fitness for duty - ohio department of transportation...general guidance recommendations ♦...

FitnessforDuty

Prescription/Over‐the‐CounterMedicationUseand

MedicalQualification

RobbieL.SarlesRLS&Associates,Inc.

May31,2012

♦ 2002:NationalTransportationSafetyBoard(NTSB)challengetoallFTAgrantrecipients:○ ReviewRx/OTCPolicies.○ EducateoperatorsofpotentialrisksassociatedwithRx/OTCuse.

♦ 2003:FTAReleasedRx/OTCMedicationToolkit:○ “State‐Of‐The‐Practice”atthattime.

History

♦ NTSBSatisfiedbyResponses,but:○ FurtherresearchneededtoestablishnatureofrelationshipbetweenRx/OTCmedicationsandtransitaccidents.

History

♦ 2009:RLS&Associates,Inc.Conducted2Surveys:○ GaugeprogressonRx/OTCpolicies&procedures.

○ Inquireaboutaccidentinvestigationpractices.○ UpdatetheFTARx/OTCMedicationToolkit.

History

♦ SurveyRespondentsindicated:○ Rx/OTCpoliciesinplace,butwerelimitedinscopeandrarelyenforced.

○ MostwerenotcollectingRx/OTCmedicationinformation.

○ IfRx/OTCmedicationinformationwascollected,littlewasdonewithit.

○ Nocorrelationbetweenthatinformationandaccidentinvestigations.

History

♦ 2009Rx/OTCSurveyRecommendations:○ StandardizethecollectionandreportingofRx/OTCmedicationuse.

○ Conductfitness‐for‐dutyassessments.○ ExpandTSIpost‐accidentprocedurestoaddressRx/OTC.

○ Educatetransitsystems.○ Educatephysicians.

History

♦ 2011:RLS&AssociatesConvenedExpertPaneltoReview2009SurveyResults.

♦ RecommendationsfromExpertPanel:○ Focusonsafetyandensuringthatsafety‐sensitiveemployeesaremedically‐qualified.

○ DevelopstandardforretainingRx/OTCmedicationinformation.

○ Educatesafety‐sensitiveemployeesonmeaningoffitness‐for‐duty.

○ Establishmedicalqualificationstandardsforindustry.

History

♦ RecommendationsfromExpertPanel:○ Collectinformationbeforeandafterimplementationtoenablecost/benefitevaluation.

○ StudyextentthatRx/OTCmedicationisacausalorcontributingfactorintransitaccidents.

○ Researchlegal/liabilityissuesofRx/OTCpolicies HIPAA ADA LaborUnions

History

ActionstoDate

♦ Rx/OTCToolkitissuedApril2011

TodownloadtheFTARx/OTCMedicationToolkit,goto:

http://transit‐safety.fta.dot.gov/PublicationsClickonDrugandAlcoholProgram.

ActionstoDate

♦ AdvisoryGroupreviewedDraftRx/OTCMedicationStudyandRecommendationsApril2011

♦ FinalStudyandRecommendationscompletedOctober2011

♦ Follow‐upPostAccidentQuestionnaireinitiatedDecember2011

GeneralGuidanceRecommendations

♦ Encouragetransitsystemstotestforadditionalsubstancesundertheirownauthorityfollowingaccidents.○ 10‐panelormore.○ Expandedopiatetesting.○ Expandedbenzodiazepinetesting.○ Methadoneandotherdrugsshouldbeconsidered.○ InadditiontoDOT5‐paneldrugtest.

♦ IncorporateRx/OTCmedicationswithcommonsideeffectsthatcanimpairdrivingintofuturePostAccidentTestingHeuristics(PATH)studies

2011‐2012PostAccidentQuestionnaire

♦ 277TotalSystemsContactedforInitialOnlineQuestionnaire:4,196Accidents○ ThesenumberswerethetotalreportedtoNTDfor2010

♦ Ofthe277systemsinitiallycontacted:○ 79Systemsresponded– 1,820Accidents

♦ Ofthe79Respondents:○ 67SystemscollectRx/OTCinformation– 1,692Accidents

♦ Ofthe67SystemsthatcollectRx/OTCinformation:○ 50Systemsprovidedfollow‐updataonselectedaccidents‐1,202Accidents

376

TransitSystemSize

SummaryOfResponses♦ Ofthe1,202possibleaccidents:

○ Datafor376(~31%)outthetotal1,202accidentsreportedtoNTDhasbeenprovided.

