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52 TABLE 5 PARTICIPANTS IN SURVEY QUESTIONNAIRE ASKED OF MEDICAL PROVIDERS OF COMMERCIAL DRIVER MEDICAL EXAMINATIONS Survey Participants on Commercial Driver Examinations Reno, Salt Lake Variables Nevada City, Utah Group Number of Participants 8 15 23 Average Age 49 48 48.5 Male/Female 0.80 0.63 0.71 MD/Mid-level Practitioner (APRN) 1.00 0.80 0.90 Percent MD Board Certified 0.38 1.00 0.62 CDME Average (number per week) 4.00 17.00 10.00 Range 020 035 <035 Providers Reporting Their Practice Is 0.25 0.80 Primarily Occupational Medicine reported here; no particular parametric statistical analyses are apparent that several medical providers lacked familiarity provided because of the limited group size. with some of the 69 medications listed. Consequently, the number of medications queried of the Reno, Nevada, group Because of the small number of respondents, one cannot was reduced to 52 medications in 10 categories, which helped infer that the responses of those surveyed are representative of limit the amount of time required to respond to the lengthy the opinions of all medical examiners of commercial drivers. questionnaire. The complete list of 69 drugs is described That is particularly relevant in view of the coming require- in subsequent sections, with annotations to indicate which ment that examiners must be qualified by examination and 17 were deleted from the second set of questionnaires before registered to perform medical certification examinations for administration to the Reno group. The average medical pro- drivers. Nonetheless, the survey responses here provide insight vider took 20 to 25 min to complete the questionnaire in both into the decision-making process in two groups of individual locations (Salt Lake City and Reno). CDMEs responsible for the medical qualification of com- mercial drivers. The medical examiners were asked to classify each medication by the actions they would normally take when These survey data represent an initial look at medical presented with that medication by a commercial driver at the provider decision making regarding driver medications in the time of his/her CDME. CDME certification process. The survey results may prompt further investigation using larger groups, better selected On the examiner survey, the medications were grouped into medication lists, and statistical methods for improving validity functional categories. Results were expressed as proportions and inference to the larger population of medical examiners. rather than percentages to avoid the appearance of statistical validity or inference that this group represents all medical In the several literature searches performed for this syn- examiners. This was a very small sample size (n = 23), and the thesis study, including that of the PubMed National Library of results cannot be said to represent all CDM examiners. Medicine Search Engine, no published reports were identified that provided this specific information. For each medication listed, survey participants were given the opportunity to choose one or multiple options to indicate either how they have previously handled such questions, or MEDICATIONS AND MEDICATION CLASSES would handle them now, at the time of the survey administra- Introduction tion (2008): The medications chosen for survey were identified by synthe- sis co-author (Leaman) based on NTSB accident reports and on personal experience performing commercial driver certi- Response options to medications listed in the Medical fication examinations over a 25-year career in occupational Examiner survey: medicine. Option 1: Never approve Option 2: Approve (only with note from treating MD) The first group of medical providers, surveyed at Salt Option 3: Approve with objective testing Lake City, Utah, was presented with a list of 69 drugs and Option 4: Approve with detailed history from driver Option 5: Approve only if prescription meds are taken medications, grouped into 12 categories. Some of the more 8 hours or more before driving commonly available pharmaceuticals were identified by their Option 6: Usually/always approve trade name so as to ensure that the respondents knew the Option 7: I do not ever see this drug medications by their recognizable names. However, in review- Option 8: I am not familiar with this drug ing responses from the Salt Lake City group, it became
