Alcohol and other drugs (AOD) - Interim guidelines

ICAO Annex 1	1.2.7.1, 1.2.7.2, 6.3.2.2, 6.4.2, 6.5.2
Civil Aviation Act	s27B
CAR Part 67	Part 67.103 b, & e, 67.105 b, & e, 67.107 b, & e
General Directions	Timing of Routine Examinations [PDF 500 KB]
	Examination Procedures [PDF 1.6 MB]
ICAO Medical Manual	Chapter 1: 1.2.35 – 1.2.37. 1.4 Definitions
	9.12 Drug Use (Abuse and Dependence)

Introduction

Alcohol has the potential to interfere with aviation safety through reductions in functional capacity (e.g. impairment or intoxication), through increased likelihood of incapacitation, and through unsafe behaviour. Those adverse effects are not limited to periods of intoxication or ‘being under the influence’ but can, in some cases, be active for much longer periods of time.

The aviation implications of (AOD) on safety are not limited to the realms of hypothetical possibilities but take a very real toll in damage and lives lost. In 2015 the Transport Accident Investigation Commission (TAIC) recommended 'regulatory changes to strengthen the management of alcohol and drugs in the aviation, rail, and maritime transport modes'.¹ This was in response to a number of transport safety investigations, including the 2012 Carterton Hot-air balloon accident.² Similarly the first edition of TAIC’s safety monitoring publication, the Watch List, included, as one of its three highest priority transport safety issues: 'The issue of people in safety-critical roles being impaired as a result of using drugs or alcohol. The Ministry of Transport has stated its zero tolerance of operator impairment where members of the public are being transported by sea, rail, and air.'¹

TAIC: 'The detrimental effects of drugs and alcohol on cognitive abilities are well documented. International research suggests the likelihood and severity of accidents increase if people responsible for performing safety-critical tasks use drugs or alcohol. In the New Zealand air, rail, and marine accidents investigated by the Transport Accident Investigation Commission, consumption of alcohol or use of other performance impairing substances recurs as a contributing factor or a potential impediment to survival. We believe more can be done in the transport sector to prevent people who are in safetycritical roles being under the influence of performance-impairing substances.'²

The Civil Aviation Authority’s medical certification system has an important role to play in preventing community losses due to the effects of alcohol and other drugs in the aviation industry. Medical Examiners are at the forefront of this system, being in a position to identify and investigate AOD-related safety concerns as well as being well placed to educate and assist at-risk aviation industry participants. This section of the CAA Medical Manual deals only with the aviation medical certification considerations of AOD use.

Alcohol

Alcohol is a recreational drug and psychoactive substance that is widely and legally available. Alcohol is used safely and in moderation by many, but still takes a huge toll of damage on our community. The New Zealand Health Promotion Agency’s published alcohol fact sheet⁴ includes advice that:

• Alcohol consumption is an important risk factor for more than 60 different disorders (WHO 2007);⁵
• 3.8% of all global deaths and 4.6% of the global burden of disease (measured in disability-adjusted life-years) are estimated to be attributable to alcohol (Rehm et al 2009) ;⁵
• Between 600 and 800 people in New Zealand have been estimated to die each year from alcohol related causes (BERL 2009 and Connor et al 2013);⁵ and
• 14% of the population are predicted to meet the criteria for a substance use disorder at some time in their lives (Wells et al 2007).⁵

This Medical Manual section provides information and describes CAA’s requirements for the medical certification of pilots who have, or may be at risk of having, an unsafe relationship with alcohol. It is beyond the scope of this Medical manual to address the wider public health management of AOD problems within the general community or the aviation community.

Alcohol: Considerations

For a wide range of reasons an individual’s alcohol consumption patterns are not always accurately reported to safety regulatory agencies. Because of these imperfect reporting patterns a range of collateral information often needs to be considered if a medical certification system aims to reduce the likelihood of harm caused by an individual’s unsafe relationship with alcohol.

