Substance Misuse Programs in Commercial Aviation Safety First (2023) / Chapter Skim
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2 Brief Descriptions of the Human Intervention and Motivational Study and the Flight Attendant Drug and Alcohol Program
2 Brief Descriptions of the Human Intervention and Motivational Study and the Flight Attendant Drug and Alcohol Program
Pages 23-46
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From page 23... ...
The discussion starts with the applicable regulatory principles governing the alcohol and substance use programs in aviation, followed by a general description of each program that includes the treatment service delivery process -- identification, referral, treatment provider selection and placement, and continuing care/recovery support services; return-to-duty procedure; program monitoring; and workplace outcomes measurement. REGULATORY CONTEXT: SUBSTANCE MISUSE PROGRAMS IN THE AVIATION SECTOR The regulatory principles that govern substance use programs in the aviation industry come from the FAA and the Department of Health and Human Services (HHS)
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From page 24... ...
for the DOT.6,7 Additionally, given the confidential nature of pilots' and flight attendants' participation in these programs, 42 CFR § 2.32, within the Substance Abuse and Mental Health Services Administration (SAMHSA) at HHS imposes restrictions on the disclosure and use of patient records for substance use disorder patients, which are maintained as part of any federally assisted program and establishes a 2 "Airman" is an FAA term and refers to pilots of all genders.
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From page 25... ...
Specifically, pilots flying for the aforementioned airlines are required to hold first class medical certification as defined by 14 CFR § 67. Section 67.107 addresses mental health, with 14 CFR § 67.107(a)
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From page 26... ...
while still capturing key elements of substance misuse. The DSM-5 criteria for a diagnosable substance use disorder require at least two of the following symptoms in a given year: • using more of a substance than planned, or using a substance for a longer interval than desired; • inability to cut down despite desire to do so; • spending substantial amount of the day obtaining, using, or recovering from substance use; • cravings or intense urges to use; • repeated usage that causes or contributes to an inability to meet important social or professional obligations; • persistent usage despite user's knowledge that it is causing frequent problems at work, school, or home; • giving up or cutting back on important social, professional, or leisure activities because of use; • usage in physically hazardous situations, or usage causing physical or mental harm; • persistent use despite the user's awareness that the substance is causing or at least worsening a physical or mental problem; • tolerance (needing to use increasing amounts of a substance to obtain its desired effects)
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From page 27... ...
The creation of HIMS allowed for pilots diagnosed with substance abuse and dependence to pursue treatment and to eventually make a return to the flightdeck, supplanting prior practice of pilots being dismissed. Because the medical certification of pilots is key to maintaining the safety of aircraft, passengers, and employees, HIMS is primarily framed as a safety program designed to ensure that the adverse effects of a pilot's substance misuse do not pose an undue risk (Snyder, 2022)
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From page 28... ...
Identification and Referral to the Program Pilots can enter HIMS in a variety of ways. Initial identification of whether a pilot meets the regulatory definition of substance abuse or dependence can be initiated by FAA request following a report of a substancerelated arrest, substance-related medical event, or other information that may suggest a substance-related issue (Snyder, 2022)
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From page 29... ...
Figure 2-2: HIMS Oversight Structure HIMS Advisory Board Federal Aviation Administration Funding and operational authorities via Decision making input contract with ALPA HIMS HQ Airline or union- Airline Employee sponsored HIMS Peer Assistance Coordination for individual Program (EAP) Program needing treatment FIGURE 2-2 HIMS oversight structure.
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From page 30... ...
The HIMS aftercare component typically coincides with the initiation of the aftercare level of treatment. In addition to the formal treatment noted above, it commonly includes meetings with peer pilot monitors, company representatives, and EAP staff, as well as engagement in mutual help programs such as 12-step programs, most commonly Alcoholics Anonymous (AA)
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From page 31... ...
Aspects of these cognitive abilities are also considered to be vulnerable to chronic substance misuse. Following completion of these assessments, the pilot is either referred for further treatment or cognitive rehabilitation activities or recommended for consideration for special issuance certification.
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From page 32... ...
HIMS Summary HIMS is a safety-oriented program designed to facilitate the identification, treatment, monitoring, and return-to-duty of pilots with substance abuse and dependence as defined by 14 CFR § 67. While the broad goals and FAA special issuance authorization standards are consistent, the program's implementation can vary between carriers.
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From page 33... ...
In addition to commonly known risk factors for developing substance use disorders, flight attendants also face challenges unique to their work environment that increase susceptibility to relapse and that can be triggering during recovery. Like pilots, flight attendants also face c hallenges including easy access to alcohol, difficult travel schedules, 15 HIMS staff response to the committee-issued questionnaire, August 2022.
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From page 34... ...