SmallUrban32%

LargeUrban64%

Rural– 4%

SummaryOfResponses

1%

2%

3%

93%

0 50 100 150 200 250 300 350 400

NoCauseDocumented

Mechanical

HumanErrorPlusOtherFactors(weather)

HumanError

NumberOfAccidents

CauseOfAccident?

♦ IsitastandardpracticeforyoursystemtoaskaboutRx/OTCinformationasapartofallPost‐Accidentinvestigations?

SummaryOfResponses

♦ WereanyRx/OTCmedicationsdiscoveredaspartofthePost‐AccidentInvestigation?○ Yes– 4Accidents(~8%)○ No– 45Accidents(~92%)

♦ WereanyRx/OTCmedicationspre‐disclosed, priortotheaccident?○ Yes– 17Systems(34%)/55Accidents(~14%)○ No– 33Systems(66%)/321Accidents(~86%)○ 98UniqueRx/OTCmedicationsdiscoveredfromthe55Accidents.

SummaryOfResponses

♦ Of376accidentsstudied○ 146instancesofmedicationusereported○ 96uniquemedications

♦ 54Medications(56%)withpotentialsideeffectsthatmayimpairdriving○ Dizziness/lightheadedness(30)○ Drowsiness/fatigue(19)○ ImpairJudgment(3)○ Causeanxiety/insomnia(2)

ReportedRx/OTCSummary

♦ 20%(28)wereantihypertensivemedications(commonlyprescribedforhighbloodpressure)

♦ 40%wereRxpainrelievers(12)

♦ Sedative/hypnotics(2)

♦ Musclerelaxers(6)

♦ OnereportofChantixforsmokingcessation

ReportedRx/OTCSummary

Trends&OtherInformation

♦ Mostsystems(85%)thatrespondedtothequestionnairearecollectingRx/OTCmedicationinformation:○ VeryfewareintegratingtheRx/OTCinformationwithPost‐Accidentinvestigations.

○ AftercollectingRx/OTCinformationfromtheemployee,nothingisdonewiththatinformation.

○ AfteranemployeereportsRx/OTCmedicationuse,systemsdonottrackhowlongtheemployeeisexpectedtotakethemedication(s).

Trends&OtherInformation

♦ ThemostcommonresponsefromsystemswhenaskedwhytheydonotinquireaboutRx/OTCinformationasapartofPost‐Accidentinvestigationswasfear/uncertaintyofviolatingHIPAA.

♦ ManysystemsonlyaskemployeesaboutRx/OTCmedicationuseasapartofinitialphysicals,annualphysicals,andbi‐annualphysicals.

ListofReportedMedicationsYELLOW = Medication Also Cited in October, 2011 Report.

Medications ReportedTrade Name

Medications ReportedGeneric name

Medication Type Rx or OTC

Common Indications Common Side Effects Which May Impair Driving

1

Accupril – (1) quinapril antihypertensive Rx hypertension (high blood pressure)

dizziness, lightheadedness

2

Advair – (1) fluticasone/salmeterol bronchodilator/steroid Rx asthma; COPD dizziness

3

Advil – (2) ibuprofen pain reliever OTC pain reliever n/a

4

Aleve – (2) naprosyn pain reliever OTC pain reliever n/a

5

Zyloprim Allopurinol - (2) treatment of gout Rx gout n/a

6

Ambien – (1) zolpidem sedative/hypnotic Rx Insomnia drowsiness, fatigue

7

Norvasc Amilodipine – (3) antihypertensive Rx hypertension (high blood pressure), control angina


8

Lotrel amlodipine/benazepril – (1) antihypertensive Rx hypertension dizziness, lightheadedness

9

Amoxil – (1) amoxicillin antibiotic Rx antibiotic n/a

10

ASA - (3) aspirin pain reliever OTC pain reliever n/a

11

Tenormin Atenolol – (1) antihypertensive Rx hypertension(highbloodpressure);controlangina

dizziness;lightheadedness

12

Avandamet – (1) rosiglitazone/metformin antidiabetic Rx hyperglycemia lightheadedness; hypoglycemia

Bold = Name of Medication as Reported by the Transit System

ListofReportedMedications

13

Avapro – (1) irbrsartan antihypertensive Rx hypertension (high blood pressure)

dizziness;lightheadedness

14

Benadryl – (1) diphenhydramine antihistamine; sedative/hypnotic

OTC allergies; insomnia drowsiness; fatigue

15

Lotensin benazepril – (1) antihypertensive Rx hypertension (high blood pressure)