In general terms the CAA’s approach to medical certification safety and alcohol:

1. Recognises a wide spectrum of alcohol use patterns and does not limit medical safety concerns to any particular defined diagnostic category or criteria;
2. Considers a range of ‘red flags’ in deciding whether an applicant may be at risk of having an unsafe relationship with alcohol;
3. Relies on multiple independent information sources to confirm safety in at-risk applicants;
4. Views severe alcohol disorders (e.g. addiction) as being chronic relapsing medical illnesses - not character flaws, moral failings, or personality defects - implying that after appropriate treatment, and adequately reassuring follow-up, pilot medical certification will be resumed, subject to stringent ongoing medical surveillance; and
5. Offers the benefit of any reasonable doubt to public safety.

Possible unsafe relationship with alcohol

Sometimes a Medical Examiner is confronted with information that suggests the possible presence of an unsafe relationship with alcohol but is not adequate to either confirm or refute that suggestion. This should not be surprising given the alcohol consumption patterns observed in our wider community.

It is important to remember that a medical certificate should not be issued unless satisfied that there is not a safety problem. This is the approach required by our legislation and is consistent with the general principle to offer the benefit of any doubt to public safety.

Red flags

There are many observations that may, in isolation or in conjunction with other observations, reasonably suggest the possibility of an unsafe relationship with alcohol. The presence of any such red flags does not mean that an alcohol problem exists, but they do mean that further information should be sought before concluding that there is not an unsafe relationship with alcohol. The red flags most often seen by the CAA include:

• Drink driving offences;
• Other offences related to, or in association with, alcohol;
• Alcohol consumption in excess of recommended safe limits;
• The presence of health problems that have a strong association with alcohol consumption and no other more likely cause;
• Mental health problems where alcohol troubles can be a co-morbidity;
• Accidental or non-accidental injuries where the circumstances suggest contribution of alcohol;
• Problems with other drugs or addictions;
• Abnormal blood test results;
• Reports from community members;
• Clinical findings suggestive of elevated alcohol consumption levels; and
• Failure to comply with previous requirements concerning alcohol consumption or monitoring / surveillance.

Previously identified unsafe relationship with alcohol

When a pilot with a previously identified unsafe relationship with alcohol is returned to flying a range of ongoing medical surveillance is usually implemented. The role of that surveillance is to provide reassurance, over time, that no unsafe recurrence has occurred.

Generally those surveillance requirements are gradually stepped-back over time, usually by reducing their frequency, as safety confidence grows. Because of the wide range of individual circumstances many medical surveillance regimens are tailored for a particular applicant, usually via the detailed consideration of an Accredited Medical Conclusion (AMC).

Medical surveillance requirements are usually implemented by conditions placed upon a medical certificate. If the holder of a medical certificate fails to comply with any such condition they are not permitted to exercise the privileges associated with the medical certificate (See Civil Aviation Rule 61.35).

If an individual is subject to ongoing medical surveillance because of an alcohol problem and an abnormal result occurs (e.g. a rising CDT titre when it has been in the normal range for a long time) then that result should be weighted highly as suggesting the likelihood of a returned or relapsed unsafe relationship with alcohol.

Alcohol: Information to be provided

Possible unsafe relationship with alcohol

When faced with the presence of any red flag, or others not listed above, the CAA’s approach is to gather additional information in an effort to adequately mitigate the red flag(s). The additional information sought, on top of the detailed history and examination findings of the Medical Examiner (ME), may include any of the following:

• Detailed written explanation from the applicant concerning the matter;
• AUDIT questionnaire administered by the applicant’s GP or ME;
• Up-to-date Ministry of Justice offences report or / and similar from relevant overseas jurisdictions;
• GP notes, or similar, over a period of time;
• Biochemical assays - e.g. Liver Function Tests (LFTs) and Full Blood Examination (FBE / FBC), Gamma Glutamyl Transferase (GGT), Carbohydrate Deficient Transferrin (CDT), Ethyl Glucuronide assays (EtG);
• Reports from AOD practitioners;
• Review reports from Addiction Medicine Specialists (FAChAM);
• Reports from ‘sponsors’ or other non-medical support persons;
• Information from other aviation safety regulatory authorities.

