Recovering Alcoholic Airmen and Medical Certification Standards
The Federal Air Surgeon’s Column
Editorial, by Jon L. Jordan, MD, JD
Almost 7% of the 344 general aviation pilot fatalities in 1994 were found at postmortem to have tissue levels of alcohol at 0.04% or higher. We in the Office of Aerospace Medicine are concerned that many of these fatalities may have been pilots who had known alcohol problems, but did not seek help for their problem because of the fear of losing their pilot privileges, either permanently or for a very long period of time. This is the same concern that we had several years ago regarding air carrier pilots: We frequently did not know that they were alcoholics until they had a withdrawal seizure at the controls of an aircraft.
Through an innovative and cooperative program established in the mid-70s with air carrier pilot groups and managers of air carrier companies, the Office of Aerospace Medicine played a key role in the establishment of a highly effective mechanism for the identification, rehabilitation, and return-to-duty of alcoholic airmen. This program, which includes a comprehensive evaluation and monitoring system, has permitted the Federal Aviation Administration to return thousands of air carrier pilots to airman duties shortly after initiation of rehabilitation. Currently, 851 airmen who have a history of alcoholism hold First-Class medical certificates. Most of these airmen are air carrier pilots. Without such a progressive approach to the certification of alcoholic air carrier pilots, it is likely that many of these airmen would never have been identified and could have been driven “underground” by an inflexible certification system. With our current system, however, these airman have been identified, properly treated, and returned to gainful employment without compromising the safety of the passengers that they carry or the other pilots with whom they share the skies.
Now, with twenty years of experience in the certification of alcoholic airmen, and in view of the excellent safety record that we have maintained, we are preparing to change the way that we certify private and other commercial pilots who have a history of alcoholism. Currently, the regulations call for two years of sustained total abstinence before certification can be considered. We are now shortening that required minimum period to one year, under the following conditions:
- favorable psychiatric and psychological testing,
- successful completion of an inpatient or intensive outpatient program with a documented commitment to abstinence,
- participation in an acceptable aftercare program consisting of individual and group counseling sessions for at least 12 months,
- establishment of a monitoring system that includes a physician with expertise in substance abuse disorders, and
- additional monitoring reports from employers, family physicians, or others, as well as alcohol testing when indicated.
We are hopeful that this plan for alcoholic general aviation pilots will stimulate early self- or peer-identification and rehabilitation. We view this change in policy as the first step toward establishing for private pilots a program similar to one that has been very successful for air carrier pilots.
The Federal Air Surgeon’s Medical Bulletin–Fall 1995
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FAA Program Probes Pilot Sobriety
By FAA Headquarters Intercom
In the decade since its start, the FAA’s DUI-DWI Investigations Program has significantly increased air safety in the United States by weeding out more than 3,000 pilots with drinking or drug problems.
The program, which marked its 10th anniversary in November, is little known outside of pilot circles.
Based at the Mike Monroney Aeronautical Center in Oklahoma City, Okla., the program’s purpose is to identify any pilot with a drug- or alcohol-related motor vehicle violation, take appropriate regulatory action, and turn that information over to the FAA’s Aeromedical Certification Division for monitoring.
In the last 10 years, more than 4 million names of pilots have been submitted to the National Driver Register, which keeps track of all motor violations recorded in the United States. The names of 100,000 pilots – mostly general aviation – have appeared on the register with drug- or alcohol-related motor vehicle violations and subsequently were investigated by the FAA.
More than 8,300 enforcement actions have been meted out, and some 3,000 pilots have lost their medical and airman certificates as a result of those investigations. That’s nearly one-third of all revocations issued by the agency.
The need for increased monitoring became evident in 1988 when the Department of Transportation’s Inspector General’s Office conducted an audit of pilots who had records for drug- or alcohol-related motor vehicle violations. To ensure compliance with a reporting requirement on the medical certificate application form and to ensure accuracy of FAA records, the FAA gave airmen who had falsified their applications a chance to avoid enforcement action if they volunteered the correct information by a specific date.
Thousands of pilots admitted to violating the regulations. Congress tasked the FAA to address the problem of pilots’ untruthfulness about their alcohol and drug abuse on applications for medical certificates. The agency began an education campaign to warn pilots that falsification of applications for airmen medical certificates would be caught, investigated and punished. Every week since the program began, the FAA sends the names of all pilots applying for medical certificates to the driver’s register. That’s about 400,000 names each year.
