Transcript MRO Safety Concern on DOT Drug Test

Medications and
Safety Concerns
Donna R. Smith, Ph.D.
Regulatory Affairs and Program Development Officer
FirstLab, Inc.
Photo Courtesy of the New Orleans Police Department
St. Petersburg, FL Sep 12, 2007
• Six people injured in PSTA bus crash when driver crashed
through trees & cars, and ended up inside a check cashing
business in St. Petersburg
• Police charged driver with felony DUI in October after
receiving his blood test results, which showed he had
Methadone, Alprazolam (Xanex) and Lorazepam in his
system.
• Driver was acting erratically prior to and after crash
according to witnesses
• Driver admitted taking medications to treat back pain
• Driver had passed all DOT drug tests
• Driver was terminated for failure to disclose medications to
PSTA as required by their policy
New Orleans Bus Accident
NTSB Report
• Probable cause
− Driver’s severe medical conditions
− Medical certification system’s inability to remove driver
from service
• Contributing factors
− Fatigue
− Use of sedating antihistamine
− Use of Marijuana
• Released to work by several treating physicians
Legal vs. Illegal Drugs
• NTSB, ONDCP, SAMHSA and other government
agency studies indicate that abuse and misuse of
prescription controlled substance medications is
more prevalent than “illicit” drug use.
• Dramatic increase in past decade in use of
medications for chronic pain, anxiety, sleep
disorders, & attention deficit disorders.
• Abuse and misuse of prescribed meds takes several
forms:
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Use for longer than medically indicated
Use in dosages higher than recommended
Use in combination with other drugs & OTC meds
Use when performing tasks that are contraindicated
DOT Drug Testing Limitations
• DOT drug testing is limited by OTETA to Schedule I
& II drug classes
• Most painkillers, anxiety drugs, sleep aids, etc. are
Schedule III, IV & V drugs
• Largest class of painkillers, synthetic opioids, are not
detected in DOT testing:
− Oxycodone, hydrocodone, hydromorphone, oxymorphone, methadone
• Benzodiazepines, barbiturates, and propoxyphene
are also not detected in DOT testing
• Urine drug test does not indicate impairment, nor can
it determine abuse or misuse of prescribed
medications
NTSB Directive to FTA
• Educate transit systems
- Potential safety risks of Rx and OTC
• Require notification of Rx/OTC use by safetysensitive employees
• Incorporate qualified medical personnel in Fitness
for Duty Assessment
• Train employees on roles and responsibilities
MRO Safety Concern on DOT Drug Test
• Issued by MRO when laboratory positive drug
test is due to use of a prescribed or medically
administered drug and MRO believes:
− Use of prescribed medication poses a significant
safety risk, or
− Medical condition for which medication is
prescribed may pose a significant safety risk
• Test result will be reported as “Negative” with
MRO comment of a safety concern
• Employee is informed by MRO that safety
concern is being reported to employer
MRO Notice to Donor
• MRO notifies donor that he/she can submit (within
5 days) documentation from prescribing physician
that demonstrates:
− Medication has been discontinued, or
− changed to one that does not cause concern
• If MRO receives such documentation, employer
will be notified that safety concern is removed
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Safety Concerns from Medical Review Officer Review
The medical review officer is required by 49CFR Part 40.327 to provide to third parties, drug test results and medical information affecting the performance of safety-sensitive duties which are obtained during the
verification process.
Employee
Social Security or ID
Date of Specimen Collection
Date of MRO determination
As a result of the MRO verification process, the MRO has determined that in addition to the drug test result there is a:
Safety Concern – Medication –Employee has reported the use of medication(s) that may pose significant safety risk or may make the employee medically unqualified for a safety-sensitive position.
In accordance with §40.135 (c) the employee has been notified that they have 5 days for the prescribing physician to contact the MRO to determine if the medication can be changed to one that does not make
the employee medically unqualified or does not pose a significant safety risk. Employer will be notified if this information is provided. If you do not receive an amended report, additional information that the
medication was discontinued or changed was not provided
Additional information obtained from the treating provider on
, that medication of concern has been discontinued or changed to one that does not present a safety concern
Additional information obtained from the treating provider on
, that medication of concern has been changed, but to one that also presents a safety concern
Safety Concern – Medical Condition – Employee has disclosed a medical condition that may have an adverse impact on the safe performance of safety-sensitive duties--Recommend evaluation by Occupational
Health professional
Safety Concern – Medical Condition – Employee has disclosed a medical condition that may result in the employee not meeting Federal medical standards - Recommend evaluation by Occupational Health
professional/Medical Examiner.