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53 Definitions: A test for controlled substances is not required as part of this biennial medical certification process. The Issuance: Granting of a medical certificate to a commer- FMCSA or the driver's employer should be contacted directly for information on controlled substances and cial driver from an appropriately designated medical alcohol testing under Part 382 of the Federal Motor examiner for any period of time. Carrier Safety Regulations. Conditional issuance: Granting of a certificate to a commercial driver by an appropriately designated The term "uses" is meant to encompass instances medical examiner, pending the driver's agreeing to of prohibited drug use determined by a physician comply with a condition of issuance such as provid- through established medical means, which may or ing the examiner with a note from the prescribing prac- may not involve body fluid testing. If body fluid test- ing takes place, positive test results should be con- titioner, providing additional detailed medical history firmed by a second test of greater specificity. The at the time of the examination, additional objective term "habit forming" is intended to include any testing, and/or medical certification with the stipulation drug or medication generally recognized as capable that the medication in question be taken 8 h or more of becoming habitual, and that may impair the user's before driving. ability to operate a CMV safely. The driver is medically unqualified for the duration of the prohibited drug(s) No issuance: Driver is not issued a medical certificate at use and until a second examination shows the driver the time of the examination. is free from the prohibited drug(s) use. Re-certification may involve a substance abuse evaluation, the success- ful completion of a drug rehabilitation program, and a Pain Medications negative drug test result. Additionally, given that the certification period is normally two years, the medical examiner has the option to certify for a period of less Tramadol (Ultram®) than two years if this examiner determines more fre- Oxycodone (Oxycontin®) quent monitoring is required. (See Conference on Oxycodone (Percocet®, Lortab®) Neurological Disorders and Commercial Drivers and Codeine (Tylenol with Codeine) Conference on Psychiatric Disorders and Commercial Morphine (Kadian®) Drivers at: http://www.fmcsa.dot.gov/facts-research/ Methadone (Dolophine®) research-technology/publications/medreports.htm.) Survey Results (Pain Medications) Applicable FMCSA Regulation and Guidance regarding con- trolled substances: Methadone Commercial drivers are prohibited from driving while taking methadone, and medical certification for com- Federal Rule 391.41(b)(12): mercial driving is also not permitted [391.41(b)(12)]. A person is physically qualified to drive a commercial vehicle if that person: Thirteen of the 23 medical examiners surveyed correctly identified this rule in the questionnaire and indicated the Does not use a controlled substance identified in 21 driver would "Never" be issued a certificate while taking that CFR 1308.11, Schedule I, an amphetamine, a narcotic, medication. Unfortunately, eight medical examiners did not, or any other habit-forming drug. with five indicating they would provide medical certification Exception: A driver may use such a substance or drug, when presented with a note from the driver's prescribing if the substance or drug is prescribed by a licensed physician; two would approve if provided with a detailed medical practitioner who is familiar with the driver's history taken in the clinic; and one if the driver took the medical history and assigned duties; and has advised medication 8 h or more before driving. There were differences the driver that the prescribed substance or drug will between locations, with only one of the eight Reno providers not adversely affect the driver's ability to safely oper- ate a commercial motor vehicle. surveyed indicating "no certificate" would be issued; the others would provide certification conditioned on receipt of This exception does not apply to the use of methadone. the prescribing physician's note, completion of a detailed history in the clinic, or results of some objective testing. The intent of the medical certification process is to medically evaluate a driver to ensure that he or she has Other opiates There appeared to be regional differences in no medical condition that interferes with the safe per- formance of driving tasks on a public road. If a driver conditional approvals for opiates, most notably methadone, fol- uses a Schedule I drug or other substance, an amphet- lowed by oxycodone (Oxycontin®) and morphine (Kadian®). amine, a narcotic, or any other habit-forming drug, it These are potent opiate medications usually prescribed for may be cause for the driver to be found medically severe chronic pain. For oxycodone (Oxycontin®), 8 of the unqualified. Motor carriers are encouraged to obtain a medical practitioner's written statement about the 23 surveyed providers would not anticipate providing a med- effects on transportation safety of the use of a particu- ical certificate to a driver who admitted taking this medica- lar drug. tion; 7 would require a physician's note; and 5 would instruct