Mark Sweeney, manager of the Compliance and Enforcement Branch of the Civil Aviation Security Division, says the number of violations have decreased in the last three years.
“There used to be a widespread problem,” Sweeney said about falsified applications. “I think the word is out that the FAA is looking into this.” Sweeney added that airline transport pilots are the most compliant with the regulations. Only about one tenth of one percent of all pilots investigated by the FAA are airline transport pilots.
Identification of Alcoholism in a Medical Office Diagnostic Setting
The Federal Air Surgeon’s Medical Bulletin • Summer 2001 By Barton Pakull, MD
The diagnosis of alcoholism in an aviation medical examination setting, where the applicant has more than one reason to deny the existence of symptoms related to the condition, presents the examining physician with a difficult challenge. Questions about how much one drinks, the pattern of doing so, and the types of beverages consumed are usually answered in a misleading manner by alcoholics before they have been rehabilitated.
However, it is necessary to ask and record the answers if one suspects that a drinking problem exists. There may be no complaints offered by the applicant and very few physical signs or laboratory findings associated with an alcoholic condition. Often, an alcoholic presents a variety of medical problems that do not necessarily suggest that alcoholism is present. These medical problems can be either chronic or acute, but because they are not usually specific indicators, they are difficult to associate with alcoholism.
Definition
A practical working definition of alcoholism is that it is a condition where loss of control over the consumption of the substance (alcohol) is accompanied by various deleterious effects on physical health, as well as personal or social functioning. Personal and social functioning includes such diverse areas of life as legal and financial matters, marital and family adjustment, and personal productivity, including occupation and education. Most important, we would expect to see deleterious effects on safety, both personal and occupational. This includes skilled performance tasks, as well as normal social activities.
Manifestations of Physical Dependence
One of the most obvious symptoms of a developing alcoholism condition is tolerance. Alcohol is a sedative drug. If a person is still able to stand after having consumed an amount of alcohol that would have sedated a normal person, then that person has developed tolerance. While reports of the amounts a person may drink are often unreliable, certainly any including of a blood alcohol level greater than 0.2% at any time is indicative of the development of some tolerance. A blood alcohol level of 0.25% or above is very strong evidence of the tolerance associated with alcoholism.
The development of tolerance eventually leads to the development of signs and symptoms of withdrawal. Alcohol withdrawal signs often begin 4 to 6 hours after discontinuing ethanol intake. The most common sign of withdrawal is morning tremulousness. Associated with morning tremors is morning drinking, which simply means that the individual is treating withdrawal symptoms with another dose of a sedative drug. A frequent symptom associated with early withdrawal is insomnia. This is most often seen in depression so that sometimes the presence of an alcoholism problem is missed. Other early symptoms of withdrawal are irritability, restlessness, apprehension, and mild difficulties with concentration. A history of isolated grand mal convulsions strongly suggests alcohol withdrawal, especially when there are other symptoms of early withdrawal and a negative EEG after the seizure. ‘The development of a full withdrawal syndrome with disorientation, hallucinations, and a pronounced coarse tremor with a rapid pulse and diaphoresis is conclusive evidence of alcohol addiction.
Common Presenting Signs and Symptoms
The odor of alcohol on the breath of an applicant, especially if the examination is done in the morning, should lead the physician to question the examinee very closely about his or her drinking recently and in general. It may be appropriate to request that the applicant voluntarily submit to a blood alcohol test as a means of quantifying alcohol consumption. Any amount of alcohol in the system at the time of a routine physical examination should make the examiner suspect an alcoholism problem, especially if the examination was done in the morning.
Another very common symptom of alcoholism is the blackout. This occurs when the individual becomes intoxicated and, though seeming to be functioning normally, will be unable to remember all or part of what happened after a certain point. These are obviously frightening experiences. If a person can control his or her drinking, he or she would not allow more than one blackout to happen. Therefore, if a history of more than one blackout is given, an alcoholism problem should be suspected.
Legal and Social Problems
Alcoholics tend to have legal and social problems such as drunk driving (DUI), or public intoxication arrests, and fights while intoxicated. Even without other evidence of alcohol abuse, two DUIs within a short period of time (e.g., 4 years) or multiple DUIs over a long period of time are highly indicative of alcoholism. Alcoholics will also admit to losing or changing friends and to socially inappropriate and embarrassing behavior related to their drinking.
