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51 Medications rather than medical conditions were chosen 4. Is there agreement among medical examiners about to be queried for this synthesis survey, because the common which medications drivers would admit taking that uses of many of the medications are "off-label," which means would still permit them to be medically certified to being prescribed for reasons not approved by the FDA for continue driving? use in treating a specific disease. Once a medication is on 5. To what extent are medical examiners providing drivers the market for one indication (disease), "the FDA has a lim- with guidance on the safe use of medications? ited role in governing use of that medication for other clin- 6. To what extent are medical examiners routinely pro- ical indications." It is both legal and common for medical viding employers with Department of Transportation providers to prescribe medication for off-label uses based DOT Long Form (Form 649-F-6045): Medical Exam- on their judgment that the patient will benefit. According to ination Report for Commercial Driver Fitness Deter- published reports, up to 21% of prescriptions in the United mination? To what extent are they communicating States are written for off-label use (Stafford 2008). Common (with or without the driver's granted release of personal information) regarding specific certification issues or examples include the use of trazodone, an antidepressant, medications in commercial drivers examined at their for insomnia, wherein it is approved for use only as an anti- behest, or do they provide employers with lists of depressant; or gabapentin, a seizure medication, which is also prohibited drugs/medications? commonly prescribed for diabetic neuropathy and for the movement disorder of restless legs syndrome (Stafford 2008; Krystal 2009). Medical Examiner Survey Participants The examiner must rely on the driver to accurately and In 2008, a questionnaire was administered to two small groups completely list his or her medications, and may rely on report- of medical examiners of commercial drivers. Twenty-three ing by the driver's prescribing physician on medication effect, examiners were surveyed at two educational meetings of prac- make his or her own assessment of medications reported, or ticing occupational medicine specialists in two locations: 8 in do both (FMCSA FAQ #77 "What medications disqualify a Reno, Nevada, and 15 in Salt Lake City, Utah. CMV Driver"). Of the 16 forms distributed on September 11, 2008, to a Salt Lake City group of occupational medicine clinic providers, 15 were completed and returned. This first survey group MEDICAL EXAMINER SURVEY REGARDING included 12 practicing occupational medicine physicians, MEDICATIONS USED BY COMMERCIAL VEHICLE DRIVERS including 3 occupational medicine residents, and 3 mid-level practitioners (Advanced Practice Registered Nurses), who Aims of the Survey of Medical Examiners were primarily working in occupational health clinics in Utah. A number of additional questionnaires were sent by e-mail to In light of the availability of information from the FMCSA those who could not attend, but no additional completed regarding the specific medications, and the recognized role surveys were received. Completed survey forms were scored and importance of medical examiner efforts in evaluating in paper form. driver medication use, in this convenience sample survey an attempt was made to characterize what decisions CDMEs Eight questionnaires were distributed and returned by anticipate they would make when faced with the decision physicians who attended a lecture given by Dr. Howard of whether to "qualify or not to qualify" a commercial driver Leaman at Reno, Nevada, on November 12, 2008. The surveys for their required medical examiners certificate based on were all returned before the talk began. Four physicians were issues concerning medications the driver may be taking. employed in private practice and reported seeing commercial drivers in their practice, two practiced in occupational medi- In this survey, the synthesis team aimed to answer the fol- cine clinics, one was an urgent care physician, and one was a corporate physician. Five of the 8 physicians were certified in lowing questions: a medical specialty: family practice or cardiovascular disease. None were certified in occupational medicine. The average 1. What are medical examiners' knowledge, understand- number of department of transportation (DOT) exams (CDME) ing, and actions in qualifying commercial drivers with per week was 4, with a range from 0 to 20 exams per medical admitted Schedule II medication use under the FMCSA provider. Some demographic information about the respon- rules and guidelines? dents in the two groups is depicted in Table 5. 2. Are examiners providing certification in accordance with published FMCSA rules and guidelines with Surveys were conducted anonymously so that responses respect to Schedule II medications? To what extent do were protected and treated confidentially, and the responses they vary from those rules and guidelines? could not be identified with any particular respondent. The 3. Is there awareness of potential hazards of medications responses on the completed questionnaires were hand-scored such that examiners require additional steps for the and entered into an Excel spreadsheet for tabulation of driver to qualify? the results. Only statistical measures of central tendency are