1 Drug Abuse & Alcoholism PRESENTED BY: ROBERT SWOTINSKY M D FOR MEDICAL EXAMINER COURSE P
2 Drugs, Drinking, and Driving CMV drivers - more fatalities than any other occupation. ~2/3rds of CMV driver fatalities involve highway crashes. If a CMV driver crashes after taking a sedative or opioid painkiller, or after drinking alcohol, the drugs/drinking will be deemed causative.
3 Drugs, Drinking, and Risk Fitness is about risk. Drug/alcohol risk is about cognitive impairment and/or sudden incapacitation.
4 Learning Objectives 1. Recognize drug or alcohol use that is disqualifying for CMV driver certification 2. Obtain additional information as needed 3. Recognize special considerations of return to duty exams after treatment for drug or alcohol abuse
5 Regulations - Drugs Qualified if: Does not use a controlled substance identified in 21 CFR 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 operate a commercial motor vehicle. 49 CFR (b)(12)
6 Regulations Drugs. Qualified if: Does not use a controlled substance identified in 21 CFR Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. Exception. A driver may use such a substance or drug if the Medical Examiner decides it s ok.
7 Case #1. Marijuana use per state law. CMV driver uses medical marijuana in accordance with state law. Q. What is the best course of action for the Medical Examiner to take? A. Disqualify the driver. B. Give the driver a 3-month certification which would allow time for records to be received. C. Give the driver a 1-year certificate after verifying his marijuana use is consistent with state law. D. Give the driver a 2-year certificate after verifying his marijuana use is consistent with state law.
8 Regulations - Alcohol Qualified if: Has no current clinical diagnosis of alcoholism. 49 CFR (b)(12) What is current? Individualized assessment. Relapse is common. DSM V defines: early remission = at least 3 months sober. sustained remission = at least 12 months sober.
9 Crash Risk Increases With BAC ~# drinks BAC % Effects Start to see cognitive impairment, e.g., by testing. No measured increased crash risk. - Under DOT rules, at BAC, the driver is sent home for the day Start to see increased crash risk. - Under DOT rules, at.04 BAC, the driver is removed from driving and referred to substance abuse professional = DUI for personal vehicles
10 CMV drivers are also governed by FMCSA s drug/alcohol regulation FMCSA s drug/alcohol rule (49 CFR Part 382) implements DOT drug/alcohol testing procedures. DOT drug/alcohol tests (Part 382) are separate from DOT physicals (Part 391), even though they may be scheduled at the same visit. A test violation e.g., positive drug test, BAC of 0.04 or above -- means removal from driving and referral to a substance abuse professional (SAP).
11 Disqualifying drugs Regulation 1. Methadone Rationale many decades ago: Heroin abusers are unreliable, i.e., a safety risk. Still applies, even when methadone is prescribed for pain. 2. Insulin 3. Seizure medicines for seizures Guidance 1. Varenicline (Chantix) (linked to crash risk due to possible dizziness, seizures, arrhythmia, diabetes) 2. Warfarin (Coumadin) during 1 st month 3. Modafinil (Provigil) during 1 st 6 wks. (Provigil is indicated for treatment of excessive sleepiness due to OSA, shift work sleep disorder, and narcolepsy. If prescribed for narcolepsy, the driver is disqualified based on the disease.) For other prescribed drugs, the ME makes the decision to qualify or disqualify on a case-by-case basis. This includes buprenorphine (Suboxone), fentanyl, hydrocodone, hydromorphone, morphine, and oxycodone.
12 Guidelines for decisionmaking If the prescribing doctor responds unsafe, the ME should disqualify. If the prescribing doctor responds safe, the ME still makes the final decision qualified or unqualified. This is the current practice and expectation of MEs. (The regulation has yet to be updated.) Be strategic and efficient. Don t ask for the prescribing doctor s opinion if you ve already decided to disqualify. The ME can do a (non-dot) drug and/or alcohol test as part of the exam. Any drug test should include confirmatory tests of screenpositive results. If ME identifies current drug/alcohol use, ME should refer the driver to a substance abuse professional (addictionologist) for treatment.
13 Evaluating drugs and driving Consider the underlying disease/injury. Drugs are prescribed to improve function. Use of amphetamines generally improves driving ability. Evidence of increased crash risk with initial dosing of certain short-acting Schedule II painkillers. Evidence does not identify crash risk from long-term use of painkillers. Evidence of crash risk with benzodiazepines, too.
14 Case #2 What 3 prescription drugs/types of drugs are, by regulation, disqualifying?
15 Yes - Regular, frequent alcohol use Does the driver: Have a consumption pattern that indicates need for additional evaluation? Pass standardized screening questions, e.g., CAGE? Have a history of driver and/or family alcohol-related medical and/or behavioral problems? Have exam findings of alcoholism/problem drinking? Overall appearance and demeanor Tremor Enlarged liver Is the driver taking other medications that may interact with alcohol?
16 CAGE questionnaire Two yes responses indicate that the possibility of alcoholism should be investigated further. 1. Have you ever felt you needed to cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you ever felt guilty about drinking? 4. Have you ever felt you needed a drink first think in the morning (eye-opener) to steady your nerves or get rid of a hangover?