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54 the driver to take the medicine 8 h before driving. For mor- 8 of 15; Reno: 3 of 4 respondents who answered) and issu- phine (Kadian®), 8 of 23 surveyed providers indicated they ing a certificate for a driver who admitted taking morphine would never qualify a commercial driver admitting to use of (Kadian®) (Salt Lake City: 7 of 15 respondents; Reno: 4 of this drug. Of the others who would conditionally allow med- 6 who responded). ical certification, 6 of 23 would require a physician's note, 4 of 23 a detailed history in clinic, and 4 of 23 indicated Stimulant Medications advising the driver to take the medication no sooner than 8 h before driving. For Tylenol with codeine, most indicated they would qualify a driver with a note from their prescriber d-Amphetamine (Adderall®) in 6 of 23 examiners, detailed history in 10 of 23 surveyed Methylphenidate (Ritalin®, Concerta®) examiners, and instructions by 11 of 23 examiners to take the Modafinil (Provigil®) medication no sooner than 8 h before driving. Caffeine (No Doze®, Vivarin®, etc.) Energy drinks (Red Bull®, etc.) Tramadol Drivers admitting use of this medication were anticipated to be in a medically certified condition on provid- ing a detailed medical history to the examiner in the clinic by Survey Results (Stimulant Medications) 13 of the 23 examiners. Six of 23 examiners indicated the dri- ver would be qualified, and the driver was instructed to take D-Amphetamine Conditional medical certification was the medication no sooner than 8 h before driving. anticipated by 14 of 23 surveyed examiners when presented with a driver who admits taking amphetamine, most often conditioned on receiving a treating physician's note (7 of 23) Summary (Pain Medications) and in 3 of 23 instances a detailed medical history in the clinic. Methadone Substantial variation existed between the two Six of the 23 examiners indicated that they would never groups of medical providers surveyed (Reno and Salt Lake medically qualify a driver who admits to taking amphetamine, City groups) in terms of providing medical certification to and 2 of 23 marked "Usually always" qualifying such a driver. drivers who admit taking the drug methadone, which is specif- Several of the examiners indicated they never see this medica- ically regulated (prohibited) in FMCSA rules 391.41(b)(12). tion in their practice with commercial drivers. Compliance Some providers of CDMEs are apparently unaware, or for with 391.41(b)(12) was similar between regions for those some reason do not comply with the DOT regulation stating who would issue the certificate [Salt Lake City (6 of 11); that this medication is prohibited for use in commercial driving. Reno (3 of 6)]. Regional differences appeared with respect to permitting For the other prescription stimulants such as methyl- drivers to be certified when taking methadone: most of the phenidate (e.g., Ritalin®), the majority of the medical providers Reno group of providers reported they would issue conditional would certify drivers using these medications if a detailed certificates to drivers, whereas in the Salt Lake City group history in clinic and a physician prescriber's written statement only 3 of 15 medical examiners would permit conditional were provided. No providers indicated they would "Never" certification for drivers who admit to methadone use. qualify a driver using methylphenidate, 13 of 23 would require the prescriber's written statement, and 7 of 23 would require Other Opiate/Pain Medications (not methadone) Question- additional detailed history in the clinic. Modafinil (Provigil®) naire responses showed consistency for the opiates/pain was "Usually/Always" approved by 4 of the 23 medical pro- medications, particularly regarding tramadol, where all of viders surveyed, with an additional 8 of the 23 providers indi- the medical providers responded they would permit con- cating they would require a prescriber's written statement, ditional or full certificate issuance to drivers who admitted and 8 requiring a detailed history in the clinic. taking it. Of the 23 providers surveyed, only 3 would require a driver's prescribing physician statement in compliance with A question concerning drivers admitting to the use of 391.41(b)(12) before issuing a certificate for a driver taking caffeine and energy drinks was marked "Usually/Always" tramadol (Ultram®). Over all the pain medications, only permitted certification in 6 and 7 of the providers, respectively, 6 of 17 respondents who would allow certification stated they with the majority, 9 and 10 of 23 providers, indicating they would require the prescribing physician's written statement would require a detailed history in the clinic for these drivers. before issuing a medical certificate to a commercial driver. Curiously, two providers indicated they would "Never" issue a medical certificate to drivers ingesting these substances. There was uniform response on "would issue" a certificate (conditional or "usually always") for oxycodone (Percocet®, In summary, for the small group surveyed, there were Lortab®) (21 of 23) and codeine (Tylenol with codeine) regional differences (Reno vs. Salt Lake City) and variation (22 of 23). There were substantial inter-group or regional in anticipated practice among providers. The source of this differences in the willingness to issue a certificate to a driver variation was not identified in the data; however, data from who admitted taking oxycodone (Oxycontin®) (Salt Lake City: another part of the questionnaire may be relevant.