Emotional and Medical Problems
People with alcoholism have emotional difficulties and may therefore mask their alcoholism with symptoms/complaints of depression and anxiety. A common indicator of an alcoholism problem is the observation by others of a personality change when drinking. This usually means that the individual becomes irritable and harder to get along with when drinking, sometimes even being verbally or physically abusive. Alcoholics often point to stresses in their lives to explain their anxiety and depression. Careful scrutiny will often reveal that it is the consequences of their drinking that cause the so-called stresses in their lives.
It is important to get the pertinent records when any information about inpatient or outpatient treatment for so called emotional problems is revealed. This also includes such things as contact with therapists or social agencies related to marital problems. Although many people seek counseling for temporary adjustment problems that are unrelated to aviation safety issues, sometimes those records indicate the presence of alcohol abuse problems or reveal that there was treatment for alcoholism.
The medical symptoms and signs associated with alcoholism are many and varied. The most common gross pathology is damage to the liver. It should also be kept in mind that pancreatitis is a medical problem that may be secondary to, or complicated by, alcoholism. Any indication of liver damage which may be related to drinking, such as elevation of liver enzyme levels, even if temporary, is to be considered a primary sign of the adverse effect on physical health related to alcoholism. Elevated blood pressure is a common finding in heavy drinkers. Although common also in nondrinkers, it is noteworthy that when a heavy drinker stops drinking his or her blood pressure often comes down. Acute gastritis is commonly associated with the heavy drinking of alcoholism. Arrhythmias and other cardiac symptoms associated with alcoholic myopathy also occur. Alcohol is known to suppress bone marrow responses resulting in hematological problems. The most common sign of this is an increased mean corpuscular volume. Often, there will be a history of frequent injuries resulting from accidents that occur during intoxication. Therefore, any history of injuries should be carefully reviewed. It should not be forgotten that the tolerance associated with alcoholism leads to a cross tolerance with other sedatives so that we often find that individuals with an alcoholism problem require more anesthesia for surgery and more sedatives than a normal person in order to obtain a therapeutic effect
The Bottom Line
To determine that an alcoholism condition exists with respect to Federal Aviation Regulations, substantial documenting evidence must exist. However, in those cases where there is reason to believe that the applicant is excessively consuming alcohol, but a clear-cut diagnosis cannot be made, deferral of certification is appropriate.
Under these circumstances, the Federal Aviation Administration will gather such additional information as may be necessary to establish or disprove the diagnosis.
Dr. Barton Pakull is Chief Psychiatrist in the FAA Office of Aerospace Medicine in Washington, DC.
The Federal Air Surgeon’s Medical Bulletin • Summer 2001
The Federal Air Surgeon’s Medical Bulletin • Fall 1998
Certification Issues Concerning Substance Abuse
Despite the potentially grave consequences of substance abuse in an aviation
environment, a significant number of aviators display abusive behavior.
- Case Study, by Richard Villata, MD, MS
The use of mind-altering substances, both legal and illicit, is a pervasive problem that has resisted vigorous attempts to eliminate or control its impact upon society.
Concern about the effects on the health and welfare of the individual and the population as a whole are amplified in the aviation setting. Despite the potentially grave consequences of substance abuse in an aviation environment, a significant number of aviators display abusive behavior. While most of this activity occurs outside of the cockpit and the time preceding flight, many general aviation accidents involve alcohol and drugs.
With the institution of random drug testing for class I and II airmen in the corporate setting, there has come an increased awareness of this activity. Certification of airmen with a history of substance abuse is a particular problem in that the issues vary depending upon the substance and circumstances regarding its use. Due to the nature of these problems, the issuance of a medical certificate is deferred to the FAA by the AME under these circumstances. A positive drug or alcohol test is also deferred to the FAA for further action. In this situation, the issuance of a medical certificate requires the satisfactory completion of various tests, examinations, and evaluations to validate that the airman has remained drug free. Because substance abuse is a complex problem involving physiological, psychological, and social components, the process of certification can be long and difficult from the perspective of the airmen and the individuals responsible for the certification. The following cases have been selected as a means of identifying and discussing some of the issues concerning substance abuse amongst aviators.
Case 1
A 20 year old male with 10 hours of flight time was seen by an AME to obtain his medical certificate. The applicant indicated a history of substance abuse and explained on the application the he had “not used LSD in over 2 years and marijuana in the past few months.” He also stated that, “I plan on doing whatever necessary to enable myself to fly. If it means quitting drugs forever, so be it.” As a result, it was decided that it would be necessary for him to submit an evaluation from a substance abuse specialist.