17 Yes - Regular, frequent alcohol use Does the driver: Have a consumption pattern that indicates need for additional evaluation? Pass standardized screening questions, e.g., CAGE? Have a history of driver and/or family alcoholrelated medical and/or behavioral problems? Rehab, AA meetings DUIs Alcohol-related arrests
18 Yes - Regular, frequent alcohol use Exam findings suggestive of alcoholism/problem drinking: Overall appearance and demeanor Odor Tremor Enlarged liver
19 Yes Narcotic or other habit-forming drug use Is the drug use for: Therapeutic or habitual need? To alter mood, affect, or state of consciousness? To extend physical limits by use of stimulants? Does the driver have a history of drug rehabilitation? As a matter of health promotion, even if not disqualifying, the medical examiner should discuss with the driver: Risks associated with OTC diet, energy, and sleep aids Prescription and OTC pain medications Risks associated with combining medications and alcohol
20 Additional information sources 1. Past records of DOT physicals 2. Records from treating provider(s) 3. Discussion with treating provider(s) 4. Substance abuse specialists (distinguish from SAPs)
21 Case #3. Driver in treatment for alcoholism. CMV driver presents for self-pay DOT physical with alcohol on his breath. The ME learns from treating provider that the driver is struggling with alcoholism. 6 weeks later, the driver presents the ME with letter from alcohol rehab center stating he completed IOP treatment and has good prognosis for continued sobriety. What is the best course of action for the medical examiner to take? A. Disqualify the driver. B. Give the driver a 3-month certification which would allow time for records to be received. C. Give the driver a 1-year certificate. D. Give the driver a 2-year certificate.
22 Mental status exam Mini mental status exam Comprehensive and interaction Cognitive impairment Abnormal affect or behavior (depressed, paranoia, antagonistic, aggressiveness)
23 Diagnostic tests and/or referrals (non-)dot drug or alcohol tests, e.g., rapid urine test, breath alcohol test Use of Schedule I drug or use of any non-prescribed controlled substance is disqualifying Breath alcohol concentration >0.04 is disqualifying. But, any detectable BAC at the clinic raises questions. Blood tests for liver-related enzyme levels, e.g., GGT Referral for mental/emotional health assessment, e.g., for co-morbid mental illness
24 History of positive drug/alcohol tests? Breath alcohol technician Designated employer representative, e.g,. for record of past positive drug tests Medical review officer Substance abuse professional
25 Contact treating provider(s) Better for the ME to contact the treatment provider directly. Don t have the driver serve as intermediary. The toughest specialty from which to get information. A signed release is de regueur. Ask for copies of notes, including recent drug/alcohol test results.
26 Case #4. History of alcoholism. CMV driver reports history of alcohol abuse, goes to AA, takes naltrexone, and says he is sober. What is the best course of action for the medical examiner to take? (May select more than 1.) A. Disqualify the driver. B. Withhold determination pending old records. C. Withhold determination pending additional test results. D. Give the driver a 2-year certificate
27 Case #5. Driver on oxycodone and Fentanyl. CMV driver reports taking oxycodone and Fentanyl patches. Should the ME ask for prescribing physician s opinion? Yes If the prescribing physician says he is aware the patient operates a CMV and believes the patient safe to drive, must the ME qualify the driver? No Yes No
28 Treatment and assessment required after a drug and alcohol testing rule violation Separate from any medical assessment (DOT physical) the employer may require, the drug/alcohol testing rule allows the worker to return to driving after a rule violation only if he/she has completed treatment recommended by a substance abuse professional (SAP). The rule violation may be a positive drug or alcohol test, or it may be a refusal to take a required drug or alcohol test.
29 Substance abuse professional (SAP) two roles 1. Gatekeeper for treatment Evaluates drivers who have positive drug/alcohol tests or other violation(s) of DOT s drug and alcohol rule. Refers drivers to treatment; monitors treatment. Recommends type and duration of follow-up testing. 2. Treatment provider Per FMCSA, the medical examiner refers the examinee to a SAP for treatment if a drug/alcohol abuse problem is identified during the DOT physical.
30 SAP as gatekeeper for treatment after drug/alcohol test violation Drug or alcohol test violation 1. Removal from safety-sensitive duty 2. SAP referral SAP initial evaluation of worker SAP recommends treatment Worker gets treatment If SAP determines treatment not complete SAP follow-up evaluation of worker Fail SAP determines treatment is complete RTD subject to 1-5 yrs of follow-up tests, LCA Pass Return-to-duty drug/alcohol test Yes Employer takes worker back SAP letter re: 1. Compliance 2. Follow-up testing No (This refers to the DOT drug/alcohol testing programs, not to DOT physicals.)
31 Fitness-for-duty DOT Physical, e.g., b/o issues of substance abuse Types Return to duty DOT physical after absence, e.g., for drug/alcohol treatment. Fitness for duty DOT physical triggered by information the medical review officer receives whiel interviewing a donor about a positive drug test. Fitness for duty DOT physical triggered by employer concern, Standard forms and exam, but ME should be informed of, and focus on, the issue at hand. As always, can include necessary ancillary testing, e.g, non-dot drug and/or alcohol test. A DOT drug test looks only for amphetamines, cocaine, marijuana, opiates (targeted at heroin), and PCP.