fitness for duty prescription/over-the-counter medication use and medical qualification robbie l....

Fitness for Duty

Prescription/Over-the-Counter Medication Use and

Medical Qualification

Robbie L. Sarles

RLS & Associates, Inc.

May 31, 2012

♦ 2002: National Transportation Safety Board (NTSB) challenge to all FTA grant recipients:○ Review Rx/OTC Policies.○ Educate operators of potential risks associated

with Rx/OTC use.♦ 2003: FTA Released Rx/OTC Medication

Toolkit:○ “State-Of-The-Practice” at that time.

History

♦ NTSB Satisfied by Responses, but:○ Further research needed to establish nature of

relationship between Rx/OTC medications and transit accidents.

History

♦ 2009: RLS & Associates, Inc. Conducted 2 Surveys:○ Gauge progress on Rx/OTC policies &

procedures.○ Inquire about accident investigation practices.○ Update the FTA Rx/OTC Medication Toolkit.

History

♦ Survey Respondents indicated:○ Rx/OTC policies in place, but were limited in

scope and rarely enforced.○ Most were not collecting Rx/OTC medication

information.○ If Rx/OTC medication information was

collected, little was done with it.○ No correlation between that information and

accident investigations.

History

♦ 2009 Rx/OTC Survey Recommendations:○ Standardize the collection and reporting of

Rx/OTC medication use.○ Conduct fitness-for-duty assessments.○ Expand TSI post-accident procedures to address

Rx/OTC.○ Educate transit systems.○ Educate physicians.

History

♦ 2011: RLS & Associates Convened Expert Panel to Review 2009 Survey Results.

♦ Recommendations from Expert Panel:○ Focus on safety and ensuring that safety-sensitive

employees are medically-qualified.○ Develop standard for retaining Rx/OTC medication

information.○ Educate safety-sensitive employees on meaning of

fitness-for-duty.○ Establish medical qualification standards for

industry.

History

♦ Recommendations from Expert Panel:○ Collect information before and after

implementation to enable cost/benefit evaluation.○ Study extent that Rx/OTC medication is a causal

or contributing factor in transit accidents.○ Research legal/liability issues of Rx/OTC policies

HIPAA ADA Labor Unions

History

Actions to Date

♦ Rx/OTC Toolkit issued April 2011

To download the FTA Rx/OTC Medication Toolkit,

go to:

http://transit-safety.fta.dot.gov/Publications

Click on Drug and Alcohol Program.

http://transit-safety.fta.dot.gov/Publications

Actions to Date

♦ Advisory Group reviewed Draft Rx/OTC Medication Study and Recommendations April 2011

♦ Final Study and Recommendations completed October 2011

♦ Follow-up Post Accident Questionnaire initiated December 2011

General Guidance Recommendations

♦ Encourage transit systems to test for additional substances under their own authority following accidents. ○ 10-panel or more.○ Expanded opiate testing.○ Expanded benzodiazepine testing.○ Methadone and other drugs should be considered.○ In addition to DOT 5-panel drug test.

♦ Incorporate Rx/OTC medications with common side effects that can impair driving into future Post Accident Testing Heuristics (PATH) studies

2011-2012 Post Accident Questionnaire

♦ 277 Total Systems Contacted for Initial Online Questionnaire: 4,196 Accidents○ These numbers were the total reported to NTD for 2010

♦ Of the 277 systems initially contacted:○ 79 Systems responded – 1,820 Accidents

♦ Of the 79 Respondents:○ 67 Systems collect Rx/OTC information – 1,692 Accidents

♦ Of the 67 Systems that collect Rx/OTC information:○ 50 Systems provided follow-up data on selected accidents-1,202 Accidents

376

Transit System Size

Summary Of Responses♦ Of the 1,202 possible accidents:

○ Data for 376 (~31%) out the total 1,202 accidents reported to NTD has been provided.

Small Urban32%

Small Urban32%

Large Urban64%

Large Urban64%

Rural – 4%Rural – 4%

Summary Of Responses

1%

2%

3%

93%

0 50 100 150 200 250 300 350 400

No Cause Documented

Mechanical

Human Error Plus Other Factors (weather)

Human Error

Number Of Accidents

Cause Of Accident?

♦ Is it a standard practice for your system to ask about Rx/OTC information as a part of all Post-Accident investigations?


♦ Were any Rx/OTC medications discovered as part of the Post-Accident Investigation?○ Yes – 4 Accidents (~8%)○ No – 45 Accidents (~92%)

♦ Were any Rx/OTC medications pre-disclosed, prior to the accident?○ Yes – 17 Systems (34%) / 55 Accidents (~14%)○ No – 33 Systems (66%) / 321 Accidents (~86%)○ 98 Unique Rx/OTC medications discovered from the 55 Accidents.


♦ Of 376 accidents studied○ 146 instances of medication use reported○ 96 unique medications

♦ 54 Medications (56%) with potential side effects that may impair driving○ Dizziness/lightheadedness (30)○ Drowsiness/fatigue (19)○ Impair Judgment (3)○ Cause anxiety/insomnia (2)

Reported Rx/OTC Summary

♦ 20% (28) were antihypertensive medications (commonly prescribed for high blood pressure)

♦ 40% were Rx pain relievers (12)

♦ Sedative/hypnotics (2)

♦ Muscle relaxers (6)

♦ One report of Chantix for smoking cessation

Reported Rx/OTC Summary

Trends & Other Information

♦ Most systems (85%) that responded to the questionnaire are collecting Rx/OTC medication information:○ Very few are integrating the Rx/OTC information with Post-

Accident investigations.○ After collecting Rx/OTC information from the employee, nothing is

done with that information.○ After an employee reports Rx/OTC medication use, systems do not

track how long the employee is expected to take the medication(s).

