Substance Misuse Programs in Commercial Aviation Safety First (2023) / Chapter Skim
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3 Evidence-Based Practices for Identifying and Treating Substance Use Disorders
3 Evidence-Based Practices for Identifying and Treating Substance Use Disorders
Pages 47-84
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From page 47... ...
Lastly, given the lack of high-quality studies of treatment outcomes specifically among professionals in safety-sensitive industries, the chapter summarizes evidence-supported practices for treatment with special attention to applying the indirect, but still valuable, research findings for professionals in safety-sensitive occupations, including pilots and flight attendants. OVERVIEW OF SUBSTANCE USE DISORDERS Substance use is common in the United States across all demographic groups.
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From page 48... ...
. These traits are exacerbated when a person is entering treatment in response to a problem at work, at the requirement of their employer, or at the requirement of a professional monitoring organization (Vayr et al., 2019; Wooley et al., 2013)
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standard drink or one alcoholic drink equivalent. 8–10 fl oz of malt liquor or 3–4 fl oz of 2–3 fl oz of 1.5 fl oz shot of flavored malt fortified wine cordial, 1.5 fl oz of 12 fl oz of 5 fl oz of brandy or distilled spirits regular beer beverages such table wine (such as sherry liqueur, or (gin, rum, as hard seltzer or port; aperitif cognac (a single jigger)
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From page 50... ...
. As noted in Chapter 1, literature discussing substance use disorders among pilots and flight attendants suggests that they may experience rates of illness like those in the general population, though there is little validated data to directly support this.
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. Furthermore, findings from the National Transportation Safety Board (2020)
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From page 52... ...
Furthermore, it found similar treatment response rates and relapse rates in all these illnesses, all of which required behavioral change as a part of treatment adherence. In brief, this newer brain disease model recognizes that changes in the brain not only occur in response to acute exposure to alcohol and drugs but can also persist long after an individual stops regular use (Leshner, 1997)
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From page 53... ...
For example, the amount of alcohol consumed on an average day or the blood alcohol content (BAC) at a given time (e.g., DUI)
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. Pilots and flight attendants employed by larger airlines are more likely to have treatment costs covered regardless of received diagnoses.
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DISEASE PREVENTION Recognizing that addiction is a disease and not a moral failing, focus and investment can be made to strategically optimize outcomes and have the most impact. A disease prevention model highlights the different components to address the disease, including health promotion, prevention, treatment, and recovery (see Figure 3-2)
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From page 56... ...
Preventive Services Task Force recommends that primary care providers screen for anxiety, depression, alcohol use, and tobacco use in adults and offer brief behavioral interventions as indicated. Many people with substance use disorders do not seek treatment on their own due to a variety of reasons, including not believing that they need treatment, not being ready to engage in treatment, being unaware of treat ment options, not knowing how to access treatment that is available, the political climate, perceived stigma of what it means to need treatment, and other social and structural barriers that are themselves linked to risks for substance use, like the cost of care, low employment status, low household income, and inadequate (or lack of housing; U.S.
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The U.S. Preventive Services Task Force recommends that individuals with problematic levels of alcohol use be offered patient-centered advice about recommended limits and information on how alcohol use relates to other health conditions.
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, the individual being assessed, their identified family, their employer and/or professional support program, and treatment providers can be included in this process, both for obtaining collateral information and for executing the recommendations. It is best practice for treatment providers, whether at formal treatment centers or an individual provider, to do a thorough assessment of an individual seeking care.
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drug and alcohol program regulation, they are required to be evaluated by a Substance Abuse Professional (SAP)
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60 SUBSTANCE MISUSE PROGRAMS IN COMMERCIAL AVIATION FIGURE 3-3 Six dimensions of multidimensional assessment. SOURCE: Guyer et al., 2021.
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This responsibility is present both in the number of people safety sensitive professionals interact with and the depth of impact their impair ment can cause. Public trust is high for professionals in safety-sensitive occupations (e.g., law enforcement, healthcare providers, pilots, flight attendants, and other transportation roles, attorneys)
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From page 62... ...
The incorporation of psychological testing, particularly cognitive testing, provides an objective measure of functioning and impairment. If cognitive abilities have not been significantly impacted by a pilot's substance use, the pilot can be cleared to return to work after having attained sobriety, having addressed any co-occurring mental health concerns, and having demonstrated a program of recovery from illness.
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The landscape of addiction treatment is a continuum of care ranging from Early Intervention Services (Level 0.5) to Medically Managed Intensive Inpatient Services (Level 5; see Table 3-2 below from ASAM)
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Able to tolerate and use full active milieu or therapeutic community 3.7 Medically Monitored Intensive 24-hour nursing care with physician Inpatient Services availability for significant problems in Dimensions 1, 2, or 3; 16 hours/day of counselor availability 4 Medically Managed Intensive 24-hour nursing care and daily physician Inpatient Services care for severely unstable patients SOURCE: Data from https://www.asam.org/asam-criteria/about-the-asam-criteria complete abstinence or a reduction in use, not by a pre-prescribed length of a treatment program (e.g., 28- or 30-day residential program; Mee-Lee et al., 2013)
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. Further, ASAM expert consensus is that drug testing can be useful during and after treatment to improve treatment outcomes (Jarvis et al., 2017)
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It is difficult to make generalizations about the effectiveness of addiction treatment based on the literature, due to many challenges and variables: unique populations studied (e.g., people with alcohol use disorders vs. people with opioid use disorders)
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From page 67... ...
