PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS

1. PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS 4TH Annual FTA Drug and Alcohol Program National Conference Nashville, TN Presented by: Robbie L. Sarles

2. FTA Disclaimer • The information contained in this presentation does not constitute Federal Regulations. Sound medical knowledge and understanding of the pharmacological properties of the prescription and over-the-counter medications, and detailed knowledge of an employee’s medical history and safety-sensitive job duties must guide the final assessment of potential risks to the public.

3. Purpose of the Rx/OTC Presentation The Purpose IS: • Safety • Technical Assistance The Purpose is NOT: • Drug and Alcohol Testing • Regulation • A list of Approved/Not Approved Medications

4. History and Background The Challenge from FTA: • Following a NTSB directive, the FTA issued a challenge to all FTA grant recipients to: • Review policies related to employees’ use of Rx/OTC medications that could potentially compromise public safety; and • Educate transit operators about the risks associated with the use of prescription and over-the-counter medications

5. History and Background The FTA Prescription and Over-the-Counter Toolkit (issued in 2003): • Designed to help educate transit systems about the potential safety risks associated with Rx/OTC medications use by transit system employees • Contained policies, procedures, training aids, and post-accident procedures

6. Current Status An FTA assessment of the status of Rx/OTC medications policies and procedures implemented by its recipients. It includes: • Extensive data gathering and analysis process; and • National evaluation of policies, procedures, and post-accident investigations utilized by FTA recipients.

7. Definitions Prescription drugs (Rx) are medications which require written authorization for use by a healthcare professional whose license permits them to prescribe medication. • The prescription must include the patient’s name, name of the substance, quantity/amount to be dispensed, instructions on frequency and method of administration, refills, and date.

8. Common Types of Rx Medications Antidepressants and Psychoactive Medication • Relieves depression and other psychological conditions Antihistamines • Reduce allergy and cold symptoms – also treat insomnia Anti-inflammatory/Pain Medication • Relieves pain

9. Common Types of Rx Medications Motion Sickness Medication • Relieves motion sickness Muscle Relaxants • Relieves sore tight muscles Steroids • Controls bodily functions

10. Common Types of Rx Medications Stimulants • Causes user to be more alert Tranquilizers and Sedatives • Relieves anxiety, stress, and insomnia

11. Common Types of Rx Medications Anti-inflammatory/Pain Medication • Relieves pain Antidepressants and Psychoactive Medication • Relieves depression and other psychological conditions Antihistamines • Reduce allergy and cold symptoms – also treat insomnia

12. Definitions Over-the-Counter (OTC) medications are any legal, non-prescription substance taken for relief of discomforting symptoms. • May include capsules, powders, tablets, or liquids.

13. Common Types of OTC Medications • Pain relief/fever reducer • Colds/Flu medication • Appetite suppressants • Bowel preparations • Sleeping aids • Stimulants

14. Cause for Concern • Some side effects of Rx and OTC medications can be a safety issue when taken by safety-sensitive employees. • Side effects can Include: Agitation Dizziness Anxiety Disorientation Blurred vision Double vision Breathing difficulty Drowsiness Chest pain Emotional instability Chest tightness False sense of well being Confusion Fatigue

15. Current FTA Assessment Strategies A three step approach was used to gather data: Step 1: Conduct a Data Search • National Transit Database (NTD) • Definitions • Accident Classifications • National Transit Safety Board • Accident Causal Factors – Information about health factors was limited to toxicology reports, employee interviews, and medical records.

16. Current FTA Assessment Strategies • FMCSA Truck Causation Study • National, Multi-Year Study • Mandated by Motor Carrier Safety Improvement Act of 1999 (MCSIA) • Conclusions • 967 Crashes were studied. Top 4 factors were driver related, not vehicle related (1. Rx drug use; 2. Traveling too fast; 3. Unfamiliar with road; 4. OTC drug use)

17. Assessment Strategies, Cont’d • Step 2: Transit System Surveys • Surveys were posted on FTA website • Survey 1: Post Accident http://transit-safety.volpe.dot.gov/survey1 • Survey 2: Rx/OTC Policies http://transit-safety.volpe.dot.gov/survey2. • Step 3: Transit System Interviews • One-on-One Interviews

18. Survey Implementation Announcements and Testing: • Surveys were tested in January 2009 • Feedback from your peers • Invitations to participate in Winter 2009 • Notice of the surveys were published in the FTA Winter 2009 Newsletter • Transit DAPMs were invited through State DOTs or directly contacted through the FTA

19. Survey Participation • 329 Systems Completed At Least One of the Surveys • 20 of the 50 Largest transit systems (FTA-covered employees) responded

20. Survey Analysis:Policies and Procedures Prescription and Over-the-Counter Medication Policies and Procedures • 186 Completed Surveys

21. Policies and Procedures

22. Rx/OTC Medication Transit Policies 63% - Part of our organization’s Substance Abuse Policy. 27% - Do not have an Rx/OTC Policy. 8% - Stand alone policy. 2% - Covered under another entity’s policy.

23. Rx/OTC Medications as Part of Substance Abuse Policy “While the use of legally prescribed drugs and non-prescription medications are not prohibited, employees must understand they have a responsibility to notify their supervisor if they are taking any medication which indicates that mental functioning, motor skills, or judgment may be adversely effected.”

24. Rx/OTC Medications as Part of Substance Abuse Policy “It is encouraged that you make sure your physician is fully aware of your medical history and any other drug you are currently taking. Read warning labels and take medications exactly as prescribed.”

