Fitness for Duty Prescription/Over-the-Counter Medication Use and Medical Qualification

1. Fitness for Duty Prescription/Over-the-Counter Medication Use and Medical Qualification Robbie L. Sarles RLS & Associates, Inc. May 31, 2012

2. History • 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.

3. History • NTSB Satisfied by Responses, but: • Further research needed to establish nature of relationship between Rx/OTC medications and transit accidents.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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. Large Urban 64% Small Urban 32% Rural – 4%

14. Summary Of Responses

15. Summary Of Responses • Is it a standard practice for your system to ask about Rx/OTC information as a part of all Post-Accident investigations?

16. Summary Of Responses • 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.

17. Reported Rx/OTC Summary • 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)

18. 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

19. 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).

20. 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.

21. List of Reported Medications Bold = Name of Medication as Reported by the Transit System

22. List of Reported Medications

23. List of Reported Medications

24. List of Reported Medications

25. List of Reported Medications

26. List of Reported Medications

27. List of Reported Medications

28. List of Reported Medications

29. Indiana Medical Qualification Program

30. 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

31. 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

32. Indiana Medical Qualification Program, cont’d • Each Section 5311 system has entered into a contract with the selected vendor • Medical Assessments are underway

33. Indiana Medical Qualification Program, cont’d • 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

34. Indiana Medical Qualification Program, cont’d • 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

35. Indiana Medical Qualification Program, cont’d • 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

36. Indiana Medical Qualification Program, cont’d • Referral Reasons • Blood Pressure 46 • Vision 23 • Hearing 19 • Diabetes 11 • Sleep Apnea 9 • Physical Abilities 4 • Cardiovascular 2

37. Indiana Medical Qualification Program, cont’d • Other Assessments • The Return to Active Status employee was granted qualification • The Supervisor Observation Concern employee was deemed unqualified

38. Indiana Medical Qualification Program, cont’d • 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

39. Indiana Medical Qualification Program, cont’d • 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.

40. Indiana Medical Qualification Program, cont’d • The following slides contain a summary of the self reported Health Risk Assessment results from November 1, 2011 through January 20, 2011.

41. Assessment Participants

42. Participant Age Average Age: 57.43

43. Self Identified Risks Average # Risk Factors: 3.3

44. Self Health Rating

45. Top 8 Medical Conditions Reported

46. Top 8 Controllable Risk Factors

47. Participants’ Readiness for Change

48. Participant Health Visit History

49. Physician Visits Past 12 Months

50. Participant Hospital Admissions Past 12 Months