16

BuSpar buspirone – (1) antianxiety Rx antianxiety drowsiness; dizziness

17

Celebrex – (2) celcoxib pain reliever, nonsteroidal anti-inflammatory

Rx pain reliever, nonsteroidal anti-inflammatory

n/a

18

Chantix – (1) varenicline smoking cessation Rx smoking cessation fatigue

19

Claritin – (1) loratadine antihistamine OTC antihistamine n/a

20

Klonopin clonazepam – (1) antianxiety Rx antianxiety drowsiness

21

n/a colchicine – (2) treatment of gout Rx gout n/a

22

Coreg – (1) carvedilol antihypertensive Rx hypertension (high blood pressure)

dizziness, fatigue

23

Coumadin – (1) warfarin anticoagulant Rx prevent blood clots n/a

24

Crestor – (1) rosuvastatin antihyperlipidemic Rx lowers cholesterol n/a

25

Detrol – (1) tolterodine anticholinergic Rx incontinence dizziness

26

Lanoxin digoxin – (1) congestive heart failure Rx congestive heart failure n/a

Medications ReportedTrade Name




ListofReportedMedicationsMedications ReportedTrade Name




27

Diovan – (3) valsartan antihypertensive Rx hypertension (high blood pressure)

dizziness, fatigue

28

Dispositron – (1) unable to identify unable to identify unable to identify unable to identify

29

Sinequan doxepin – (1) antidepressant; antianxiety Rx depression, anxiety drowsiness

30

(drocode) dihydrocodeine – (1)

pain reliever, moderate to severe

Rx pain reliever, moderate to severe

drowsiness

31

venlafaxine Effexor – (1) antidepressant Rx depression dizziness

32

Vasotec enalapril – (1) antihypertensive Rx hypertension (high blood pressure)

dizziness, fatigue

33

Plendil felodipine – (1) antihypertensive Rx hypertension (high blood pressure)

dizziness, fatigue

34

Propecia; Proscar finasteride – (1) androgen hormone inhibitor Rx enlarged prostate; male pattern hair loss

dizziness; hypotension

35

Flexeril – (3) cyclobenzaprine skeletal muscle relaxant Rx muscle spasm drowsiness; fatigue

36

Flonase – (1) fluticasone steroid Rx intranasal steroid n/a

37

Flovent – (1) fluticasone steroid Rx asthma n/a

38

Glucotrol glipizide – (1) antidiabetic Rx hyperglycemia(Diabetes) lightheadedness;hypoglycemia

39

n/a glucosamine – (1) OTC nutritional supplement OTC OTC nutritional supplement n/a





40

estradiol Gynodiol – (1) estrogen Rx estrogen replacement n/a

41

Hydrodiuril hydrochlorothiazide – (5) antihypertensive Rx hypertension (high blood pressure)


42

Vicodin; Lortab; Lorcet hydrocodone with acetaminophen – (1)



drowsiness

43

Motrin; Aleve ibuprofen – (3) pain reliever Rx or OTC

pain reliever n/a

44

dutasteride/tamsulosin Jalyn – (1) hormone Rx prostate enlargement n/a

45

Lasix – (1) furosemide diuretic Rx hypertension (high blood pressure)

n/a

46

Levemir – (1) insulin antidiabetic Rx hyperglycemia lightheadedness; hypoglycemia

47

Synthroid levothyroxine – (1) hypothyroidism Rx hypothyroidism n/a

48

Lexapro – (1) escitalopram selective serotonin reuptake inhibitor (SSRI)

Rx antidepressant impair judgment, thinking, or motor skills

49

Lidex – (1) fluocinonide topical steroid Rx topical steroid n/a

50

Lipitor – (1) Atorvastatin antihyperlipidemic Rx lower cholesterol n/a

51

Prinivil lisinopril – (7) antihypertensive Rx hypertension (high blood pressure)


52

Claritin loratadine – (1) antihistamine OTC Allergysymptoms n/a





53

Lortab – (2) hydrocodone with acetaminophen



drowsiness

54

Lotrel – (2) amlodipine/benazepril antihypertensive Rx hypertension (high blood pressure)


55

Lyrica – (1) pregabalin anticonvulsant Rx pain reliever, neuropathic dizziness

56

Medrol – (1) methylprednisolone steroid Rx inflammation n/a

57

Glucophage metformin – (3) antidiabetic Rx hyperglycemia lightheadedness, hypoglycemia

58

Lopressor metoprolol – (1) antihypertensive Rx hypertension (high blood pressure)


