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68 located only a few reports of experimental studies on most of of the more widely advertised nutritional food items and to the chemical compounds identified as supplements in this incorporate that information in some "hand-out" literature on document. Although some scientists searching for the "ideal the whole category of supplements outlined in the literature stimulants" quickly discount the variety of supplements widely review in this synthesis. sold in truck stops and convenience stores, it is clear that commercial drivers are purchasing them. It appears incumbent on this community of researchers involved with commercial Functional Energy Drinks drivers to systematically examine the efficacy of many "supplements," and then to recommend protocols for their The active ingredients (caffeine plus others) in some functional safe use. Accordingly, any risks associated with using these energy drinks (FEDs) were found to impact (interrupt) some supplements, alone or in combination, or owing to concerns aspects of daytime sleep following a simulated night shift. about their source and their purity, should be identified and These researchers concluded that whereas FEDs may be the findings promulgated. effective "pepper-uppers" for a single night shift, additional investigatory research is warranted into the use of FEDs over successive night shifts; and also to investigate the effects Guarana of drinking multiple containers of FEDS on the same day-- that is, daily dose determinations. The commercial advertising Guarana (a caffeine-like substance) is showing up in many media has barraged the public with countless claims of the food and drink supplements, often in combination with other benefits of new energy drink products. The daily use of popu- ingredients, some of them also touted as being psychoactive larly sold energy drinks (e.g., Red BullTM, Monster HitmanTM substances (e.g., caffeine, taurine, and ginseng). Guarana's shots, and a dozen others containing psychoactive substances) caffeine-like ingredients, and its somewhat similar positive is quite widespread. The synthesis team suggests that some effects on cognitive performance to those of caffeine itself, good laboratory research on this category of supplements is suggest that guarana, alone or in combination with other sub- warranted to set the record straight regarding their effica- stances, should be investigated further. Additional research ciousness, or lack thereof, and, if possible, to delineate any on guarana is called for to identify its effects individually and recommended use protocols and identification of risks or synergistically with other psychoactive ingredients in food hazards in consuming such products. and drink supplements. Then educational materials could be developed to promulgate the findings in the commercial driver safety community. RESULTS AND DISCUSSION OF MEDICAL EXAMINERS SURVEYS Herbal Relaxants Since at least the 1970s, the use by commercial drivers of supplements, drugs, and prescribed medications has been Herbal remedies are promoted to relieve stress, and promote recognized as accident-associated features of transportation relaxation and sleep. Although a number of herbal relaxants crashes, without clearly identifying specific casual inference (e.g., passion flower, lavender, kava, valerian, ginseng, and (NTSB studies and reports). Medical providers and examiners St. John's Wart) are described in the literature review here are frequently faced with decisions to qualify (or not qualify) (see chapter five and Appendix C), not many qualifying sci- drivers who admit to taking medications and prescribed entific studies were found attesting to their efficaciousness, psychoactive chemical substances, many of which are not nor their potential effects on performance. A study to identify covered or not covered consistently in published guidance the increased use of such substances in the commercial driving from the FMCSA (Graziano et al. 2011). The convenience community could determine whether or not subsequent con- survey of medical examiners in this synthesis study gave trolled experiments of them are warranted. insights into some aspects of how they conduct their work in accomplishing Certification of Driver Medical Examinations (CDMEs). The survey highlighted some of their knowledge Nutritional Food Supplements base and the voids, in terms of dealing with chemical sub- stances in their exams of commercial drivers, and it portrayed Nutritional food supplements, amino acids, additional carbo- some differences in practice approach, part of which might be hydrates, antioxidants, multi-vitamins, and a myriad of others at least regionally based. Although the findings of the survey are described briefly in the literature review (see also Appen- of 23 medical examiners are outlined in detail in chapter six, dix C). At first glance, it does not appear that much addi- some of the more cogent points are reiterated here by way of tional research on these items is warranted, at least not by summary and conclusions. way of prioritization in comparison with the other supple- ments that should be investigated further, such as those listed Medical examiner variance. CDME examiners have in the previous paragraph. However, because drivers and their varying knowledge, attitudes, and beliefs leading to employers are inquisitive about what they see, hear, and read actions anticipated in certification decisions with about, it is important to describe what is known about some respect to drivers who admit to taking prescription,

