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61 Employers in one of the two regions surveyed apparently conditions, if any. Examiners were also surveyed on what regularly demand the DOT "Long Form" (Form 649-F-6045) driver education on medication effects, alertness, and employer from medical examiners performing driver examinations. As communications they would normally provide to drivers they a result, in many clinics, before being examined commercial examine. Finally, medical examiner handling of the Medical drivers are required to sign an individual release form to Examination Report "DOT Long Form" (Form 649-F-6045) permit sharing medical information with their employer. It is was described with respect to employer distribution. unclear what impact this has on the veracity of the answers to the medical examiners' questions of the driver. The responses within the two groups surveyed, although not statistically representative of all CDMEs, showed that Some employers contract with third party administrators within those groups there was inconsistent decision making to review the commercial driver examinations and to help that did not always follow FMCSA rules and recommended them ensure compliance with federal rules, providing some guidelines. More consistent responses ("I would not issue oversight for the medical qualification process. A number of a certificate") were given with regard to driver use of the other employers permit the drivers to be certified by their drug methadone, which is specifically forbidden, than for primary care physicians, which allows for greater variability other drugs. However, despite the prohibition rule, 3 of the in meeting the medical certification standards than either of 15 CDMEs answered that they would issue a conditional cer- the two previously mentioned options, but better knowledge tification to a driver who admitted using methadone. Overall, of the drivers' underlying health history. This, as the survey of those who indicated they would issue CDME certificates respondents indicated, permits a driver to "doctor shop"; to to drivers on an opiate medication or amphetamine, only find a doctor who is friendly to the driver's particular needs 6 to 7 out of 23 medical examiners would require a prescribing to remain medically certified. physician's written statement as required by 391.41(b)(12); only two would require a prescriber note for Tramadol. Drivers Some of the synthesis survey respondents indicated (and admitting to the use of this medication were anticipated to be it has been the personal experience of co-author Leaman) that issued certificates by every provider questioned. there has been significant pressure from employers to pass drivers who may not be medically qualified. The request Antihistamines, neuroleptics, sedatives and hypnotics, to "do the minimum required" has prompted employers to stimulants, movement disorder medications, heart medica- switch providers of medical services until they identify one tions, and assorted other medications were included in the who "passes" the drivers, virtually regardless of their med- questionnaire, and these produced inconsistent responses by ical condition. The medical conditions for which medications providers regarding actions they anticipated they might take described in this report are prescribed have all been at issue. in qualifying or not qualifying drivers who admitted ingesting these classes of medications. Such inconsistencies were found Medical examiners do not have access to drug testing between the two regions surveyed and among providers in information performed under 49 CFR Part 40, which fre- both regions. quently identifies opiates or other substances that bear on driver safety and medical qualification. Further, some employers who Only 2 of the 23 examiners indicated that they gave any are contacted by MRO under provisions for "Stand Down" advice to commercial drivers on maintaining alertness or (49 CFR 40.4) become concerned when they are not contacted combating fatigue. Almost one-quarter of the surveyed by the medical examiner following an exam where the driver medical providers admitted they provided "no education" to may admit to opiate medication use [permitted with a pre- drivers on effects of medication on alertness. However, when scriber's written statement, under 391.41(b)(12)]. This is a they themselves had prescribed the drug to drivers for med- particularly acute problem following the discovery that a ical conditions they were treating, approximately one-half of mishap has taken place. survey participants anticipated cautioning those drivers about the effects of such medications. No medical examiner sur- veyed provided drivers' employers with a list of "prohibited" SUMMARY OF MEDICAL EXAMINER SURVEY medications. The survey was limited by the small number of participants Employers vary by region about whether they require the (n = 23) and the selected medication list. A convenience sample DOT Long Form (Form 649-F-6045), with the surveyed group survey of a small group of certifying medical examiners in of providers indicating that it was required almost half the two Western cities was done to illustrate medical examiner time. Medical providers similarly vary by region in terms of the decision making and actions regarding medications and alert- amount of communication they have with employers regarding ness education during the course of the examination (CDME). their specific driver employees. Most of the medical providers Twenty-three medical examiners were presented with a list who indicated that communication did occur stated in com- of 69 different medications. For each drug, they were asked ments that it was either very general on the topic of safety whether a driver might be medically certified to drive a com- concerns and work fitness or it was on issues the company mercial vehicle while taking the medication and under what would likely learn from the MRO under 49 CFR 40.21.