59

Motrin – (5) Ibuprofen pain reliever Rx pain reliever n/a

60

Naprosyn – (2) Naproxen – (2) Pain reliever Rx pain reliever n/a

61

Nifediac – (1) nifedipine antihypertensive Rx hypertension (high blood pressure)


62

n/a nitroglycerin – (1) vasodilator Rx treat angina dizziness

63

Norvasc – (1) amilodipine antihypertensive Rx hypertension (high blood pressure), control angina


64

n/a omega-3 fatty acids – (1) nutritional supplement OTC nutritional supplement. n/a

65

Prilosec – (3) omeprazole – (2) gastroesophageal reflux disease (GERD)

Rx or OTC

gastroesophageal reflux disease (GERD)

n/a





66

Paxil – (1) paroxetine selective serotonin reuptake inhibitor (SSRI)


67

n/a pectin – (1) OTC nutritional supplement OTC OTC nutritional supplement n/a

68

Percocet – (2) oxycodone with acetaminophen



drowsiness

69

Plavix – (2) clopidogrel antiplatelet Rx stroke prevention n/a

70

Prevacid – (2) lansoprazole gastroesophageal reflux disease (GERD)

Rx or OTC

gastroesophageal reflux disease (GERD)

n/a

71

Proventil – (1) albuterol bronchodilator Rx bronchodilator nervousness

72

Provigil – (1) modafinil stimulant Rx narcolepsy anxiety, insomnia

73

Accupril quinapril – (1) antihypertensive Rx hypertension (high blood pressure)


74

Zantac ranitidine – (1) gastroesophageal reflux disease (GERD)

Rx gastroesophageal reflux disease (GERD)

n/a

75

Rhinocort – (1) budesonide steroids Rx Allergy symptoms n/a

76

Zocor simvastatin – (3) antihyperlipidemic Rx Lower cholesterol n/a

77

Januvia sitagliptin – (1) antidiabetic Rx hyperglycemia lightheadedness; hypoglycemia

78

Soma – (1) carisoprodol muscle relaxant Rx muscle relaxant drowsiness





79

Synthroid – (1) levothyroxine hypothyroidism Rx hypothyroidism n/a

80

Restoril temazepam – (1) sedative/hypnotic Rx Insomnia drowsiness, fatigue

81

Synthroid (levo)thyroxine – (1) Thyroid Hormone Rx Hypothyroidism n/a

82

Zanaflex tizanidine – (1) skeletal muscle relaxant Rx muscle spasm dizziness

83

Toprol – (1) metoprolol antihypertensive Rx hypertension(highbloodpressure);controlangina

drowsiness;dizziness;blurredvision

84

Ultram tramadol – (1) pain reliever, moderate to severe


drowsiness

85

Oeptro trazodone – (3) Antidepressant Rx depressant drowsiness

86

Tylenol with Codeine #3 – (2) acetaminophen with codeine #3



drowsiness

87

Unidentified diabetic medication – (1)

unable to identify unable to identify unable to identify unable to identify

88

Unidentified high blood pressure medication – (1)

unable to identify unable to identify unable to identify unable to identify

89

Viagra – (1) sildenafil erectile dysfunction Rx erectile dysfunction n/a

90

Vicodin – (3) hydrocodone with acetaminophen



drowsiness

91

Victoza – (1) liraglutide antidiabetic Rx hyperglycemia lightheadedness; hypoglycemia





92

Wellbutrin – (2) bupropion antidepressant Rx antidepressant agitation, anxiety, insomnia

93

Xanax – (2) alprazolam benzodiazepine Rx antianxiety drowsiness, dizziness

94

Zantac – (1) ranitidine gastroesophageal reflux disease (GERD)


n/a

95

Zegerid – (1) omeprazole gastroesophageal reflux disease (GERD)


n/a

96

Zoloft – (1) sertraline selective serotonin reuptake inhibitor (SSRI)


IndianaMedicalQualificationProgram

Overview

♦ In2011,theIndianaDOTmandatedaMedicalQualification(MQ)Programforallofits45Section5311Grantees.TheMQProgramincludes:○ AcomprehensiveMQPolicy○ PhysicalandCognitivemedicalassessmentsforallsafetysensitiveemployees

○ Rx/OTCMedicationPolicy

IndianaMedicalQualificationProgram

♦ IndianaCouncilonSpecializedTransportation(INCOST)conductedaprocurementforavendortoperformmedicalqualificationassessmentsandotherservicesundertheoversightofaMedicalDeterminationOfficer