Medical Review Officer Name:
Medical Review Officer Signature:
Date:
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Employer Actions on MRO Safety Concern
• Options for resolving safety-concerns
− Have prescribing physician provide statement that
employee is able to perform safety-sensitive duties
while taking medications
− Have employee undergo “fitness for duty” evaluation
by employer designated physician
• Important for transit employer to have medication
policy and procedures in place
• MRO cannot make “fitness for duty”
recommendation based on donor interview and
urine drug test result
Medication Safety Issues
• Possible “impairing” effects
• Risks associated with medical conditions for
which meds are being used
• Interactions with other medications and OTC
products
• Compliance with recommended dosing
− Dosage amounts
− Timing of taking meds
• Therapeutic course; acute vs. chronic
• Employee lack of awareness of impairing effects
Medication Use
Side effects of concern
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Somnolence
Fatigue
Impaired judgment
Hypotension
Sedation
Erratic performance
• Impaired reflexes
• Dyskinesias and other
neurologic dysfunction
• Headaches
• Muscle weakness
• Visual disturbance
FTA Prescription and OTC Toolkit
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Policies
Procedures
Training Aid
Post-Accident Procedures
Several lists of Rx and OTC medications used by
various federal and private agencies
• References and Resources
• http://transit-safety.volpe.dot.gov/Publications
• http://transit-safety.volpe.dot.gov/safety/datesting/Presentations
Policy Options
• Responsibility is placed on the employees to report &
determine their own ability to safely perform their
duties while using medications
• Requiring authorization by medical practitioners that
employee can safety perform duties while using
prescribed medications
• Use of a list of medications to guide employees and
medical practitioners on which medication may or
may not be used, and those medications that must
be approved for use
• Evaluation of employee’s fitness for duty based on
prescribed medications by employer designated
physician
Policy Considerations
• Employees often under-report medications used
• Reporting medical information to supervisors may
place inappropriate level of responsibility and liability
on them
• Lists of acceptable and unacceptable medications
are difficult to keep updated and all inclusive
• Prescribing physicians are often unaware of
employee’s duties or unwilling to risk their patient’s
not being able to work
• If having employee’s physician authorize employee
working while taking prescribed meds, statement
must be specific and include understanding of
employee’s duties
Policy Considerations
• Use of DOT driver medical standards or equivalent
with biennial physical examinations
• Fitness for duty examinations by employer
designated physician
• Review of employee medication reports or personal
physician statements by employer designated
medical consultant
• Annual review of employee’s medications/medical
history
• Ongoing employee education and awareness efforts,
emphasizing new medications, medical facts, etc.
FMCSA Driver Medical Standards
• Specifically disqualifying medications
− Insulin – all forms, unless given exemption
− Seizure medication
− Methadone—increasingly being prescribed for
chronic pain
− Modafinil—stimulant used to increase
wakefulness, alertness
Rx & OTC Drugs and Performance
• Pain medicines – Codeine, Darvocet, Morphine, Vicodin, oxycontin
Drowsiness
Slower reaction times
Mental confusion
Anxiety
Agitation
Dizziness
Blurred vision
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Tranquilizers and Sedatives – Ativan, Diazepam, Xanax, Halcion,
Valium,
Drowsiness
Amnesia
Agitation
Dizziness
Weakness
Unsteadiness
Disorientation
Rx & OTC Drugs and Performance (Cont.)
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Muscle relaxers – Flereril, Parafon Forte,
Robaxin
Drowsiness
Fatigue
Nervousness
Confusion
Dizziness
Visual disturbances
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Anti-motion sickness – Antivert, Dramimine,
Phenergan
Drowsiness
Restlessness
Hallucinations
Blurred vision
Rx & OTC Drugs and Performance
• Antihistamines – Benadryl
Drowsiness
Slowed reactions
Impaired vision
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Stimulants – Sudafed, ephedrine, Aderall
Jitteriness
Diminished concentration
False sense of alertness
Irritability
Post-high fatigue
Current Issues
• Dramatic increase in use of controlled substance
medications to treat chronic pain, anxiety,
depression, attention deficit disorders, in US
population
• Hundreds of new drugs on the market every year that
have potential “impairing” effects
• Medication interactions are often unknown and not
monitored because people get multiple medications
from several physicians
• Aging population being prescribed more and more
drugs
• Painkillers, tranquillizers, sleep aides readily
available via the internet and “walk-in” clinics