The results of the psychiatric evaluation revealed that his first use of multiple substances began at age 15. This included alcohol and marijuana — approximately twice a week — as well as LSD. Between the ages of 15 and 17, he used LSD on 10 occasions because, “My escape route was drugs.” He admitted feeling depressed during high school and considering suicide He reported a history of blackouts in high school. His use of marijuana increased until he was using it every other day by the time he was in college. Alcohol was used mostly on weekends during high school for the purpose of intoxication; he considers his use of alcohol to be “social.” In sum, he denied having a problem with drug or alcohol abuse and denied the negative consequences of such use.
Further inquiry into his social and developmental history showed a problem with control of anger prior to age 12 and characterized his childhood as “rough.” He had received 7 speeding tickets, but none was alcohol- or drug-related. The remainder of his medical and psychiatric history was unremarkable, and his mental status exam was normal. A letter was submitted by his flight instructor attesting to the merits of the applicant.
Disposition: Denial of certificate until demonstration of sobriety for 2 years.
Case 2
The applicant is a 49 year old male with a history of alcohol, amphetamine, and cocaine abuse. He held a Class I certificate until 1990, when a drug test based on reasonable suspicion revealed the use of amphetamine. The airman stated that his brother-in-law had placed amphetamine in his blood pressure medication and notified his company that the airman was using drugs. He claimed that this was done to get even after they had some personal differences. Despite his assertion that he was not using drugs, his certificate was revoked and his employment was terminated after ten years of uneventful performance. He then entered a rehabilitation program with continued therapy through an aftercare program for a period of 6 months.
A psychiatric evaluation in 1992 revealed that the applicant had a normal childhood with no significant stressors or indications of future difficulties. The only significant risk factor for substance abuse was a history of alcoholism in some of the siblings of his parents, but there were no indications of psychiatric problems within the family. Alcohol use started at age 16, with a frequency of 2-3 times a week, and as many as 18 drinks at a time. His drinking decreased during college, increased sharply when he was in Vietnam, and then diminished to weekend drinking afterwards. He began to try cocaine in 1982, using it off and on for 3 years.
He was diagnosed with cardiomyopathy in 1988 and was told that he should stop drinking altogether. It was at this time thathe started to substitute prescription drugs for alcohol. He claims to have used over 23 different drugs including Darvocet, Vicodin, and morphine but stated that he did not think that he was addicted to those drugs at that time. Eventually, he did admit to being an alcoholic/addict and claims to have been sober since 1991.
He applied for a Class I Certificate in 1993, which was denied. He became more involved in AA and NA meetings, entered into another aftercare program, and continued to have yearly psychiatric evaluations. His application for certification was denied in early 1994, as it was felt that he was still not taking complete responsibility for his substance abuse.
A follow-up evaluation later that year indicated that he had made significant progress, and it was recommended that a medical certificate be issued. Due to some questions about the history of hypertension and cardiomyopathy, it was necessary for the applicant to submit further medical information concerning those conditions. An ECG and a Bruce protocol stress test were negative, so a Class I Certificate was issued in 1995.
Since then, he has remained drug- and alcohol-free and was certified again in 1997. He has been employed and hopes to regain a position with his former employer.
Disposition: Reissued Class I certificate in 1995 and 1997.
Case 3
A 50 year-old airman with a Class I certificate and no previous history of substance abuse tested positive for opiates in 1994. A back injury caused considerable lower back pain and his mother gave him some of his father’s pain pills — Tylenol #3. Apparently, he obtained some relief with the medication and was given several more to use at home. He used the medication on 2 other occasions during the week that he remained off duty. During this period, he was notified by his company to report for a drug test. The custody and control forms were completed and he instructed the agent to note on the form that he had taken a Tylenol #3. A urine sample was provided despite concerns by the applicant that there was no blue dye in the toilet water.
Upon his return to duty two weeks later, he was instructed to return for a second test because the chain of custody had been broken on the first test. The lab was again informed of the medication that had been taken. Shortly afterwards he received a call from his medical review officer (MRO) informing him that he the test was positive. The MRO stated that the airman should not have taken another person’s prescription, and he was removed from flight status. After being placed on administrative furlough, he contacted the drug program manager, the employee assistance program, and the human resources department. He was informed that there was nothing that they could do because the matter was between the applicant and the FAA. A copy of the anti-drug program procedures was requested but never received.
The FAA informed him that the drug test was invalid because the chain of custody had been broken and that he could not be re-tested on a random basis. Despite notifying everyone concerned, he was unable to resolve the situation.
