Medication Drug Use

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Medications/Drug Use:

Medications/Drug Use Susan Matthews Ph.D., APRN, FAANP

GOAL:

GOAL The goal of this module is to make the FMCSA certified medical examiner aware of medications and to assess the driver for signs and symptoms of adverse side effects and document examination findings and effect on fitness for duty in accordance with FMCSA physical qualification standards and policies

OBJECTIVE:

OBJECTIVE The objective of this module is to prepare the examiner to apply knowledge of medications and their side effects in the certification or disqualification of the CMV driver.

Identification and History:

Identify , query, and note issues in a driver’s medical record and/or health history as available, which may include: Substance use and abuse, for example: Alcohol. Illicit or legal drugs. Narcotics. Identification and History

Physical Examination and Evaluation :

Physical Examination and Evaluation Examine driver’s mental status and note: Comprehension and interaction Cognitive impairment, for example: Orientation Intellect Memory Obsessions Circumstantial/tangential Speech Signs of depression, paranoia, antagonism, or aggressiveness, which may require follow-up with a mental health professional.

Diagnostic Tests and/or Referrals :

Diagnostic Tests and/or Referrals Obtain additional information when indicated by: Blood analyses (e.g., electrolytes, toxicology, blood chemistries). Drug-level monitoring (e.g., digoxin, theophylline). Refer a driver who exhibits evidence of any of the following disorders for follow-up care and evaluation by an appropriate specialist or primary care provider: Mental/emotional health (e.g., depression, schizophrenia).

Health Education Counseling :

Advise the driver: Regarding side effects and interactions of medications and supplements (e.g., narcotics, anticoagulants, psychotropics ) including: Over-the-counter (OTC) medications (e.g., antihistamines, cold and cough medications), which could negatively affect his/her driving. Inform the driver of the rationale for delaying or potentially disqualifying certification, which may include: Health dysfunctions (e.g., depression, bipolar). Health Education Counseling

Risk Assessment :

Risk Assessment Consider such general health and wellness factors as: Adverse health effects associated with rotating work schedules and irregular sleep patterns. Long-term effects of fatigue associated with extended work hours without breaks. Risk factors associated with common dietary choices available to drivers. Stressors likely associated with extended time away from driver social support system.

Certification Outcomes and Intervals :

Certification Outcomes and Intervals Disqualify a driver who: Is currently taking methadone. Has a current clinical diagnosis of alcoholism. Uses a controlled substance, including a narcotic, an amphetamine, or another habit-forming drug, without a prescription from the treating physician. Disqualify a driver when evidence shows a condition exists that will likely interfere with safe operation of a CMV, which may include sufficient supporting opinions and information from specialists.

Three types of medications may be used by the commercial driver::

Three types of medications may be used by the commercial driver: Prescription Over the counter (OTC) Supplements and herbs

MEDICATIONS THAT ARE DISQUALIFYING:

MEDICATIONS THAT ARE DISQUALIFYING Methadone Medical Marijuana (Schedule 1) Insulin Anticonvulsants used to treat epilepsy Schedule 1 medications First generation antidepressants (amitriptyline)

Key Points for Medications Use Examination:oints for Medications Use Examination:

Key Points for Medications Use Examination: oints for Medications Use Examination Regulations — You must review and discuss with the driver any "yes" answers: Does the driver use medications to: Treat cardiovascular disease? Reduce hypertension? Control blood glucose level? Oral hypoglycemics? Insulin (regardless of route)? Control seizures or treat epilepsy? Treat nervous or psychiatric disorders?

Key Points for Medications Use Examination:for Medications U :

Key Points for Medications Use Examination: for Medications U Recommendations — Questions that you may ask include: Does the driver experience: Dizziness or light-headedness? Hypotension? Sedation? Depressed mood? Cognitive deficit? Decreased reflex responses? Unsteadiness?

Key Points for Medications Use Examination:for:

Key Points for Medications Use Examination: for Regulations — You must evaluate: On examination, does the medication have: The desired effect on the underlying disease (e.g., blood pressure is lowered)? Side effects that interfere with safe driving (e.g., uncontrollable tremor or orthostatic hypotension)?