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55 Antidepressants and Other Psychiatric Survey Results (Antihistamines) Medications The most commonly occurring response from the medical Psychotropic Medications examiners in this drug category was "Approve only if med- ication taken 8 h or more prior to driving." The number of the examiners indicating no medication use within 8 h of driving Selective Serotonin Reuptake Inhibitors (SSRIs) Venlafaxine (Effexor®) included: diphenhydramine (Benadryl®) 17 of 23; hydrox- Fluoxetine (Prozac®) yzine (Atarax) 12 of 23; and certirizine (Zyrtec) 10 of 23. Sertraline (Zoloft®, etc.) There appeared to be little regional variation in these recom- Atomoxetine (Straterra®) mendations. Of those surveyed, only one provider of the 23 Bupropion (Wellbutrin®) indicated that he/she would "Never" certify a driver taking Mirtazapine (Remeron® and other heterocyclic antidepressants) diphenhydramine (Benadryl®) or hydroxyzine (Atarax). Tranylcypromine [Parnate® (MAO Inhibitor)] Amitriptyline (Elavil®) Lithium (Eskalith®) Neuroleptic Medications Quetiapine (Seroquel®) Abilify/Geodon (deleted for the 2nd round of questionnaires) Gabapentin (Neurontin®) Pregabalin (Lyrica®) Dilantin Phenobarbital Lamotrigine (Lamictal®) Survey Results (Psychotropic Medications) (Keppra®) (deleted in 2nd questionnaire) For SSRI-type antidepressants, 14 of 23 surveyed medical examiners would qualify drivers with additional history in clinic; only 2 of 23 indicated that they would require a Survey Results (Neuroleptic Medications) written statement from the provider who prescribed the driver's antidepressant. The surveyed examiners consistently indicated conditional approval for gabapentin (Neurontin®) and pregabalin In the surveyed group, no examiners indicated they (Lyrica®). For gabapentin (Neurontin®), 18 of the 23 sur- would "Never" qualify a driver who admitted taking any of veyed examiners would provide conditional approval, with the medications queried. Other than lithium, conditional 11 requiring that the driver provide additional detailed history approval was the most common response, with detailed in clinic, 4 requiring that the driver provide a note from the history in clinic required for most medications queried. In prescribing physician, and 2 would instruct the driver to take the case of lithium, 13 of 23 medical examiners would require the medication 8 or more hours before driving. For dilan- the driver to provide a written statement from their pre- tin, typically used for seizure control and sometimes periph- scribing physician. eral neuropathy, the response was different, and varied by location. Eight of the 23 examiners indicated they would Quetiapine (Seroquel®--a member of a class of medications "Never" medically qualify a driver taking this medication; known as atypical antipsychotics) and amitriptyline (Elavil®) most of these examiners were in Salt Lake City. In Reno, four and mirtazapine (Remeron®) (sedating antidepressants), were of the eight surveyed practitioners indicated they would require the only medications in this class where examiners anticipated a physician's note. To either effect, the examiners appear to be advising the driver to take the medication no sooner than 8 h further inquiring why the medication is being used (seizures, before driving. Unfortunately, this was not prevalent, and only neuropathy, or some other reason). The FMCSA specifically 3 of 23 examiners indicated no driving sooner than 8 h after states that, "Use of medication to prevent seizures is dis- use of amitriptyline medication, and 2 of 23 indicated this for qualifying" (FAQ #77). Similar to their responses to dilantin, mirtazapine (Remeron®) or Quetiapine (Seroquel®). medical examiners evaluating drivers admitting use of pheno- barbital either would never qualify the driver (8 of 23) or would require the driver to present a prescribing physician Antihistamines note (6 of 23). Lamotrigine (Lamictal®) is a neuroleptic agent, typically used as a mood stabilizer in bipolar disorder. Twelve of the 23 medical providers either would never qualify a Diphenhydramine (Benadryl®) driver who admitted to taking this medication or would Hydroxyzine (Atarax®) require the driver to present a medical note before consider- Loratadine (Claritin®) Monoleukast (Singulair®) ing qualification for a commercial driver medical certificate. Astemizole (Hismanal®) Four of the 23 surveyed would "approve," conditioned on a Cetirizine (Zyrtec®) detailed history in the clinic, and five examiners indicated that they never see this medication.
