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CTBSSP COMMERCIAL TRUCK AND BUS SAFETY SYNTHESIS 19 Sponsored by the Effects of Psychoactive Chemicals Federal Motor Carrier on Commercial Driver Health Safety Administration and Performance: Stimulants, Hypnotics, Nutritional, and Other Supplements A Synthesis of Safety Practice

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TRANSPORTATION RESEARCH BOARD 2011 EXECUTIVE COMMITTEE* OFFICERS Chair: Neil J. Pedersen, Administrator, Maryland State Highway Administration, Baltimore Vice Chair: Sandra Rosenbloom, Professor of Planning, University of Arizona, Tucson Executive Director: Robert E. Skinner, Jr., Transportation Research Board MEMBERS J. BARRY BARKER, Executive Director, Transit Authority of River City, Louisville, KY DEBORAH H. BUTLER, Executive Vice President, Planning, and CIO, Norfolk Southern Corporation, Norfolk, VA WILLIAM A.V. CLARK, Professor, Department of Geography, University of California, Los Angeles EUGENE A. CONTI, JR., Secretary of Transportation, North Carolina DOT, Raleigh JAMES M. CRITES, Executive Vice President of Operations, Dallas-Fort Worth International Airport, TX PAULA J. HAMMOND, Secretary, Washington State DOT, Olympia ADIB K. KANAFANI, Cahill Professor of Civil Engineering, University of California, Berkeley SUSAN MARTINOVICH, Director, Nevada DOT, Carson City MICHAEL R. MORRIS, Director of Transportation, North Central Texas Council of Governments, Arlington TRACY L. ROSSER, Vice President, Regional General Manager, Wal-Mart Stores, Inc., Mandeville, LA STEVEN T. SCALZO, Chief Operating Officer, Marine Resources Group, Seattle, WA HENRY G. (GERRY) SCHWARTZ, JR., Chairman (retired), Jacobs/Sverdrup Civil, Inc., St. Louis, MO BEVERLY A. SCOTT, General Manager and CEO, Metropolitan Atlanta Rapid Transit Authority, Atlanta, GA DAVID SELTZER, Principal, Mercator Advisors LLC, Philadelphia, PA LAWRENCE A. SELZER, President and CEO, The Conservation Fund, Arlington, VA KUMARES C. SINHA, Olson Distinguished Professor of Civil Engineering, Purdue University, West Lafayette, IN DANIEL SPERLING, Professor of Civil Engineering and Environmental Science and Policy; Director, Institute of Transportation Studies; and Interim Director, Energy Efficiency Center, University of California, Davis KIRK T. STEUDLE, Director, Michigan DOT, Lansing DOUGLAS W. STOTLAR, President and CEO, Con-Way, Inc., Ann Arbor, MI C. MICHAEL WALTON, Ernest H. Cockrell Centennial Chair in Engineering, University of Texas, Austin EX OFFICIO MEMBERS PETER H. APPEL, Administrator, Research and Innovative Technology Administration, U.S.DOT J. RANDOLPH BABBITT, Administrator, Federal Aviation Administration, U.S.DOT REBECCA M. BREWSTER, President and COO, American Transportation Research Institute, Smyrna, GA ANNE S. FERRO, Administrator, Federal Motor Carrier Safety Administration, U.S.DOT JOHN T. GRAY, Senior Vice President, Policy and Economics, Association of American Railroads, Washington, DC JOHN C. HORSLEY, Executive Director, American Association of State Highway and Transportation Officials, Washington, DC DAVID T. MATSUDA, Deputy Administrator, Maritime Administration, U.S.DOT VICTOR M. MENDEZ, Administrator, Federal Highway Administration, U.S.DOT WILLIAM W. MILLAR, President, American Public Transportation Association, Washington, DC TARA O'TOOLE, Under Secretary for Science and Technology, U.S. Department of Homeland Security, Washington, DC ROBERT J. PAPP (Adm., U.S. Coast Guard), Commandant, U.S. Coast Guard, U.S. Department of Homeland Security, Washington, DC CYNTHIA L. QUARTERMAN, Administrator, Pipeline and Hazardous Materials Safety Administration, U.S.DOT PETER M. ROGOFF, Administrator, Federal Transit Administration, U.S.DOT DAVID L. STRICKLAND, Administrator, National Highway Traffic Safety Administration, U.S.DOT JOSEPH C. SZABO, Administrator, Federal Railroad Administration, U.S.DOT POLLY TROTTENBERG, Assistant Secretary for Transportation Policy, U.S.DOT ROBERT L. VAN ANTWERP (Lt. Gen., U.S. Army), Chief of Engineers and Commanding General, U.S. Army Corps of Engineers, Washington, DC BARRY R. WALLERSTEIN, Executive Officer, South Coast Air Quality Management District, Diamond Bar, CA *Membership as of March 2011.