Mentoring peers are fellow flight attendants, many having gone through treatment themselves, and they are trained by FADAP's central office. FADAP also engages in primary prevention of substance misuse by making available educational materials, videos, and self-assessment screening tools, as well as by conducting educational seminars to key airline stakeholders on early identification and intervention for substance use disorders.
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From page 35... ...
FAA contracts with the Association of Flight Attendants (AFA-CWA) , a union representing about 50,000 flight attendants at 19 airlines, for administrative oversight of the program.21 The central FADAP staff comprises a manager, coordinator, and administrator, who are primarily responsible for program oversight, including the development and implementation of educational activities to increase substance misuse awareness among flight attendants and their families.22 The staff performs the following tasks: • develops an outreach plan for educating and recruiting flight atten dant volunteers as peers or workplace-based recovery mentors; • develops educational materials and conducts educational seminars, peer training, annual conferences, and other, similar activities; • maintains a FADAP database and website, used as the key infor mational resource for program awareness among flight attendants and their families; • identifies and maintains a list of approved treatment providers based on input from various sectors, FADAP staff site visits and evaluations of staffing credentials, and facility accreditations (FADAP staff provides a minimum half-day training for facility staff on FADAP, flight attendant culture, occupational demands, stressors, and required communication and paperwork)
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From page 36... ...
While there is no formal written agreement between the EAP and FADAP, they collaborate and, whenever possible, they comanage flight attendants referred for short-term substance use treatment. Airlines are not mandated by the FAA to establish a FADAP peer program, nor are they obligated to support the cost of FADAP operations.24 However, airline management may choose to extend support however they deem appropriate, such as coordinating travel for peers to attend FADAP training, paying for expenses associated with attending the program's seminars and conferences, allowing peers time off to attend its educational seminars, or offering FADAP training to flight attendant leaders and supervisors.
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From page 37... ...
. Peers undergo a one-day training given by FADAP staff on topics including: • nature and models of addiction; • successful interventions, which motivate the flight attendant to seek treatment; Figure 2-4: FADAP Oversight Structure FADAP Advisory Board Federal Aviation Administration Funding and operational authorities via Decision making input contract with AFA-CFW FADAP HQ Airline or union- Airline Employee sponsored FADAP Peer Assistance Coordination for individual Program (EAP)
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From page 38... ...
. Flight attendants may self-identify, or referrals may be received from colleagues, family members, flight attendant unions, EAPs, supervisors/managers, or others such as flight attendants involved in a ccident investigations, a failed drug test administered by the DOT, or disciplinary action due to substance misuse.
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From page 39... ...
Peer Interview Continuing Care Clinical Assessment Discharge Planning Treatment Placement FIGURE 2-5 Treatment service delivery process through FADAP. 39 SOURCE: Data from https://www.fadap.org/more-about-fadap and responses to the committee questionnaire to FADAP.
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From page 40... ...
FADAP supports an abstinence model for flight attendants returning to safety-sensitive duties. According to FADAP staff, based on a random survey they conducted among peer programs at various airlines, the ratio of residential treatment placements to nonresidential and peer support is 1:3.31 That means, for 28 FADAP's 2021 Annual Report was provided by FADAP to the committee for review but is not available for the public.
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From page 41... ...
At another airline, an automatic authorization for 28–30 residential days is provided to flight attendants placed by FADAP peers into health insurance-covered and FADAP-approved residential treatment programs. Per FADAP staff estimates, the allowable rate per day ranges from $600 to $900 in a residential facility, $450 to $650 in a partial hospital outpatient program, and $250 to $350 in an IOP.
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From page 42... ...
The recovery support services include, among others: • 12-step support, such as through Wings of Sobriety; • flight attendant family education classes and educational materials; • resource materials on flying and medication (available on the FADAP website) ; • wearing FADAP recovery pins; and • mentorship program for flight attendant in recovery.
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From page 43... ...
Some examples follow: • Process measures: -- primary treatment diagnosis for drug, alcohol, and mental health (using DSM-5-TR) ; -- level of satisfaction with FADAP peer program, using Likert scale questionnaire; -- level of satisfaction with treatment provider, using Likert scale questionnaire; -- treatment engagement, using Likert scale questionnaire (rated by both the treatment provider and the flight attendant)
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From page 44... ...
FADAP Summary While in-depth analysis is covered in Chapter Five, some general observations can be made about FADAP's model for treatment referral and recovery support as it offers a framework in which unpaid peers play an essential role in the flight attendant's decision to seek treatment, be engaged in treatment, and have a successful journey to recovery for a safe return to duty. However, a more proactive effort in secondary and tertiary prevention through early identification and intervention, rather than waiting until the flight attendant is "ready," may encourage more flight attendants to seek support and treatment earlier.
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From page 45... ...
Therefore, the database does not capture all of FADAP peer interactions with flight attendants. Flight attendants who received services through nonresidential treatment and peer support (e.g., intensive outpatient, outpatient, individual therapy, MHGs)
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