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56 Sedatives and Hypnotics instructions to take the medication no sooner than 8 h before driving were the conditions of certification. Two of 23 exam- iners indicated they would "Never" qualify, and 2 others Lorazepam (Ativan®) indicated they "Usually/always" qualify commercial drivers Clonazepam (Klonopin®) Diazepam (Valium®) who admitted taking these medications. Six of the 23 indicated Temazepam (Restoril®) they "Never see" these medications. Flurazepam (Dalmane®) Buspirone (Buspar®) Levodopa/carbidopa (Synemet®) provoked 10 of the Zolpidem (Ambien®) 23 examiners to mark "request a prescribing physicians note"; Eszopiclone (Lunesta®) 4 of 23 indicated they would "Never" qualify a commercial Trazodone (Desyrel®) Melatonin driver taking this medication; and 2 of 23 indicated that they "Usually/always" qualify a commercial driver who admits to using this medication. Survey Results (Sedatives and Hypnotics) Cardiac Medications and Drugs Lorazepam (Ativan®), clonazepam (Klonopin®), and diazepam for Heart Conditions (Valium®) have significantly different half-lives affecting the time impairment may potentially last after a dose is taken. These were deliberately placed side-by-side in the question- Dobutamine (Dobutrex®) naire to identify whether half-lives were a consideration in Amiodarone (Cordarone®) medical examiner decision making. Similarly, the hypnotic Digitalis medications, also of widely varying half-lives, were placed side-by-side to identify differences in examiner anticipated actions. Survey Results (Cardiac and Heart Medications) In the group surveyed, examiners indicated they would The medical examiners response to dobutamine (Dobutrex®) conditionally certify, and not automatically qualify or dis- indicated that this medication is not commonly observed. qualify, drivers who admitted taking these medications. Six of 23 medical examiners reported they "Never" see this This was consistent between both groups of examiners medication in commercial driver certification examinations. (Salt Lake City and Reno). The majority of the responses Sixteen medical examiners indicated they would conditionally indicated examiners instructing drivers not to drive within approve a driver if they were to submit a prescribing physi- 8 h of taking the medication (9 to 14 of 23). Fewer examiners cian note, provide a detailed medical history, and undergo would insist on a note from the driver's prescriber (4 to 7 of 23). objective testing. Only two medical providers indicated they Hypnotics zolpidem (Ambien®) and eszopiclone (Lunesta®) would "Never qualify" an individual who admitted to using had the most providers advising taking the medication at dobutamine. least 8 h before driving (14 of 23 for both); temazepam (Restoril®) the next highest (12 of 23); and, lorazepam (Ati- Three of 23 examiners indicated they would "Never" van®), clonazepam (Klonpin®), and diazepam (Valium®) and qualify a driver who admitted taking amidarone (Cordarone®); flurazepam (Dalmane®) had similar numbers of examiners 4 would require a detailed history in the clinic, 2 objective indicating they would qualify the driver if he/she took their testing, and 11 of 23 would require a note from the treating medication no sooner than 8 h before driving (9 to 10 of 23). physician. For digitalis, 17 of the 23 surveyed examiners indicated they Dopamine Agonists would conditionally approve drivers taking this medication, with 4 of 23 indicating "Usually/Always." A physician note (11 of 23), detailed medical history in the clinic (4 of 23), and Pramipexole (Mirapex®) Ropinirole (Requip®) requiring objective testing (2 of 23) were the conditions spec- LevodopaCarbidopa (Synemet®) ified for certification of drivers admitting taking digitalis. LevodopaCarbidopaEntacapone (Stalevo®) (deleted in 2nd questionnaire) Other Medications and Commercial Drivers Survey Results (Dopamine Agonists) Varenicline (Chantix®) Theophylline (deleted in 2nd questionnaire) The medical examiners were also asked about pramipexole Prochlorperazine (Compazine®) (Mirapex®) and ropinirole (Requip®). Twelve and 13 of the (deleted in 2nd questionnaire) 23 respondents indicated they would approve a driver pre- Diphenoxylate and atropine (Lomotil ®) senting for certification with either of these medications. A (deleted in 2nd questionnaire) prescribing physician's note, detailed history in clinic, and