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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 A Synthesis of Safety Practice AUTHORS GERALD P. KRUEGER and HOWARD M. LEAMAN PRINCIPAL CONTRACTOR GENE BERGOFFEN MaineWay Services Fryeburg, Maine With contributions from: DANIEL MURRAY and RACQUEL PICKETT American Transportation Research Institute S UBSCRIBER C ATEGORIES Motor Carriers Safety and Human Factors Research Sponsored by the Federal Motor Carrier Safety Administration TRANSPORTATION RESEARCH BOARD WASHINGTON, D.C. 2011 www.TRB.org

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COMMERCIAL TRUCK AND BUS SAFETY CTBSSP SYNTHESIS 19 SYNTHESIS PROGRAM Safety is a principal focus of government agencies and private-sector orga- Project MC-19 nizations concerned with transportation. The Federal Motor Carrier Safety ISSN 1544-6808 Administration (FMCSA) was established within the Department of Trans- ISBN: 978-0-309-14322-6 portation on January 1, 2000, pursuant to the Motor Carrier Safety Improve- Library of Congress Control Number 2010940339 ment Act of 1999. Formerly a part of the Federal Highway Administration, the FMCSA's primary mission is to prevent commercial motor vehicle- 2011 National Academy of Sciences. All rights reserved. related fatalities and injuries. Administration activities contribute to ensuring safety in motor carrier operations through strong enforcement of safety reg- ulations, targeting high-risk carriers and commercial motor vehicle drivers; COPYRIGHT INFORMATION improving safety information systems and commercial motor vehicle tech- nologies; strengthening commercial motor vehicle equipment and operating Authors herein are responsible for the authenticity of their materials and for standards; and increasing safety awareness. To accomplish these activities, obtaining written permissions from publishers or persons who own the the Administration works with federal, state, and local enforcement agencies, copyright to any previously published or copyrighted material used herein. the motor carrier industry, labor, safety interest groups, and others. In addi- Cooperative Research Programs (CRP) grants permission to reproduce tion to safety, security-related issues are also receiving significant attention in light of the terrorist events of September 11, 2001. material in this publication for classroom and not-for-profit purposes. Administrators, commercial truck and bus carriers, government regulators, Permission is given with the understanding that none of the material will be and researchers often face problems for which information already exists, used to imply TRB, AASHTO, FAA, FHWA, FMCSA, FTA, or Transit either in documented form or as undocumented experience and practice. This Development Corporation endorsement of a particular product, method, or information may be fragmented, scattered, and underevaluated. As a conse- practice. It is expected that those reproducing the material in this document quence, full knowledge of what has been learned about a problem may not be for educational and not-for-profit uses will give appropriate acknowledgment brought to bear on its solution. Costly research findings may go unused, valu- of the source of any reprinted or reproduced material. For other uses of the able experience may be overlooked, and due consideration may not be given material, request permission from CRP. to recommended practices for solving or alleviating the problem. There is information available on nearly every subject of concern to com- mercial truck and bus safety. Much of it derives from research or from the work of practitioners faced with problems in their day-to-day work. To pro- NOTICE vide a systematic means for assembling and evaluating such useful informa- tion and to make it available to the commercial truck and bus industry, the The project that is the subject of this report was a part of the Commercial Commercial Truck and Bus Safety Synthesis Program (CTBSSP) was estab- Truck and Bus Safety Synthesis Program, conducted by the Transportation lished by the FMCSA to undertake a series of studies to search out and syn- Research Board with the approval of the Governing Board of the National thesize useful knowledge from all available sources and to prepare docu- Research Council. mented reports on current practices in the subject areas of concern. Reports The members of the technical panel selected to monitor this project and from this endeavor constitute the CTBSSP Synthesis series, which collects to review this report were chosen for their special competencies and with and assembles the various forms of information into single concise documents pertaining to specific commercial truck and bus safety problems or sets of regard for appropriate balance. The report was reviewed by the technical closely related problems panel and accepted for publication according to procedures established and The CTBSSP, administered by the Transportation Research Board, began overseen by the Transportation Research Board and approved by the in early 2002 in support of the FMCSA's safety research programs. The pro- Governing Board of the National Research Council. gram initiates two synthesis studies annually that address concerns in the The opinions and conclusions expressed or implied in this report are those area of commercial truck and bus safety. A synthesis report is a document of the researchers who performed the research and are not necessarily those that summarizes existing practice in a specific technical area based typically of the Transportation Research Board, the National Research Council, or the on a literature search and a survey of relevant organizations (e.g., state program sponsors. DOTs, enforcement agencies, commercial truck and bus companies, or other organizations appropriate for the specific topic). The primary users of the syn- theses are practitioners who work on issues or problems using diverse approaches in their individual settings. The program is modeled after the suc- The Transportation Research Board of the National Academies, the National cessful synthesis programs currently operated as part of the National Coop- Research Council, and the sponsors of the Commercial Truck and Bus erative Highway Research Program (NCHRP) and the Transit Cooperative Research Program (TCRP). Safety Synthesis Program do not endorse products or manufacturers. Trade This synthesis series reports on various practices, making recommendations or manufacturers' names appear herein solely because they are considered where appropriate. Each document is a compendium of the best knowledge essential to the object of the report. available on measures found to be successful in resolving specific problems. To develop these syntheses in a comprehensive manner and to ensure inclu- sion of significant knowledge, available information assembled from numer- ous sources, including a large number of relevant organizations, is analyzed. For each topic, the project objectives are (1) to locate and assemble docu- mented information; (2) to learn what practice has been used for solving or alleviating problems; (3) to identify all ongoing research; (4) to learn what problems remain largely unsolved; and (5) to organize, evaluate, and docu- ment the useful information that is acquired. Each synthesis is an immediately useful document that records practices that were acceptable within the limi- tations of the knowledge available at the time of its preparation. The CTBSSP is governed by a Program Oversight Panel consisting of indi- Published reports of the viduals knowledgeable in the area of commercial truck and bus safety from a number of perspectives--commercial truck and bus carriers, key industry trade COMMERCIAL TRUCK AND BUS SAFETY associations, state regulatory agencies, safety organizations, academia, and SYNTHESIS PROGRAM related federal agencies. Major responsibilities of the panel are to (1) provide are available from: general oversight of the CTBSSP and its procedures, (2) annually select syn- thesis topics, (3) refine synthesis scopes, (4) select researchers to prepare each Transportation Research Board synthesis, (5) review products, and (6) make publication recommendations. Business Office Each year, potential synthesis topics are solicited through a broad indus- 500 Fifth Street, NW try-wide process. Based on the topics received, the Program Oversight Panel Washington, DC 20001 selects new synthesis topics based on the level of funding provided by the and can be ordered through the Internet at FMCSA. In late 2002, the Program Oversight Panel selected two task-order http://www.trb.org/bookstore contractor teams through a competitive process to conduct syntheses for Fis- cal Years 2003 through 2005. Printed in the United States of America