Trends & Other Information

♦ The most common response from systems when asked why they do not inquire about Rx/OTC information as a part of Post-Accident investigations was fear/uncertainty of violating HIPAA.

♦ Many systems only ask employees about Rx/OTC medication use as a part of initial physicals, annual physicals, and bi-annual physicals.

List of Reported MedicationsYELLOW = 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 (high blood pressure); control angina

dizziness; lightheadedness

12

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

Bold = Name of Medication as Reported by the Transit System

List of Reported Medications

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










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 Allergy symptoms 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 (high blood pressure); control angina

drowsiness; dizziness; blurred vision

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)


Indiana Medical Qualification Program

Overview

♦ In 2011, the Indiana DOT mandated a Medical Qualification (MQ) Program for all of its 45 Section 5311 Grantees. The MQ Program includes:○ A comprehensive MQ Policy○ Physical and Cognitive medical assessments for

all safety sensitive employees ○ Rx/OTC Medication Policy

Indiana Medical Qualification Program

♦ Indiana Council on Specialized Transportation (INCOST) conducted a procurement for a vendor to perform medical qualification assessments and other services under the oversight of a Medical Determination Officer

Indiana Medical Qualification Program, cont’d

♦ Each Section 5311 system has entered into a contract with the selected vendor

♦ Medical Assessments are underway


♦ Assessments Completed September 1, 2011 through January 20, 2012○ New Hires 93○ Annual 404○ Return to Active Status 1○ Supervisor Observation Concern 1○ Post Accident 0


♦ New Hire Results○ 89 granted one year qualification○ 2 were temporarily disqualified and referred for

additional testing that resulted in qualifying status

○ 2 were deemed unqualified


♦ Annual Assessment Results○ 337 granted one year qualification○ 19 granted three month qualification○ 1 granted six month qualification○ 114 were referred for additional testing ○ 44 of the 114 were temporarily disqualified,

however 35 of the 44 now meet MQ requirements

○ 3 were deemed unqualified


♦ Referral Reasons○ Blood Pressure 46○ Vision 23○ Hearing 19○ Diabetes 11○ Sleep Apnea 9○ Physical Abilities 4○ Cardiovascular 2


♦ Other Assessments○ The Return to Active Status employee was

granted qualification○ The Supervisor Observation Concern employee

was deemed unqualified


♦ Average number of prescription and over the counter medications reported ○ New Hires average number of medications =

1.78○ Qualified for one year employees average

number of medications =4.48○ Qualified for six months employees average

number of medications = 5.69○ Qualified for three months employees average

number of medications = 6.08


♦ The Indiana Medical Qualification Program Medical Assessment requires individuals to complete a Health Risk Assessment questionnaire. The results of the questionnaire are used as a tool for the Medical Determination Officer to evaluate the overall health of the individual and to provide the individual will wellness information if desired.


♦ The following slides contain a summary of the self reported Health Risk Assessment results from November 1, 2011 through January 20, 2011.

Assessment Participants

Average Age: 57.43

Participant Age

Average # Risk Factors: 3.3

Self Identified Risks

Self Health Rating

Top 8 Medical Conditions Reported

Top 8 Controllable Risk Factors

Participants’ Readiness for Change

Participant Health Visit History

Physician Visits Past 12 Months

Participant Hospital Admissions Past 12 Months

Participant TobaccoSubstance Abuse

Participant Substance Abuse Alcohol

Participant Medication Use as Relaxation Aid

Participant Satisfactionwith Life and Work

Participant Stress Level

Medical Determination Officer Comments

♦ The Medical Determination Officer identified several conditions that are cause for concern for safety sensitive transit employees. The conditions causing concern in no particular order are:○ Sleep Apnea○ Cardiovascular Disease○ Diabetes

Medical Determination Officer Comments, cont’d

○ Cerebrovascular Disease○ Hypertension○ Musculoskeletal Disorder○ Cognitive Decline○ Physical Agility Concerns○ Medication Issues○ Physician/Patient Relationship○ Wellness and Self Care Issues

Indiana Medical Qualification Before and After Survey Results

Indiana’s 5311 transit systems were asked to complete a survey to determine the impact of implementing the Medical Qualification (MQ) Program.

– The survey focused on safety-sensitive transit employees only. • The financial impact of implementing the MQ Program.• The impact implementing the MQ had on staffing and

employee time off from safety-sensitive functions.• Management perspective of safety-sensitive employee

wellness and safety.

Before and After Data

The survey captured data for the year prior to implementing the MQ Program (2010) and data the year the MQ Program was implemented (2011) to allow for implementation impact comparison.

Survey Participants

Indiana has 48 designees required to participate in the Indiana Medical Qualification Program. 42 designees had established MQ Programs at the time of the survey. The designees safety-sensitive staff range in size from 3 employees to 150 employees.

Survey participants staff ranged in size from 3 safety-sensitive employees to 150 safety-sensitive employees.

24 designees completed the survey representing 57% of designees with established MQ Programs.

fitness for duty prescription/over-the-counter medication use and medical qualification robbie l....

Documents

rxotc information

rxotc medication information

rxotc use

reported rxotc summary

unique rxotc medications

rxotc survey recommendations

fta rxotc medication

rxotc policies procedures