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57 Survey Results (Other Medications) Interactions with Drivers' Employers (e.g., carriers) For varinicline (Chantix®), 8 of 23 medical examiners Q: Do you provide a list of prohibited drugs for indicated they would "Never" medically certify a driver of commercial drivers to employers? commercial vehicles who admitted taking this medication. ___ Yes ___ No Four of the 23 indicated conditional approval pending the If Yes, what is the source of the list? receipt of a detailed medical history, and one respondent, ________________________________________ "only if the driver took the medication no sooner than 8 h No medical examiners surveyed indicated that they provide prior to driving." There were significant regional differ- any list of medications to employers with whom they work. The ences, with 5 of 8 examiners in Reno indicating they would only published list of medications mentioned by the providers "Usually/Always" certify and only 1 of the 15 Salt Lake was that by Airline Owners and Pilots Association (AOPA). examiners indicating so. Q: Do employers require the "long form" medical examiners report? Educating Drivers About Medications ____ yes, most of the time _____ no, not usually The medical examiner survey participants were asked whether Percent of Medical Examiners Reporting or not they engaged the commercial drivers they were exam- Employers Require the DOT "Long Form" ining in discussions to "educate them" about medications or from them after Medical Examination of drugs of any kind, or even to discuss nutritional supplements Commercial Drivers and their possible effects on driving performance. Salt Lake Reno Combined Q: What "education or training" (guidance, infor- Long Form 10/15 2/8 12/23 mation pamphlets, etc.) do you usually give to Required commercial drivers regarding any medications? Long Form 5/15 6/8 11/23 Please answer the question above whether the driver Not Required admits to self-medicating, or regarding the drug pre- scriptions you are giving them as a part of treatment Summary of employers requiring DOT Long Form. you recommend or monitor with your patient? The "DOT Long Form" (Form 649-F-6045) containing a driver's personal medical history, physical examination, and __ None, __ "Driving caution" on prescription examiner's certification decision is required by employers in written for driver, some but not all geographic regions. Factors influencing this __ Other material: list below are not clear, and there was considerable variability within the two regions surveyed (Salt Lake City and Reno). Responses: Driver Education on Medications by Medical Q: What interactions do you usually have with Providers during the Commercial Driver drivers' employer over issues of prescribed Medical Evaluation medications for their drivers? Salt Lake Reno Combined Medical Examiners reporting Employer Communication on Driver's Specific Medication No Education 1/15 1/8 2/23 Driving Caution 9/15 4/8 13/23 Salt Lake Reno Combined Other 2/15 1/8 3/23 Employer 6/15 0/8 6/23 Verbatim responses (other material): "Verbal Interaction guidance," three examiners, one each: "Never use No Employer 9/15 8/8 17/23 sedating meds within 8 hours of driving"; "No Interaction driving on narcotics, sleeping meds"; and "Can't Responses: Salt Lake City--Verbatim responses use benzodiazepines within 8 hours of driving." given by medical examiners: "usually none, if concerned will call and talk to Conclusion on advice to drivers on safe medication use: employer about driving on meds" In this small survey, the education of commercial drivers "inform them if disqualified" about medications is most often limited to "Driving caution" "very limited" on prescriptions written by only some medical examiners who "hardly have any, but if [we] do, usually [it's] as part of their own medical practice are also providing medical about narcotics" care to commercial drivers (8 of 23). "Verbal guidance" is "phone call" given by very few providers regarding medication use (8 of 23). "usually I am justifying to the employer why Driver guidance appears to be limited to the restriction of I am concerned about a driver's meds and medication use to 8 h before working (driving). educating them on safety issues."