Key Points for Medications Use Examination:for:

Important considerations for medication use while driving: Does the medication: Indicate the presence of underlying disqualifying disease or injury? Effectively treat the disease or medical condition? Exhibit side effects that interfere with safe driving? Have side effects that interfere with lifestyle functions such that the driver may cease to comply with treatment (e.g., decreased libido). Key Points for Medications Use Examination: for

Key Points for Medications Use Examination:for:

Important considerations for medication use while driving: Does the medication: Have potential for gradual or sudden incapacitation, or exacerbation of underlying medical condition, due to missed dose (e.g., seizure, psychosis)? Require monitoring to maintain a therapeutic dose or prevent toxicity (e.g., Coumadin)? Interact with other drugs, food, and/or alcohol, interfering with the ability to drive? Key Points for Medications Use Examination: for

Key Points for Medications Use Examination:for:

Important considerations for medication use while driving: Does the driver: Understand and comply with medication plan, including monitoring? Know what warning signs might indicate medication toxicity, interaction, etc.? Store medications properly when driving long haul or cross country? Key Points for Medications Use Examination: for

Key Points for Medications Use Examination:for:

Important considerations for medication use while driving: Does the driver: Read and understand warning labels on medications and supplements? Consult the treating healthcare professional and/or a pharmacist before using new medication or combining medications while driving. Key Points for Medications Use Examination: for

Key Points for Medications Use Examination:for:

Regulations — You must document discussion with the driver about: Any affirmative history, including: Onset date, diagnosis. Medication(s), dose, and frequency. Any current limitation(s). Key Points for Medications Use Examination: for

Key Points for Medications Use Examination:for:

You must document discussion with the driver about: Potential negative effects of medication use, including OTC medications, while driving. Any abnormal finding(s), noting: Effect on driver ability to operate a CMV safely. Necessary steps to correct the condition if appropriate, or reasons for disqualification. Any additional tests and evaluation. Key Points for Medications Use Examination: for

Medication Guidance Advisory Criteria:

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Anticoagulant Therapy 1 month stabilized 1 year Provides copy of INR At least monthly INR monitoring INR not monitored INR not in therapeutic range Medical condition disqualifying Underlying neurological condition Antidepressant Therapy None 1 year Medication has been shown to adequate/effective, safe and stable Uses first generation antidepressant Has side effects that interfere with safe operation of CMV

Medication Guidance Advisory Criteria:

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Anticonvulsant No Recommended time frame You should not certify the driver until the medication has been shown to be adequate/effective, safe, and stable. 2 years It is recommended that driver have annual medical exams. ME may obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Nature and severity of the underlying condition does not interfere with safe driving. The treatment does not endanger the health and safety of the driver and the public. The driver uses anticonvulsant medications to control or prevent seizures.

Medication Guidance Advisory Criteria:

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Antihistamine Min. The driver should abstain from medication 12 hours prior to operating a CMV. NOTE: Schedulers should relieve affected drivers from duty until proper treatment for the illness has been completed. 2 years The treatment does not endanger the health and safety of the driver and the public. Treatment interferes with driving ability.

Medication Guidance Advisory Criteria:

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Antipsychotic Therapy No recommended time frame You should not certify the driver until the medication has been shown to be adequate/effective, safe, and stable. 1 year ME may obtain additional tests and/or consultation to adequately assess driver medical fitness for duty. Nature and severity of the underlying condition does not interfere with safe driving. The treatment does not endanger the health and safety of the driver and the public. The driver has: Disqualifying underlying condition Treatment side effects that interfere with safe driving.

