Substance Misuse Programs
in Commercial Aviation

Safety First

_____

Richard G. Frank, Dylan Rebstock, and
Melissa Welch-Ross, Editors

Committee on the Study and
Recommendations on the HIMS,
FADAP, and Other Drug and Alcohol
Programs within the USDOT

Board on Behavioral, Cognitive, and
Sensory Sciences

Division of Behavioral and Social
Sciences and Education

Transportation Research Board

Health and Medicine Division

Consensus Study Report

NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by a contract between the National Academy of Sciences and the Federal Aviation Administration (#693KA9-22-T-00002). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-70278-2
International Standard Book Number-10: 0-309-70278-X
Digital Object Identifier: https://doi.org/10.17226/27025
Library of Congress Control Number: 2023944913

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2023. Substance Misuse Programs in Commercial Aviation: Safety First. Washington, DC: The National Academies Press. https://doi.org/10.17226/27025.

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COMMITTEE ON THE STUDY AND RECOMMENDATIONS ON THE HIMS, FADAP, AND OTHER DRUG AND ALCOHOL PROGRAMS WITHIN THE USDOT

RICHARD G. FRANK¹ (Chair), Brookings Institution

DAVID L. ALBRIGHT, University of Alabama

DANIEL N. DASILVA, Morris Psychological Group

ROBYN L. HACKER, University of Colorado

JERMAINE D. JONES, Columbia University

MADELINE H. MEIER, Arizona State University

MICHELLE N. MEYER, Geisinger Health System

KATHRYN E. NEWCOMER, George Washington University

BERNADETTE E. PHELAN, Retired, Arizona Department of Transportation

JEFFREY SELZER, New York State Committee for Physician Health

MO WANG, University of Florida

Board Liaison

TERRIE E. MOFFITT,² Duke University

Study Staff

DYLAN REBSTOCK, Study Director

MELISSA WELCH-ROSS, Senior Program Officer

LYLE CARRERA, Research Associate

JACQUELINE L. COLE, Senior Program Assistant

MEGAN SNAIR, Science Writer

YNGVILD OLSEN, Consultant

___________________

¹ Member, National Academy of Medicine

² Member, National Academy of Medicine

NOTE: See Appendix E, Disclosure of Unavoidable Conflict of Interest.

BOARD ON BEHAVIORAL, COGNITIVE, AND SENSORY SCIENCES

TERRIE E. MOFFITT¹ (Chair), Duke University

RICHARD N. ASLIN,² Haskins Laboratories

JOHN BAUGH, Washington University, St. Louis

WILSON S. GEISLER, The University of Texas at Austin

MICHELE J. GELFAND, Stanford Graduate School of Business

ULRICH MAYR, University of Oregon

KATHERINE L. MILKMAN, The University of Pennsylvania

ELIZABETH A. PHELPS, Harvard University

DAVID E. POEPPEL, New York University

STACEY SINCLAIR, Princeton University

TIMOTHY J. STRAUMAN, Duke University

DANIEL J. WEISS, Director

___________________

¹ Member, National Academy of Medicine

² Member, National Academy of Science

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ROBERT WALLACE,

University of Iowa, and HORTENSIA AMARO, Florida International University. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Acknowledgments

This report reflects contributions from a number of individuals and groups. The committee takes this opportunity to recognize those who so generously gave their time and expertise to inform its deliberations.

To begin, the committee would like to thank the Federal Aviation Administration and the Office of Senator Jeanne Shaheen for their sponsorship, guidance, and support of this study.

The committee greatly benefited from the opportunity for discussion with individuals who attended and presented at the open session meetings or provided written testimony: Kip Bowen, David Fielding, Heather Healy, Suzanne Kalfus, Andrew LeBovidge, Rick Mahoney, Tom McLellan, Pat Moy, Billy Petersen, Sarah Polk, Jerry Powers, Bryan Price, Iyon Rosario, Quay Snyder, David St. Helaire, and Nora Volkow.

The committee thanks these individuals for their time and the candid perspectives they provided.

The committee could not have done its work without the support and guidance provided by the National Academies of Sciences, Engineering, and Medicine project staff: Dylan Rebstock, Study Director; Melissa Welch-Ross, Senior Program Officer; Lyle Carrera, Research Associate; and Jacqueline L. Cole, Senior Program Assistant. We appreciate Patrick Burke for his financial assistance on this project and gratefully acknowledge Daniel J. Weiss of the National Academies’ Board on Behavioral, Cognitive, and Sensory Sciences for his guidance.

Many other staff within the National Academies provided support to this project in various ways. The committee would like to thank Samantha Chao, Connie Citro, Chris King, Sandy McDermin, Tom Menzies, Sharyl

Nass, Kirsten Sampson Snyder, and Jeanne Rivard for their expertise and support throughout the life cycle of this research study and report.

This committee is grateful to the research assistants and commissioned paper authors who generously contributed to this body of work: Heather Belanger, Anne Marie Houppert, Gary Kay, Christopher Lao-Scott, Cara Nordberg, and Jennifer Wisdom.

In addition to the contributions above, a great number of stakeholders offered resources, expertise, and insight to support the committee’s work.

Contents

Acronyms and Abbreviations

Summary

1 Introduction

CONTEXT

STUDY APPROACH

Identification of People in Need of Treatment

The Role of FADAP and HIMS in the Ecology of Aviation Safety and Healthcare

Heavy Reliance on Inpatient and Residential Treatment Modalities

HIMS and FADAP Make Strong Assertions for Their Successes

ORGANIZATION OF THE REPORT

2 Brief Descriptions of the Human Intervention and Motivational Study (HIMS) and the Flight Attendant Drug and Alcohol Program (FADAP)

REGULATORY CONTEXT: SUBSTANCE MISUSE PROGRAMS IN THE AVIATION SECTOR

HIMS

Definitions and Sources of Information

Special Issuance Authorization

Program Design and Structure

Boxes, Figures, and Tables

BOXES

S-1 Project Statement of Task

1-1 Project Statement of Task

1-2 HIMS Overview

1-3 FADAP Overview

3-1 Disease Model of Addiction

3-2 Qualities of Safety-Sensitive Professionals Leading to Important and Distinct Needs for Assessment and Treatment

3-3 Categories of Stigma Toward Individuals with Substance Use Disorders

4-1 Five Important Aspects of a Safety Culture

4-2 Key Elements for Good Monitoring and Evaluation for HIMS and FADAP

6-1 Committee-Identified Key Features of Evidence-Based Practices

FIGURES

2-1 Governance operating model for HIMS

2-2 HIMS oversight structure

2-3 FADAP governance operating model

Acronyms and Abbreviations