IndianaMedicalQualificationProgram,cont’d

♦ EachSection5311systemhasenteredintoacontractwiththeselectedvendor

♦ MedicalAssessmentsareunderway


♦ AssessmentsCompletedSeptember1,2011throughJanuary20,2012○ NewHires 93○ Annual 404○ ReturntoActiveStatus 1○ SupervisorObservationConcern 1○ PostAccident 0


♦ NewHireResults○ 89grantedoneyearqualification○ 2weretemporarilydisqualifiedandreferredforadditionaltestingthatresultedinqualifyingstatus

○ 2weredeemedunqualified


♦ AnnualAssessmentResults○ 337grantedoneyearqualification○ 19grantedthreemonthqualification○ 1grantedsixmonthqualification○ 114werereferredforadditionaltesting○ 44ofthe114weretemporarilydisqualified,however35ofthe44nowmeetMQrequirements

○ 3weredeemedunqualified


♦ ReferralReasons○ BloodPressure 46○ Vision 23○ Hearing 19○ Diabetes 11○ SleepApnea 9○ PhysicalAbilities 4○ Cardiovascular 2


♦ OtherAssessments○ TheReturntoActiveStatusemployeewasgrantedqualification

○ TheSupervisorObservationConcernemployeewasdeemedunqualified


♦ Averagenumberofprescriptionandoverthecountermedicationsreported○ NewHiresaveragenumberofmedications=1.78

○ Qualifiedforoneyearemployeesaveragenumberofmedications=4.48

○ Qualifiedforsixmonthsemployeesaveragenumberofmedications=5.69

○ Qualifiedforthreemonthsemployeesaveragenumberofmedications=6.08


♦ TheIndianaMedicalQualificationProgramMedicalAssessmentrequiresindividualstocompleteaHealthRiskAssessmentquestionnaire.TheresultsofthequestionnaireareusedasatoolfortheMedicalDeterminationOfficertoevaluatetheoverallhealthoftheindividualandtoprovidetheindividualwillwellnessinformationifdesired.


♦ ThefollowingslidescontainasummaryoftheselfreportedHealthRiskAssessmentresultsfromNovember1,2011throughJanuary20,2011.

AssessmentParticipants

AverageAge:57.43

ParticipantAge

Average#RiskFactors:3.3

SelfIdentifiedRisks

SelfHealthRating

Top8MedicalConditionsReported

Top8ControllableRiskFactors

Participants’ReadinessforChange

ParticipantHealthVisitHistory

PhysicianVisitsPast12Months

ParticipantHospitalAdmissionsPast12Months

ParticipantTobaccoSubstanceAbuse

ParticipantSubstanceAbuseAlcohol

ParticipantMedicationUseasRelaxationAid

ParticipantSatisfactionwithLifeandWork

ParticipantStressLevel

MedicalDeterminationOfficerComments

♦ TheMedicalDeterminationOfficeridentifiedseveralconditionsthatarecauseforconcernforsafetysensitivetransitemployees.Theconditionscausingconcerninnoparticularorderare:○ SleepApnea○ CardiovascularDisease○ Diabetes

MedicalDeterminationOfficerComments,cont’d

○ CerebrovascularDisease○ Hypertension○ MusculoskeletalDisorder○ CognitiveDecline○ PhysicalAgilityConcerns○ MedicationIssues○ Physician/PatientRelationship○ WellnessandSelfCareIssues

IndianaMedicalQualificationBeforeandAfterSurveyResults

Indiana’s5311transitsystemswereaskedtocompleteasurveytodeterminetheimpactofimplementingtheMedicalQualification(MQ)Program.

– Thesurveyfocusedonsafety‐sensitivetransitemployeesonly.• ThefinancialimpactofimplementingtheMQProgram.• TheimpactimplementingtheMQhadonstaffingandemployeetimeofffromsafety‐sensitivefunctions.

• Managementperspectiveofsafety‐sensitiveemployeewellnessandsafety.

BeforeandAfterData

ThesurveycaptureddatafortheyearpriortoimplementingtheMQProgram(2010)anddatatheyeartheMQProgramwasimplemented(2011)toallowforimplementationimpactcomparison.

SurveyParticipantsIndianahas48designeesrequiredtoparticipateintheIndianaMedicalQualificationProgram. 42designeeshadestablishedMQProgramsatthetimeofthesurvey.

Thedesigneessafety‐sensitivestaffrangeinsizefrom3employeesto150employees. Surveyparticipantsstaffrangedinsizefrom3safety‐sensitiveemployeesto150safety‐sensitiveemployees.

24designeescompletedthesurveyrepresenting57%ofdesigneeswithestablishedMQPrograms.

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