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FAA Articles and Case Studies | ALCOHOL
Recovering Alcoholic Airmen and
Medical Certification Standards
The Federal Air Surgeon's Column
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.
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 1998
Certification Issues Concerning Substance Abuse
Despite the potentially grave consequences of substance abuse in an
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.
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.
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.
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.
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.
1. Hurlbut, K.M. Drug-induced psychoses. Emergency Medicine Clinics of
North America. 9(1): 31-52, 1991 Feb.
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