25. Rx/OTC Medications as Part of Substance Abuse Policy “Employees should consult with their physician or pharmacist regarding over the counter medication and check the alcohol content of medications.”

26. Rx/OTC Medications as Part of Substance Abuse Policy “Employees are not prohibited from the appropriate use of lawfully-prescribed drugs or non-prescription over-the-counter (OTC) medications. However, the use or consumption of any substance, including prescription and non-prescription medication, which carries a warning label indicating that mental functioning, motor skills, or judgment may be adversely affected must be reported, in advance of such use or consumption, to the Policy Administrator.”

27. Rx/OTC Medications as Part of Substance Abuse Policy “Use of a controlled substance in accordance with the instructions of a physician will only be considered when the employee's physician has supplied a written statement ....advising that the substance does not reasonably, affect the employees ability to safely operate a service vehicle. If ..... the employees performance may be affected or compromised by the use of the prescribed medication, the employee will be considered unfit for duty and the Medical Authority will advise the employee and the employee's supervisor that he/she is temporarily medically disqualified.” Provided by: Triangle Transit, NC

28. Rx/OTC Medications as Part of Substance Abuse Policy “Safety-sensitive employees who fail to report their use of prescription and over the counter medication and subsequently have a positive drug or alcohol screen are subject to discipline, up to and including discharge. It is imperative that employees inform their physicians and/or pharmacists of their employment requirements regarding fitness for duty prior to obtaining medication.” Provided by: Triangle Transit, NC

29. Stand Alone Policy “...Policy is the responsibility of TriMet’s Occupational Health Physician in conjunction with all managers and supervisors...” Prohibited behaviors:.... Provided by TriMet, Portland, OR

30. Stand Alone Policy-Brochure Medications of Concern if used while Performing SS work.

31. Stand Alone Policy-Brochure

32. Rx/OTC Medications as State Traffic Law “The New York State Department of Motor Vehicles Commissioner’s Regulations Part 6 states the following: (a) A person is physically qualified to drive a bus if he or she does NOT use an amphetamine, narcotic, or any habit-forming drug. This regulation applies to whether or not a physician has prescribed the disqualifying drug.” Provided by Niagara Frontier Transit, NY

33. Rx/OTC Medications as State Traffic Law Article 19-A of New York State Traffic Law: “Accordingly, no operator who is using a prescription or non-prescription amphetamine, narcotic, or other habit-forming drug will be certified to operate a bus, train or MetroLink passenger vehicle for NFTA/Metro.” Provided by Niagara Frontier Transit, NY

34. Reporting Requirements

35. Reporting Requirements

36. Communicating with the Physicians

37. Physician’s Note for Fitness for Duty

38. Physician’s Note for Fitness for Duty 15% of Survey participants provide a Fitness for Duty Form for Rx Medications. 7% of survey participants provide a Fitness for Duty Form for OTC Medications.

39. Physician’s Note for Fitness for Duty The form above must be attached to the physician’s letterhead or voided prescription form. Provided by Niagara Frontier

40. Essential Job Functions Q&A Question? • How are essential job functions communicated to the prescribing physicians? • Employee’s responsibility? • A copy of the employee’s job description is provided to Dr? • Included on Fitness for Duty Form provided to Dr?

41. Communicating with the Physician Answer: • Nearly 44% of respondents said that it is the employee’s responsibility to communicate with physician. • Approximately 26% have no process in place. • Approximately 20% provide an employee’s job description to the physician.

42. Communicating with the Physician “Safety-Sensitive Job Functions” “Physician Instructions” “List of medications of concern....” Provided by JAUNT

43. Communicating with the Physician “Please Check One... Employee may not perform safety-sensitive duties. -or- Employee is released to perform safety-sensitive duties while taking this medication.” Provided by JAUNT

44. Communicating with the Physician “Physician Completes” “I have reviewed employee’s medical records and am familiar with employee’s job duties.” Provided by Prairie Five CAC (Montevideo, MN)

45. Communicating with the Physician Tri-Met Safety-Sensitive Employee Prescription Drug Use Form -Employee Signature -Physician provides list of medications and start/end date of prescription Provided by TriMet

46. Consequences • What Are the Consequences for an Employee who Fails to Report Rx/OTC use? • Progressive Discipline Up to and Including Suspension – 40% • No Action Taken – 27% • Verbal Warning or Reprimand Only – 12% • Written Warning or Reprimand Only – 4% • Other – 17% • “Violation of union rule books.” • “Employee can be treated as positive test on drug screen.” • “Depends upon the circumstances.”

47. Attendance Policies

48. Attendance Policies • Sample attendance policies included: • “After 3-days continuous absence, requires a doctor’s statement to return to work.” • “Any Rx/OTC medication that is prescribed by a physician cannot have any restrictions for duty, or the employee must take sick leave until they are off of the medication and cleared by the physician.” • “Sick leave use has a limit and employees may use sick leave to address medication use but cannot exceed maximum sick hours available. Physician report is required.”

49. Attendance Policies • What is used to determine if an employee should continue to perform his/her safety-sensitive duties? • 60% use the prescribing physician’s medical assessment. • 13% use the transit system’s physician’s medical assessment. • 13% use the management’s common medical knowledge. • 4% use a physician’s desk reference. • 10% use some other source.

50. Employee Awareness Training