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50 CHAPTER SIX MEDICATIONS AND COMMERCIAL DRIVER MEDICAL CERTIFICATION: REPORT ON A SURVEY OF MEDICAL EXAMINERS OF COMMERCIAL DRIVERS INTRODUCTION ically and statistically robust detailed study of the medical examiner role in providing CDMEs. The study was conducted Both prescribed medications and self-administered "over- between 2005 and 2007 and it reported on 2,297 surveyed the-counter" drugs may affect driver alertness, the onset of medical examiners of commercial drivers within each of driver fatigue, and overall driver performance. Concerns have the designated professions performing these examinations been raised about the association between drugs and medica- (medical doctors, doctors of osteopathy, chiropractors, physi- tions as contributing factors to the cause of highway crashes. cian's assistants, and advanced practice nurses.) The significant involvement of medications in accidents is Tasks associated with the performance of CDMEs were demonstrated in FMCSA's Large Truck Crash Causation identified and their importance was assessed; the knowledge, Study (Craft et al. 2007). In that study, prescription and OTC skills, and abilities required to perform those tasks were also drug use were considered "accident associated factors" in identified so as to facilitate examiner training and testing 26% and 17%, respectively, of the 967 accidents. (An accident in connection with the development of a proposed National associated factor was defined by the study authors as a "factor Registry of Certified Medical Examiners (NRCME). Of the that could be important," not the "critical reason" or "event" 146 tasks performed by medical examiners during the exam- causing the crash.) inations of commercial drivers, five medication-related tasks were identified. Each was given high importance by the exam- Further importance of the involvement of medications iners (3.713.91/4), and study participants (89%98%) indi- in highway accidents is provided by research conducted cated they performed those tasks for almost all commercial on Australian truck drivers in a volunteer study published in driver examinations completed. 2004 (Howard et al. 2004). In this study, drivers who con- sumed benzodiazepine-type medications were found to be A number of sources for medical examiner guidance on 1.91 times more likely to have had a crash in the previous the potential effect of medications on commercial driver 3 years, 3.44 times more likely to have crashed with use of safety have been published by the FMCSA. These include antihistamines, 2.4 times more likely to have crashed with use of narcotic analgesics, and after consuming alcoholic rules prohibiting use of insulin [391.41(b) 3] and controlled drinks, only 1.09 times more likely to crash. They were no substances [391.41(b)12] and advisory guidelines includ- more or less likely to have crashed if they consumed stimulant ing frequently asked questions (FAQs) on the FMCSA Med- drugs such as caffeine (Howard et al. 2004). ical Program Web Page, medical conference reports, evi- dence guidelines, and medical expert panel reports, as well Commercial truck and bus/motorcoach drivers are required as the NRCME Medical Examiner Handbook. In addition, by law to undergo medical evaluation on a periodic basis (with the Medical Review Board of the FMCSA commented exten- no longer than 2 years between examinations) to be permitted sively on medication use and made recommendations to the to drive or to continue driving commercial vehicles (49 CFR FMCSA. All of these documents have been published by 391.11). The public and drivers' employers rely on med- the FMCSA, are available for public access on the FMCSA ical practitioners in the conduct of Commercial Driver Medical website, and can be used to assist medical examiners in deter- Examinations (CDMEs) to ascertain whether an individual mining whether drivers who admitted taking certain med- driver meets the standards of applicable federal safety rules ications would be able to drive safely. Each of these sources (49 CFR 391.41) . . . that the driver has no "established med- are in separate web locations, are organized by disease entity, ical history of clinical diagnosis of" . . . a medical condition . . . and, for the most part, cover medications in the context of "likely to interfere with the safe operation of a commercial the specific diseases. This information is rapidly changing, motor vehicle." with many of these sources being published during the devel- opment of this synthesis report. See the FMCSA website The medical examiner role in evaluating and advising for details and the status of each. Review of these sources of drivers on use of medications was detailed in the FMSCA- information for the medical examiner is beyond the scope of sponsored "Role Delineation Study." This was a methodolog- this synthesis.