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69 self-administered medications or drugs, and chemical more than three-quarters of respondents, based on detailed supplements. medical history or prescribing physician written statements Regional differences. There was significant regional vari- (or both). Drivers admitting use of dilantin, and particularly ation in responses (Salt Lake City, Utah, versus Reno, phenobarbital (typically used to prevent seizures or for neu- Nevada) that can possibly be attributed to the experience ropathy), were either never qualified or required a prescrib- and number of examinations performed by individual ing physicians written statements in the majority (but not all) examiners. respondents. Sedatives and hypnotics were also generally widely accepted, with the examiners offering advice to the drivers regarding not taking the medication within 8 h or more Medication Survey before driving. Of particular note were the longer-acting seda- tives clonazepam and trazodone (an antidepressant frequently Medical Examiner Response Inconsistencies used off-label as a hypnotic). Surveyed medical examiner responses to particular drugs and medications were inconsistent, and for one medication Other Medications (Methadone), inconsistent with published federal regulations. For example, in the synthesis survey 8 of 23 surveyed medical Movement disorder medications appeared on the survey list of examiners indicated they would issue a conditional certificate medications specifically owing to their use for Restless Legs to a commercial driver who admitted using methadone [for- Syndrome and product warnings for episodes of "sudden onset bidden under 391.41(b)(12)]. Tramadol, on the other hand, sleepiness" that have been reported to cause motor vehicle was acceptable to slightly more than half of the 23 surveyed accidents in private vehicles. There appeared to be little aware- CDMEs (with detailed history provided in the clinic). Tra- ness of these factors in that only 2 of 23 the examiners sur- madol was an accident associated factor (medication) in at least veyed answered "Never issue" and slightly less than half one NTSB investigated accident (A.J. Barberi, DCA04MM001, would issue a certificate conditioned on driving no sooner than Oct. 15, 2003). 8 h for drivers admitting use of pramipexole (Mirapex) or ropinirole (Requip). Drivers who admitted use of selected Response to Stimulants cardiac medications would generally be approved with addi- tional history or a prescriber's written note. Examiners sur- Commercial drivers admitting to the use of stimulants pro- veyed seldom marked "Never approved." One of the listed voked mixed and varied responses from medical examiners. medications, dobutamine, is primarily used in ambulatory More than half of the surveyed examiners (14 of the 23) treatment of severe congestive heart failure. NTSB identified anticipated providing medical certification to a driver who dobutamine as an accident-associated factor in one NTSB admitted taking amphetamine. This was most often condi- investigated crash. [NTSB HAR 01/01 (PB2001-96201)]. tioned on receiving a treating physician's written statement, but could also occur with only a detailed history in clinic (3 Similarly, when asked about anti-arrhythmic amiodarone, of 23). Examiners indicated that medical cards were gener- only 3 of 23 examiners answered that they would never issue ally issued for drivers admitting use of prescription stimu- a medical certificate, with the majority indicating that drivers lants (d-amphetamine, methylphenidate, and modafinil) with would be required to submit a prescriber's written statement. or without an accompanying written statement from the pre- Other medications with a propensity to cause sedation or scribing physician and additional medical history in the clinic. adverse drug reactions or interactions, as well as adverse psy- chological effects, were generally not uniformly handled with Antidepressants are usually approved for drivers who admit respect to certification decisions. This was particularly true to taking them, after obtaining a detailed history in the clinic-- regarding varenicline (Chantix), for which only 35% of sur- with the exception of lithium (used for bi-polar disorder), for veyed examiners answered they would "Never issue" a medical which a provider written statement would be required by more certification card, despite advisory information to that effect than half of the respondents. Responses from the majority of provided by the FMCSA, which had been posted on FMCSA's (but not all) examiners indicated that first-generation antihist- website in FAQ and in a statement from the administrator. amines are frequently (but not always) associated with instruc- tions given to drivers not to take them within 8 h of driving. Second-generation antihistamines had fewer such warnings Driver Education and Employer Interactions from the medical examiners. Convey little education. Surveyed medical examiners reported that they generally provided little education or Neuroleptics and Hypnotics guidance on safe medication use to commercial drivers or their employers in the context of their CDME process. The broad class of neuroleptic medications queried drew Principal employer communication. Interactions between mixed responses. Medications typically used for neuropathy medical examiner and drivers' employer, including verbal (gabapentin and pregabalin) were conditionally approved for and making the "Long Form" available to employers were