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished schol- ars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. On the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Acad- emy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achieve- ments of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, on its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academys p urposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Acad- emy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. The Transportation Research Board is one of six major divisions of the National Research Council. The mission of the Transportation Research Board is to provide leadership in transportation innovation and progress through research and information exchange, conducted within a setting that is objective, interdisci- plinary, and multimodal. The Board's varied activities annually engage about 7,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transporta- tion, and other organizations and individuals interested in the development of transportation. www.TRB.org www.national-academies.org

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CTBSSP OVERSIGHT COMMITTEE CTBSSP SYNTHESIS STAFF STEPHEN R. GODWIN, Director for Studies and Special Programs CHAIR JON M. WILLIAMS, Program Director, IDEA and Synthesis Studies NORM LITTLER, American Bus Association, Washington, DC DONNA L. VLASAK, Senior Program Officer DON TIPPMAN, Senior Editor MEMBERS DEMISHA WILLIAMS, Senior Program Assistant LAMONT BYRD, International Brotherhood of Teamsters, DEBBIE IRVIN, Program Associate Washington, DC B. SCOTT CLAFFEY, Great West Casualty Company, Bloomington, ID CHRISTOPHER CREAN, Peter Pan Bus Lines, Inc., Springfield, MA ALESSANDRO "ALEX" GUARIENTO, MV Transportation, Inc., Plano, TX STEPHEN A. KEPPLER, Commercial Vehicle Safety Alliance, Greenbelt, MD BRENDA LANTZ, North Dakota State University, Lakewood, CO DEAN NEWELL, Maverick Transportation LLC, N. Little Rock, AR DAVID OSIECKI, American Trucking Associations, Alexandria, VA E. JAN SKOUBY, Missouri Department of Transportation, Jefferson City, MO CARI SULLIVAN, Two Men and a Truck International, Inc., Lansing, MI TOM WEAKLEY, Owner-Operator Independent Drivers Association Foundation, Grain Valley, MO GREER WOODRUFF, J.B. Hunt Transport Services, Inc., Lowell, AR CHRISTOPHER ZEILINGER, Community Transportation Association of America, Washington, DC FMCSA LIAISON ALBERT ALVAREZ MARTIN WALKER FHWA LIAISON MICHAEL S. "MIKE" GRIFFITH JOHN C. NICHOLAS APTA LIAISON GREG HULL AASHTO LIAISON LEO PENNE TRB LIAISON CHARLES W. NIESSNER RICHARD PAIN

