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4 METHODOLOGY AND APPROACH be usable in practice in select commercial transportation applications. Literature Review The literature review presented here is of the narrative This synthesis provides a narrative review and description type. It describes and appraises previous work, but does not of much of what is known from the scientific literature specify methods by which any particular studies cited were about psychoactive chemicals that some commercial drivers identified, selected, and/or evaluated. Many of the citations at times ingest, and reports on the known and probable are from scientific peer-reviewed journals. Many textbook effects of such chemicals on operator performance, safety, chapters cited were written by leading scientists in their fields, and health. These substances include many prescription whose knowledge of decades of their own and their peers' and self-administered medications, sleep-inducing hypnotics, published works lends credibility to their synopsis on select wakefulness-promoting stimulants, and a large number topics. The choice of which articles to cite in this narrative of products best labeled as dietary and nutritional supple- review was largely determined by the synthesis team's judg- ments, many of which contain psychoactive agents and are ment that a particular reference explicated the points being readily available over the counter in grocery and drug made or provided an alternative or clarifying viewpoint that the stores and at convenience stores located at fueling rest stops reader can seek out to suit his or her own interest in the topic. along the U.S. highways. Reports identified and reviewed This review does not appraise all available research that may included: be relevant to a particular topic, but it does attempt to focus on key points and findings while citing numerous additional Scientific journal articles presenting results of experi- identified published studies in an extensive web-only Refer- ments involving psychoactive substances and equipment ence section (Appendix D), plus a web-only Bibliography operator performance, as well as laboratory studies (Appendix E) of citations that are useful, but not directly of generic performance and skill tests having a direct cited in the text. relationship to driving behavior (i.e., studies of drug effects on reaction time, psychomotor tracking, vigilance, This narrative presents an overview and some discussion of judgment, decision making, and so on); previous experimental and analytical works, selected because Occupational health and safety reports pertaining directly they explain effects of psychoactive chemicals (drugs, to chemical substance use by transportation operators medications, supplements, and so on) on operator performance, (commercial drivers, aviators, and others) and their particularly drug effects on psychomotor tracking, reaction performance; time, judgment, and decision-making performance--all Rules and advisory guidelines from FMCSA published directly related to driving performance. The review suggests and available for use by the public and by CDMEs; current gaps in knowledge on these topics. The information Documents in the widely dispersed government- contained in the review can assist in developing a rationale for sponsored technical report literature, especially those of proposing new research that still remains to be accomplished. federal research organizations such as the U.S. military It also may be used to scope the types of interventions avail- medical research and civil aeromedical research labora- able to be included in more thorough analyses of the issues tories, the National Institutes of Health research institutes, raised in the problem statements described earlier. and public health centers (e.g., National Institute of Drug Abuse); and A variety of professional scientific publications, text- Bibliography of References Cited book chapters, committee reports, symposia proceedings, and Additional Literature position papers, and others that are largely produced During the extensive search for, review, and critique of outside the refereed journal literature. numerous scientific references for this synthesis, it became apparent that a great number of reports on psychoactive drugs Also provided as Appendix B is a brief analytical review and chemicals and performance are available (some previous of the medical and performance research that supports the review articles examined cite dozens, even hundreds of current operational policy statements of the several U.S. studies). Many of the reports identified here appear directly military services, each of which permits selective, limited- related to the task at hand, whereas many others only provide time, operational use of psychoactive chemical substances to additional background or are only tangentially related. In be taken by military personnel under highly controlled military both cases, the articles and reports are widely scattered. The circumstances. Such state-of-the-art/practice research portends references (web-only Appendix D) contain all of those citations the potential, but with significant accompanying cautions, for actually cited in this report. It was deemed appropriate to employing psychoactive chemicals for operational fatigue provide at least a bibliographic listing of related citations in countermeasures in other work settings. It also anticipates the belief that presenting them together in a single listing discussion of whether such chemical substances would ever might save other researchers significant search time when

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5 looking for additional publications pertinent to these topics. Survey of Commercial Carrier Policies The Bibliography (web-only Appendix E) lists those citations on Driver Use of Chemical Substances determined to be sufficiently related to effects of psycho- active substances on performance and health to warrant A structured interview questionnaire for use by CMV stake- including, that are not specifically mentioned in the text, but holders (predominately truck carrier fleet managers, safety that could provide additional background. advocates, and other company officials) was administered to elicit key information about current policies, applications, and programs involving the use, or restriction of use, of Survey of Medical Examiners Performing psychoactive chemical substances by commercial drivers. Commercial Driver Medical Examinations The survey questionnaire asked specific questions about fleet managers' knowledge base, and about current company The synthesis team distributed a survey questionnaire about policies regarding driver use of stimulants, hypnotics, and medications and drugs to a small convenience sample of nutritional supplements. The survey was sufficiently open- 23 medical providers who administer CDMEs to commer- ended to gather information about experiences with current cial drivers seeking medical qualification and certification to approaches, procedures, and safety policies in place, to identify drive commercial vehicles. The questionnaire was administered problems, and to elicit proposed solutions regarding the use in two western geographical regions of the United States: of chemical substances in the commercial transportation 15 medical examiner responses were obtained in a Salt Lake industries. Survey questions were specifically designed to City, Utah, survey; and 8 medical examiners were surveyed cover the scope and objectives outlined previously. The in Reno, Nevada. survey questionnaire for motor carrier company officials was distributed by members of the American Transportation The questionnaire asked these medical examiners about: Research Institute (ATRI) to (1) the American Trucking Associations (ATA) Safety and Loss Prevention Management Their anticipated certification decisions regarding chem- Council, (2) a Health and Wellness working group within ical substances identified while performing medical that council, and (3) several wellness clinics located at travel qualification exams of CMV drivers, centers that target over-the-road drivers. The participants Their role in providing medical advice about driver consisted of safety and human resource personnel within the alertness and combating fatigue, trucking industry, including motor carriers and allied profes- Their advice on the use of and identifiable hazards sionals (e.g., motorcoach companies and health and wellness associated with ingesting chemical substances in the clinics). Motor carrier representatives were invited to partic- workplace, and ipate by e-mail, which included an Internet link on ATRI's Advice they might or might not give to CMV drivers website where respondents could gain access to the online and to their employers. version of the Chemical Effects Survey. In particular, providers were asked about the certification There were 31 company responses. These companies actions and information resources relied on in making driver employed a range of from 10 to a maximum of 6,200 drivers, certification decisions. The survey questions asked of med- with a company average of more than 800 drivers. Most ical examiners also solicited suggestions for improvements respondents were truck carrier firms. The survey also netted in the administration and conduct of occupational medicine responses from one commercial driver training company and and CDME practices concerning use of chemical substances by one charter bus company. The specific questions posed in the drivers, and about the health and safety implications attached survey are depicted in the context of the presentation of the thereto. A summary of the questionnaire results is presented in results along with summary statistics for the surveys, and are chapter six of this synthesis report. described in chapter seven of this report.