The services of a clinical psychologist were obtained at personal expense so that he could be evaluated for substance abuse. The psychologist determined that, while the use of someone else’s prescription medication was irresponsible, the applicant did not have a substance abuse problem. This information was submitted to the FAA, along with letters from the applicant and his mother attesting to the chain of events. The employer was subsequently notified by the FAA, and it was recommended that any action taken with regard to the test be rescinded.
Disposition: No regulatory basis for the second test. Special Issuance of certificate.
Discussion
These cases illustrate some of difficulties concerning the certification of airman with a history of alcohol or other substance abuse. Use of psychoactive agents is a complex problem because it is hard to quantify the degree to which a problem may exist. Denial or minimization of substance use by an airman cannot be proved or disproved in many instances, unlike the more readily observable clinical parameters such as blood pressure readings. However, it is just as relevant; the potential implications are just as serious. Equally important, it is necessary to quantify the nature and degree of the alleged substance use/abuse. Obviously, there is quite a difference between an individual who has used a narcotic medication on a short-term basis for a legitimate medical problem versus someone who has abused amphetamines or LSD. The effects of psychoactive agents can be expressed long after the period of use, e.g., flashbacks. Alcohol, amphetamines, cannabinoids, cocaine, LSD, mescaline, and PCP can all cause flashbacks or psychosis, whereas the opiates generally do not (1). There has also been some evidence that heavy alcohol abuse, amphetamine, PCP, LSD, or ecstasy use can produce a psychosis similar to that seen in schizophrenia (2,3,4).
The addictive characteristics of various drugs do not equate with long-term psychiatric sequelae. An individual can be addicted to pain-killers for low-back pain for a lengthy period of time and not be at the same level of risk as someone who heavily abused amphetamines or LSD. Some drugs, such as ecstasy, are potent neurotoxins that can cause permanent brain damage. This is especially critical since some of these drugs are known to damage dopaminergic or serotonergic neural pathways that are vital to normal sleep, mood, memory, and cognitive functioning.
When an applicant discloses the use of a psychoactive agent, or it is discovered in the course of screening, it raises a host of issues: Sobriety, overall mental health, and long-term psychiatric stability must be addressed. Also, a stressful event can provoke a recurrence of symptoms, such as paranoid psychosis, in former amphetamine users (5). Therefore, it is necessary to closely monitor these individuals through ongoing psychiatric evaluations to verify their functional level.
Substance abuse in an aviation setting is not to be taken lightly; it is extremely important that the pilot’s cognitive functioning not be impaired. The use of psychoactive substances by aviators can have potentially serious consequences, as evidenced by the toxicological results of general aviation fatalities. In a noteworthy number of cases (approximately 10%), alcohol and/or controlled substances have been present in the blood and tissues of general aviation pilots.
Fortunately, the situation does not exist to this degree in a commercial aviation setting; however, that does not necessarily translate to off-duty time. As evidenced by the previous cases, substance use or abuse does exist among Class I and II airmen. Random drug testing continues to play an important role in the enforcement of a drug-free status for commercial pilots, but it does not help to identify airmen with alcohol abuse problems. In the case of Class III airmen, there is no comparable way of testing and enforcing a drug- and alcohol-free status other than through the AME or through a reportable incident. For the most part, the integrity of a drug/alcohol-free aviation environment relies largely on self-reported airman information. Consequently, it is important to stress the importance of maintaining a drug-free status and the use of common sense with regard to alcohol consumption.
References
1. Hurlbut, K.M. Drug-induced psychoses. Emergency Medicine Clinics of North America. 9(1): 31-52, 1991 Feb.
2. Steinpresis, R.E. The behavioral and neurochemical effects of Phencyclidine in humans and animals: Some implications for modeling psychosis. Behavioural Brain Research. 74(1-2): 45-55, 1996 Jan.
3. Ellison, G. Stimulant-induced Psychosis, the Dopamine theory of schizophrenia, and the habenula. Brain Research – Brain Research Reviews. 19(2): 223-39, 1994 May.
4. Simatov, R., and Tauber, M. The abused drug MDMA (Ecstasy) induces programmed death of human serotonergic cells. FASEB Journal. 11(2): 141-6, 1997 Feb.
5. Hamamura, T., Ichimaru, Y., and Fibiger, H.C. Amphetamine sensitization enhances regional C-Fos expression produced by conditioned fear. Neuroscience. 76(4): 1097- 103, 1997, Feb.