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FOREWORD Administrators, commercial truck and bus carriers, government regulators, and researchers often face problems for which information already exists, either in documented form or as undocumented experience and practice. This information may be fragmented, scattered, and underevaluated. As a consequence, full knowledge of what has been learned about a problem may not be brought to bear on its solution. Costly research findings may go unused, valuable experience may be overlooked, and due consideration may not be given to recommended practices for solving or alleviating the problem. There is information available on nearly every subject of concern to commercial truck and bus safety. Much of it derives from research or from the work of practitioners faced with problems in their day-to-day jobs. To provide a systematic means for assembling and evaluating such useful information and to make it available to the commercial truck and bus industry, the Commercial Truck and Bus Safety Synthesis Program (CTBSSP) was estab- lished by the Federal Motor Carrier Safety Administration (FMCSA) to undertake a series of studies to search out and synthesize useful knowledge from all available sources and to prepare documented reports on current practices in the subject areas of concern. Reports from this endeavor constitute the CTBSSP Synthesis series, which collects and assembles information into single concise documents pertaining to specific commercial truck and bus safety problems. The CTBSSP, administered by the Transportation Research Board, was authorized in late 2001 and began in 2002 in support of the FMCSA's safety research programs. The program initiates several synthesis studies annually that address issues in the area of com- mercial truck and bus safety. A synthesis report is a document that summarizes existing practice in a specific technical area based typically on a literature search and a survey of relevant organizations (e.g., state DOTs, enforcement agencies, commercial truck and bus companies, or other organizations appropriate for the specific topic). The primary users of the syntheses are practitioners who work on issues or problems using diverse approaches in their individual settings. This synthesis series reports on various practices; each document is a compendium of the best knowledge available on measures found to be successful in resolving specific problems. To develop these syntheses in a comprehensive manner and to ensure inclusion of signifi- cant knowledge, available information assembled from numerous sources is analyzed. For each topic, the project objectives are (1) to locate and assemble documented informa- tion; (2) to learn what practices have been used for solving or alleviating problems; (3) to identify relevant, ongoing research; (4) to learn what problems remain largely unsolved; and (5) to organize, evaluate, and document the useful information that is acquired. Each synthe- sis is an immediately useful document that records practices that were acceptable within the limitations of the knowledge available at the time of its preparation.

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PREFACE This synthesis study identifies available information and research gaps relating to the By Donna L.Vlasak use of chemical substances by commercial drivers and is intended to provide up-to-date Senior Program Officer information to inform decision makers about the near-, mid-, and long-range planning Transportation needs for research and educational outreach programs. Its aim is to assist the commercial Research Board transportation safety community and the Federal Motor Carrier Safety Administration (FMCSA) in addressing issues involving the proliferation and availability of psychoactive chemical substances. Objectives included the provision of a narrative technical review of the scientific and ana- lytical literature, summarizing what is documented about the effects of psychoactive chem- icals on equipment operator performance; an extensive bibliographic reference listing of published literature on these topics; and two convenience surveys, offering information about gaps in knowledge and lessons learned. Appendixes present a description of the evi- dence available about the strength of a variety of chemical substances of which drivers appear to partake, as well as another supplemental bibliographic reading list of secondary source documents. Results from the literature review and the two convenience surveys of small numbers of Commercial Driver Medical Examiners and of commercial vehicle stakeholders point to the need for development and provision of more detailed user-friendly information about the numerous chemicals, drugs, supplements, popular energy enhancement products, and other chemical substances that might impact commercial drivers' performance and health. Numer- ous areas where additional commercial motor vehicle safety issue studies may be called for are also identified in this report. Dr. Gerald P. Krueger, Krueger Ergonomics Consultants, Alexandria, Virginia; Dr. Howard M. Leaman, Intermountain Sleep Disorders Center, Intermountain Health Care, Salt Lake City, Utah; and Gene Bergoffen of MaineWay Services, Fryeburg, Maine; with contributions from Daniel Murray and Racquel Pickett, American Transportation Research Institute, collected and synthesized the information and wrote the report. The Commercial Truck and Bus Safety Synthesis Program Oversight Committee members are acknowledged on the preceding page. This synthesis is an immediately useful document that records the practices that were acceptable within the limitations of the knowledge available at the time of its preparation. As progress in research and practice continues, new knowledge will be added to that now at hand.