. At all levels of care, the consensus position of substance use treatment professionals is that treatment plans should include the option for MAT for people seeking abstinence from alcohol, opioids, or tobacco.6 Treatment providers and centers not offering this form of support are restricting 6 Although there is substantial evidence for medications to treat co-occurring psychiatric illness in people with substance use disorders and evidence that the treatment of co-occurring disorders improves addiction treatment outcomes, this report will not examine this important aspect of medication as the FAA has a separate program for mental illness-related medication (for more information, see https://www.faa.gov/ame_guide/app_process/exam_tech/item47/ amd/antidepressants)
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From page 68... ...
Methadone is an opioid receptor agonist medication and is a Schedule II drug under the Controlled Substances Act. Although methadone is often described as "controversial" and has been criticized and stigmatized as a treatment that "trades one addiction for another," there is good evidence that methadone improves a wide variety of outcomes related to opioid use disorder and that continued improvements are seen as duration of treatment with methadone lengthens (Castells et al., 2009; Connock et al.,
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. Methadone is considered an "essential" medication by the WHO, and its use within the United States has occurred almost exclusively in a system of federal and state licensed and regulated Opioid Treatment Programs (OTPs)
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. ONGOING HEALTH STATUS MONITORING AND TESTING While in treatment, toxicology testing is typically left to the discretion of the treating clinician, unless it is embedded in regulations associated with the treatment, such as in OTPs where methadone is dispensed, or when treatment is mandated by a criminal justice agreement.
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From page 71... ...
Outcomes for physicians in structured monitoring programs -- in which a positive test will reliably result in being removed from work -- are reported to be the best in addiction treatment. It is possible that toxicology monitoring with clear contingencies for positive tests is an important driver of these reported outcomes, but there is almost no research on whether toxicology testing, as opposed to other aspects of treatment, improves treatment outcomes (Jarvis et al., 2017)
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From page 72... ...
Residential treatment is often cited as contributing to good outcomes for professionals in safety-sensitive occupations, yet it is unclear from research whether this is as important as ongoing treatment, regular toxicology monitoring, engagement in a professional monitoring program, or the combination of these elements (Beauliu et al., 2021; McCarty et al., 2014)
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From page 73... ...
Other safety-sensitive professionals, including flight attendants, nurses, train engineers, law enforcement, and attorneys, typically engage in residential treatment as dictated by insurance coverage. Stigma and Fear of Job Loss The public often holds stigmatized views toward individuals with ental illness, and the intensity of these stigmatized views is greater for m substance use disorders than for other psychiatric disorders (Yang et al., 2017)
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These different categories of stigma intersect with other factors such as race, gender, socioeconomic status, age, professional identity, and sexual orientation, potentially contributing to challenges in seeking or obtaining treatment (Cheetham et al., 2022; see Box 3-3)
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study (N = 1,616) admitted to underreporting information to their AME about one or more conditions, some even acknowledging that their underreporting may have affected flight safety "some" or to a "high extent." The number of pilots underreporting was higher for commercial pilots (nearly 16%)
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From page 76... ...
For these pilots, the three most common identified drugs were hydrocodone, a sedating opioid used to treat severe pain; citalopram, an antidepressant; and diazepam, a sedating benzodiazepine used to treat severe anxiety and muscle spasms (National Transportation Safety Board, 2020) .10 While the FAA is clear in its stance on the use of impairing substances, a percentage of pilots are using them, obtaining prescriptions, and not reporting these to their AMEs and risking public safety (Strand et al., 2022)
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From page 77... ...
Fewer pilots in HIMS have opioid-related difficulties and opioid use disorders; however, the relapse rate to opioids in the HIMS program is higher than that for alcohol use disorders. These numbers, if they match national trends, may be on the rise, and the number of flight attendants with opioid-related difficulties and opioid use disorders may be higher than that of pilots.
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From page 78... ...
Providing the most powerful intervention for treating opioid use disorders would significantly decrease the rate of relapse and minimize the risk of overdose for pilots, flight attendants, and other professionals in safety-sensitive occupations. ROIs and Confidentiality ROIs facilitate communication among treatment providers, programs, collateral contacts, identified supports, and professional monitoring organizations.
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From page 79... ...
The dilemma is that, while ROIs can facilitate communication among providers and professional monitoring organizations, an ROI that requires the release of the full medical record may be a barrier to necessary disclosures in treatment and can infringe on pilots receiving the care they need to maintain public safety.
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Selecting a Treatment Program Professional monitoring organizations dictate which treatment programs are acceptable for care. Airline HIMS and FADAP identify which programs are acceptable for their pilots and flight attendants; however, the criteria used for selecting programs are unclear and options are not always provided.
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From page 81... ...
While psychological testing could be beneficial in making determinations for fitness for duty for all professionals in safety-sensitive occupations, flight attendants and other transportation professionals are not required to complete this type of assessment. Their LOS in treatment is also typically shorter and prohibitive of obtaining a true, current baseline understanding of cognitive functioning; sober time is needed to obtain this.
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From page 82... ...
Given how their work schedules are made, flight attendants can rarely participate in a gradual step-down through the continuum of care. Instead, they regularly go directly from one of the highest levels of addiction treatment back to a routine work environment with long and irregular hours, access to alcohol, and minimal oversight and accountability.
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From page 83... ...
. AA is often described as featuring "treatment" and "self-help." However, AA meetings are not led or guided by addiction treatment professionals, although on-site AA meetings are often embedded as part of treatment programs.
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From page 84... ...
. Nevertheless, the HIMS highly recommends AA for most of its participants.15 14 Birds of a Feather was formed in response to the need for meeting places for pilots and cockpit crewmembers related to recovery from alcoholism, and is not tied to any company, government institution, or treatment center.
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