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58 Responses: Reno: Verbatim responses on specific information given None of medical examiners surveyed indicated by medical examiners included: that they interact with employers regarding "always require written release of information" specific medications. "driving safety issues, inform if not qualified, and reason" Summary of medical examiner interaction with "basic information: pass or no pass, if Personal employer on driver's prescribed medication. In this small Medical Doctor follow up required" survey, the medical examiners appeared to vary by region on "justify concerns regarding medications and whether they interacted with drivers' employers on specific safety--educate about general DOT policy" medications taken by their drivers (employees). Verbatim "without a release, I educate in general terms . . . ; responses indicated that medical examiner interaction with e.g., the DOT policy is . . . Common sedating drivers' employers is very limited, often only to justify rea- medications are . . . common side effects of sons for disqualification or providing information on a driver medicine x are . . ." related to his or her operating safety and often specifically "hardly ever" regarding narcotic medications. "reason why card not issued" "1 or 2 responses concerned elderly drivers, Percent of Medical Examiners Reporting Company only give out information that pertains to Official Interaction Regarding Specific Drivers driving safety" Salt Lake Reno Combined "if concerned, I will call and talk to employer about driving on medications . . . especially if Employer 9/15 1/8 10/23 concerned about circumventing not receiving Interaction card by going elsewhere for card" No Employer 5/15 7/8 12/23 Interaction Responses: Reno: No information was reported Q: Do you interact with company officials regarding given without a release form. specific patients (drivers)? ___ Yes ___No Summary of medical examiner release of information to driver's employer: After completing the driver's med- Verbatim responses given by medical examiners ical examination (CDME), regional variation on information included: release to employers was identified in the small group of "inform if not qualified, and give reasons" medical examiners surveyed. This was the case for both med- "pass or no pass" ication issues as well as examination issues. In Salt Lake "exam status (pass no pass, awaiting info)" City, 6 of the 15 medical examiners did report interacting "medical condition likely will not interfere with with the drivers' employers, whereas in Reno none of med- obtaining medical certification, or inform ical examiners reported interacting with employers. about outright rejection in general terms if personal" When verbatim responses were examined, it became "warn if going elsewhere for medical card" evident that the medical information reportedly given by 6 of "address driving safety issues, physician follow-up the 15 members of the Salt Lake group related to work fit- required" ness or issues regarding medications that the employer will "justify concerns regarding medications and likely learn from the Medical Review Officer (MRO) in drug safety--educate regarding general DOT testing notification under 49 CFR Part 40.21 (Provision for policy" "Stand Down"). "without releasing specific information; e.g., common sedating meds, common side effects Q: Do you provide a list of prohibited drugs for are." commercial drivers to employers? ___ Yes ___No Q: What information do you give without a written release of information? Responses: Salt Lake City and Reno ___None, __other, note below: No medical examiners indicated they provide a Responses: Salt Lake City drug list to employers for the purpose of determin- ing which medications are "safe" or "approved," Employer interactions: two medical examiners sur- although one mentioned the FAA list and the Airline veyed did not give employers information about Owners and Pilots Association (AOPA) pamphlets driver physicals without release of information. as general guidelines.