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CONTENTS 1 SUMMARY 3 CHAPTER ONE INTRODUCTION Background, 3 Objectives and Scope, 3 Methodology and Approach, 4 6 CHAPTER TWO RESEARCH ISSUES REGARDING PSYCHOACTIVE CHEMICALS Synthesis Problem Statement Applied to the Literature Review, 6 Drug Definitions and Categorization, 6 Chemical Substance Effects and Driving Performance, 7 Drug and Alcohol Influences in Crash Statistics, 9 Drug Influences on Performance Compared with Alcohol Effects, 10 Influence of Chemicals on Driver Performance, 11 12 CHAPTER THREE HYPNOTICS AND SLEEP-PROMOTING COMPOUNDS Introduction to Sleep-Promoting Chemicals, 12 Prescription Benzodiazepines as Sleep-Promoting Compounds, 13 Nonbenzodiazepine Sleep-Promoting Medications, 13 Sleep-Promoting Compounds and Driving Performance, 16 Alternative Sleep-Inducing Compounds, 18 Summary of Operational Consequences of Sleep-Promoting Compounds, 23 Second-Generation Nonsedating Antihistamines for Allergies, 23 27 CHAPTER FOUR STIMULANTS AND ALERTNESS-ENHANCING COMPOUNDS Introduction to Stimulants and Alertness-Enhancing Compounds, 27 Stimulants and Alertness-Enhancing Compounds, 27 39 CHAPTER FIVE SUPPLEMENTS: NUTRITIONAL, HERBAL, ENERGY BOOSTERS, DIETARY, AND HEALTH FOODS Introduction to Supplements, 39 Definitions of Supplements, 39 Psychoactive Herbal Supplements, 40 Energy Supplement Drinks, Food Bars, Candy Chews, and Others, 44 Energy Boost Powders, Pills, Food Bars, Etc., 48 50 CHAPTER SIX MEDICATIONS AND COMMERCIAL DRIVER MEDICAL CERTIFICATION: REPORT ON A SURVEY OF MEDICAL EXAMINERS OF COMMERCIAL DRIVERS Introduction, 50 Medical Examiner Survey Regarding Medications Used by Commercial Vehicle Drivers, 51

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Medications and Medication Classes, 52 Discussion of Surveys of Medical Examiners, 59 Summary of Medical Examiner Survey, 61 62 CHAPTER SEVEN MOTOR CARRIER POLICIES ON DRIVER USE OF CHEMICAL SUBSTANCES Introduction and Methodology, 62 Questionnaire Survey Results, 62 65 CHAPTER EIGHT SYNTHESIS CONCLUSIONS AND DISCUSSION Introduction, 65 Findings from the Literature Review, 65 Results and Discussion of Medical Examiners Surveys, 68 Motor Carrier Policies Regarding Chemical Substances, 70 Overall Conclusions from the Survey of Medical Examiners and Motor Carrier Managers, 70 71 APPENDIX A ADDITIONAL RESEARCH ON CHEMICALS AFFECTING PERFORMANCE AND HEALTH 79 APPENDIX B U.S. MILITARY POLICIES REGARDING USE OF HYPNOTICS AND STIMULANTS 83 APPENDIX C NUTRITIONAL SUPPLEMENTS FOR INDUCING RELAXATION, TENSION RELEASE, SLEEP, AND MORE 93 APPENDIX D REFERENCES 112 APPENDIX E BIBLIOGRAPHY OF ADDITIONAL READINGS APPENDIXES D AND E OF THIS REPORT CAN BE FOUND AT: WWW.TRB.ORG, SEARCH ON "CTBSSP SYNTHESIS 19."