needs to remain medically certified. Some of the synthesis survey respondents indicated (and it has been the personal experience of co-author Leaman) that there has been significant pressure from employers to pass drivers who may not be medically qualified. The request to “do the minimum required” has prompted employers to switch providers of medical services until they identify one who “passes” the drivers, virtually regardless of their med- ical condition. The medical conditions for which medications described in this report are prescribed have all been at issue. Medical examiners do not have access to drug testing information performed under 49 CFR Part 40, which fre- quently identifies opiates or other substances that bear on driver safety and medical qualification. Further, some employers who are contacted by MRO under provisions for “Stand Down” (49 CFR 40.4) become concerned when they are not contacted by the medical examiner following an exam where the driver may admit to opiate medication use [permitted with a pre- scriber’s written statement, under 391.41(b)(12)]. This is a particularly acute problem following the discovery that a mishap has taken place. SUMMARY OF MEDICAL EXAMINER SURVEY The survey was limited by the small number of participants (n = 23) and the selected medication list. A convenience sample survey of a small group of certifying medical examiners in two Western cities was done to illustrate medical examiner decision making and actions regarding medications and alert- ness education during the course of the examination (CDME). Twenty-three medical examiners were presented with a list of 69 different medications. For each drug, they were asked whether a driver might be medically certified to drive a com- mercial vehicle while taking the medication and under what conditions, if any. Examiners were also surveyed on what driver education on medication effects, alertness, and employer communications they would normally provide to drivers they examine. Finally, medical examiner handling of the Medical Examination Report “DOT Long Form” (Form 649-F-6045) was described with respect to employer distribution. The responses within the two groups surveyed, although not statistically representative of all CDMEs, showed that within those groups there was inconsistent decision making that did not always follow FMCSA rules and recommended guidelines. More consistent responses (“I would not issue a certificate”) were given with regard to driver use of the drug methadone, which is specifically forbidden, than for other drugs. However, despite the prohibition rule, 3 of the 15 CDMEs answered that they would issue a conditional cer- tification to a driver who admitted using methadone. Overall, of those who indicated they would issue CDME certificates to drivers on an opiate medication or amphetamine, only 6 to 7 out of 23 medical examiners would require a prescribing physician’s written statement as required by 391.41(b)(12); only two would require a prescriber note for Tramadol. Drivers admitting to the use of this medication were anticipated to be issued certificates by every provider questioned. Antihistamines, neuroleptics, sedatives and hypnotics, stimulants, movement disorder medications, heart medica- tions, and assorted other medications were included in the questionnaire, and these produced inconsistent responses by providers regarding actions they anticipated they might take in qualifying or not qualifying drivers who admitted ingesting these classes of medications. Such inconsistencies were found between the two regions surveyed and among providers in both regions. Only 2 of the 23 examiners indicated that they gave any advice to commercial drivers on maintaining alertness or combating fatigue. Almost one-quarter of the surveyed medical providers admitted they provided “no education” to drivers on effects of medication on alertness. However, when they themselves had prescribed the drug to drivers for med- ical conditions they were treating, approximately one-half of survey participants anticipated cautioning those drivers about the effects of such medications. No medical examiner sur- veyed provided drivers’ employers with a list of “prohibited” medications. Employers vary by region about whether they require the DOT Long Form (Form 649-F-6045), with the surveyed group of providers indicating that it was required almost half the time. Medical providers similarly vary by region in terms of the amount of communication they have with employers regarding their specific driver employees. Most of the medical providers who indicated that communication did occur stated in com- ments that it was either very general on the topic of safety concerns and work fitness or it was on issues the company would likely learn from the MRO under 49 CFR 40.21.

Next: Chapter Seven - Motor Carrier Policies on Driver Use of Chemical Substances »
Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements Get This Book
×
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

TRB’s Commercial Truck and Bus Safety Synthesis Program (CTBSSP) Synthesis 19: Effects of Psychoactive Chemicals on Commercial Driver Health and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements identifies available information and research gaps relating to the use of chemical substances by commercial drivers and is intended to provide up-to-date information to inform decision makers about the near-, mid-, and long-range planning needs for research and educational outreach programs.

The report is designed to help the commercial transportation safety community and the Federal Motor Carrier Safety Administration in addressing issues involving the proliferation and availability of psychoactive chemical substances.

Appendixes D and G to CTBSSP Synthesis 19 are available only in the pdf version of report.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  6. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  7. ×

    View our suggested citation for this chapter.

    « Back Next »
  8. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!