Medication Guidance Advisory Criteria:

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Anxiolytic and Sedative Hypnotic Therapy None 2 years or more frequently if indicated Hypnotic, If the medication is short-acting (half-life less than 5 hours) (e.g. Zolpidem) Using the lowest effective dose Used for short period of time (less than 2 weeks). Non-sedating anxiolytic (e.g. Buspirone) Using sedating anxiolytic Symptoms or side effects that interfere with safe operation of CMV

Medication Guidance Advisory Criteria :

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: CNS Stimulant Therapy Example: ADHD Medications; Modafinil None 1 year Non-disqualifying underlying condition No drug-induced impairment No tendency to increase dose Disqualifying medical condition (narcolepsy) Symptoms or side effects that interfere with safe operation of CMV

Medication Guidance Advisory Criteria :

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Incretin Mimetic No recommended time frame You should not certify the driver until the medication has been shown to be adequate/effective, safe, and stable. 1 year NOTE: The Federal Motor Carrier Safety Administration (FMCSA) recommends frequent monitoring determined on a case-by-case basis. The driver with diabetes mellitus who uses an incretin mimetic: Meets all the physical qualification standards. Has a treatment plan that manages the disease and does not: Include the use of insulin. Have side effects that interfere with safe driving. The nature and severity of the medical condition and/or the treatment of the driver endangers the safety and health of the driver and the public. NOTE: FMCSA recommends that a driver taking an incretin mimetic provide a written statement from the treating health care professional. The written statement should: Describe driver tolerance to the medication . Indicate how frequently the driver is monitored for adequate blood glucose control. Include efficacy of treatment.

Medication Guidance Advisory Criteria :

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Insulin Therapy Min. 1 month If the driver with diabetes mellitus was previously diagnosed and on treatment that did not include the use of insulin Min. 2 months, if the driver with diabetes mellitus is newly diagnosed and was not on prior treatment 1 year Annual Recertification: Driver should provide ME with current copy of Annual Diabetes Assessment Package. Grandfathered driver should provide a copy of the endocrinologist report. Meets all other physical qualification requirements of 49 CFR 391.41(b) except for use of insulin and: Has a Federal diabetes exemption or is eligible to apply for the exemption. Was a participant in good standing on March 31, 1996, in the Federal diabetes waiver study program and continues to meet all qualification requirements of 49 CFR 391.64(a). Driver has any other disqualifying condition other than use of insulin. In the last 12 months, had a severe hypoglycemic reaction resulting in: Seizure. Loss of consciousness. Need of assistance from another person. Period of impaired cognitive function that occurred without warning.

Medication Guidance Advisory Criteria :

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Insulin Therapy (continued) In the last 5 years, has had recurring (two or more) disqualifying severe hypoglycemic reactions (as described above). Loss of position sensation. Loss of pedal sensation. Resting tachycardia. Orthostatic hypotension. Diagnosis of: P eripheral neuropathy that interferes with safe driving. Proliferative retinopathy (e.g., unstable proliferative or non-proliferative

Medication Guidance Advisory Criteria :

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Lithium Therapy No recommended time frame You should not certify the driver until the medication has been shown to be adequate/effective, safe, and stable. 1 year ME may obtain additional tests and/or consult with a mental health specialist. The driver: Is asymptomatic. Has lithium levels that are maintained in the therapeutic range. Has no impairment that interferes with safe driving. The driver has: Disqualifying underlying condition. Disqualifying symptoms. Lithium levels that are not in the therapeutic range.

Medication Guidance Advisory Criteria :

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Narcotic Antitussive Therapy Min. The driver should abstain from medication 12 hours prior to operating a CMV. NOTE: Schedulers should relieve affected drivers from duty until proper treatment for the illness has been completed. 2 years The treatment does not endanger the health and safety of the driver and the public. Treatment interferes with driving ability.

Medication Guidance Advisory Criteria :

Medication Guidance Advisory Criteria Medication Minimum Waiting Period Before Certification Maximum Certification Period Consider Certification if: Do not certify if: Oral Hypoglycemics No recommended time frame You should not certify the driver until the medication has been shown to be adequate/effective, safe, and stable. 1 year Driver m eets all the physical qualification standards. Has a treatment plan that manages the disease and does not: Include the use of insulin. Have side effects that interfere with safe driving. The nature and severity of the medical condition and/or the treatment of the driver endangers the safety and health of the driver and the public.

REMEMBER:

REMEMBER Medical fitness for duty includes: The ability to perform strenuous labor Have good judgment, impulse control, and problem-solving skills. Overall requirements for commercial drivers as well as the specific requirements in the driver role job description should be deciding factors in the certification process.

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