Substance Misuse Programs in Commercial Aviation Safety First (2023) / Chapter Skim
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1 Introduction
1 Introduction
Pages 9-22
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From page 9... ...
The physical health effects can include sleep difficulties, liver disease, heart disease, cancer, 1 While not a universally adopted term, the committee chose to follow the precedent of the Department of Health and Human Services (HHS) , the Centers for Disease Control, and the Surgeon General in using "substance misuse" in this report to describe the broad spectrum of problematic substance use from a policy/regulatory perspective that might not rise to the diagnostic threshold of a substance use disorder.
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The Flight Attendant Drug and Alcohol Program (FADAP) was then initiated in 2010 to provide guidance and resources for flight attendants.
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The committee appointed to carry out the study was composed of experts with the range of skills and backgrounds necessary to assess the workings of programs such as FADAP and HIMS, including psychiatrists and psychologists who focus on the treatment of people with substance use disorders in safety-sensitive occupations, psychologists who regularly evaluate pilots participating in HIMS, evaluation specialists, professionals who oversee state regulation of safety-related professions involving the transportation industry, and health economists. 2 Concerns over the impact of substance misuse have been heightened by FAA investigations of civil aviation crashes that show a strong association of such events with evidence of sub stance misuse.
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From page 12... ...
CONTEXT Because of the high safety and security demands inherent in piloting, the FAA has instituted a multipronged approach to protect the public and the aviation workforce, recognizing that flying a commercial airliner engages all neurocognitive domains. A pilot operates a complex machine in an environment susceptible to rapid change affected by weather conditions, plane mechanics, geography, air traffic, time of day, and other human factors.
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From page 13... ...
Commercial airline pilots must also have a first-class airman medical certificate.4 The evaluations for these certificates are performed by aviation medical examiners. Part of this medical examination is a record of the pilot's behavioral health history, which includes any substance dependence or abuse as defined by the FAA.5 Key definitions and requirements for the first-class airman medical certificate include the following: • For the FAA, "substance" includes alcohol, other sedatives and hypnotics, anxiolytics, opioids, central nervous system stimulants such as cocaine and amphetamines, and other psychoactive drugs.
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From page 14... ...
It has evolved from a study into a professional monitoring program that seeks to coordinate the identification and treatment of pilots with substance use disorders as well as a return-to-work process for them, all under the FAA Special Issuance Regulations, and therefore carriers have strong incentives to rehabilitate pilots who develop a substance use problem, as opposed to simply firing and replacing them. BOX 1-2 HIMS Overview HIMS is described as "an occupational substance abuse treatment program, specific to pilots, that coordinates the identification, treat ment, and return-to-work process for affected aviators." It is an industry wide effort in which managers, pilots, healthcare professionals, and the FAA work together to preserve careers and enhance air safety.
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The services it offers are described on its website as follows, addressed to potential program participants: • 24/7 access to a flight attendant peer who understands and can talk with you about substance abuse -- whether it is a concern about a flying partner's use or your own; • referral to treatment programs that understand the culture of the flight attendant profession; • post-treatment support services to help you sustain your recovery while balancing work and home life; and • educational materials and conferences on substance abuse pre vention, intervention, and treatment. SOURCE: Data from https://www.fadap.org The mission of FADAP as published on its website is "to support a culture of safety which will be able to assist flight attendants in meeting their personal and professional goals through substance-abuse awareness, combined with self and peer referrals for assistance, and the implementation of a flight-attendant-specific recovery support system"6 (see Box 1-3)
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Given the time available to conduct the study, in contrast with the kind of in-depth study of the programs and profes sional contexts of each mode that would be required to make recommen dations about potential changes to practice and policy, the committee could not focus as much on other transportation industry programs.8 To further its understanding of HIMS and FADAP, the committee assembled information on the histories and the design of the programs, including their current structure and operating processes. The information gathered included available published reports on the programs, answers to the committee's questions about the programs from FAA officials, and dis cussions with parties that oversee and participate in the programs.
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Individuals who provided briefings and testimony to the committee and the topics covered, as well as the papers commissioned by the committee, are presented in Appendix B Because a central feature of both FADAP and HIMS is the facilitation of clinical interventions for substance use disorder misuse, the committee reviewed literature, including research on substancerelated problems among people employed in safety-sensitive occupations, on substance use disorders among flight attendants and pilots, and, as noted earlier, on evidence-based treatments.
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Without access to these data the committee cannot, for instance, resolve questions that arose during the study about the quality of HIMS 11 During a Zoom meeting on April 27, 2022, with National Academies staff, the HIMS program manager offered to share queries and results from the HIMS database; follow-up attempts to agree on a data-sharing agreement that had specific confidentiality protections did not receive a response from HIMS. Following multiple requests, ALPA's HIMS Advisory Board denied the committee's request for data from the FAA-funded HIMS database on November 3, 2022, asserting the aforementioned contract with the FAA and concerns over confidentiality and data disclosure that might erode program integrity.
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Comparing qualitative and quantitative data is required, because qualitative reports from successful participants in a program are typically based on self-selected respondents and therefore may not offer reliable indications of a program's efficacy. In pursuing its charge, the committee sought to address a series of issues related to the ability of the FAA, HIMS, and FADAP to identify cases of substance use disorders, their approach to addressing those conditions, the degree to which the approach conforms with contemporary clinical science, and how the programs perform in promoting safety and returning pilots and flight attendants to work.
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Other key institutions include EAPs run by unions and airlines, standard health insurance that covers and pays for treatment, mutual support groups such as A lcoholics Anonymous and SMART Recovery, and private financial resources. HIMS facilitates treatment for about 1.4 percent of all pilots (Skaggs & Norris, 2021)
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Thus, the committee sought to confirm that these assertions are grounded in evidence, but the combination of incomplete data and questions about data quality and departures from evidence in the literature precluded the committee from being able to fully form conclusions related to this part of its charge. ORGANIZATION OF THE REPORT Following this introduction, Chapter 2 provides the history and descriptions of HIMS and FADAP.
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