Reports or references from aviation or community members - isolated, single, first-time red-flag

This situation most often occurs in the form of a single drink-drive offence in a first-time medical certificate applicant. If the ME interview and examination does not disclose any additional alcohol red flags some additional confirmatory information should be sought, but a medical certificate can be issued while that additional information is being gathered.

Typically the following would be sought as a minimum:

• Detailed written explanation from the applicant concerning the red-flag matter; and
• AUDIT questionnaire administered by the applicant’s GP or ME; and
• Up-to-date Ministry of Justice offences report or / and similar from relevant overseas jurisdictions.

Previously identified unsafe relationship with alcohol

The particular suite of surveillance requirements is tailored on a case-by-case basis in recognition of the individual situation and circumstances. The alcohol-related surveillance obligations placed upon CAA medical certificate holders, include the following:

• Self-monitoring diaries;
• Periodic Biochemical assays - e.g. Liver Function Tests (LFTs) and Full Blood Examination (FBE / FBC), Gamma Glutamyl Transferase (GGT), Carbohydrate Deficient Transferrin (CDT), Ethyl Glucuronide assays (EtG);
• Periodic reports from aviation or community members;
• Updated GP notes, or similar, over a period of time;
• Reports from ‘sponsors’ or other non-medical support persons;
• Reports from AOD practitioners or / and AOD specialist medical practitioners.

Two or more unresolved red-flags

Typically such cases involve a drink drive conviction, new or in a first time applicant, and some other feature suggesting the possibility of potentially unsafe alcohol consumption patterns.

Typically the following would be sought:

• Detailed written explanation from the applicant concerning their alcohol consumption;
• AUDIT questionnaire administered by the applicant’s GP or ME;
• Up-to-date Ministry of Justice offences report or / and similar from relevant overseas jurisdictions;
• GP notes, or similar, over a period of time; and
• Biochemical assays (Typically LFT, FBE / FBC, GGT and CDT).

Alcohol: Disposition

Civil Aviation regulatory medical practitioners encounter a wide range of alcohol problems, from barely a problem at all through to a severe, chronic, relapsing condition with other associated medical problems. For this reason it is not possible to provide specific detailed guidelines that cover every situation likely to be encountered.

If the ME assesses a case that is not easily decided by considering this information then the ME should discuss the details with a CAA Medical Officer.

An ME should not issue a medical certificate until he / she is satisfied that no alcohol-related problem exists and that the applicant does not have an unsafe relationship with alcohol.

An ME should not issue a medical certificate on an assumption that if CAA sees a problem they will intercede. The ME’s primary and over-riding responsibility must be towards public safety.

Isolated, single, first-time red-flag

• If the further information discloses no additional concerns then it would be reasonable to assess the condition as not being of aeromedical significance.

Non isolated red-flag

If any of the information sought discloses additional red flags, such as additional drink drive convictions or potentially unsafe alcohol consumption patterns, then further information should be sought before concluding the applicant safe for the issue of a medical certificate.

Such cases should be handled by immediate liaison directly with CAA Medical Officers.

• Applicants with additional red flags should be assessed as having a condition that is of aeromedical significance and handled via the statutory flexibility route, requiring an Accredited Medical Conclusion (AMC).

Previously resolved red-flags

Typically this applies to an applicant who has previously been worked-up as outlined above, with red flag(s) having been identified and investigated.

In such a case the applicant may be considered as meeting the relevant medical standards only if:

• The red-flags had been clearly worked up and no actual unsafe situation identified; and
• No further red-flags or concerns have been raised.

Otherwise an ME should not assess the applicant as meeting the medical standards, should consider seeking further information (along the lines outlined above), and should consider seeking for the application to be processed via the statutory flexibility (AMC) process.

Previously identified unsafe relationship with alcohol

Severe

• Applicants with a history of addictive or other severe alcohol disorders should not be assessed as meeting the medical standards.
• If such an applicant continues to comply with ongoing medical surveillance obligations, and if none of those results raises additional concerns, then the ME should consider seeking for the application to be processed via the statutory flexibility (AMC) process.
• If the applicant has failed to comply with medical surveillance obligations, or if some other feature raises additional concerns, the CAA medical unit should be advised immediately and no CAA medical certificate should be issued or extended.

Intermediate

• Generally, applicants with an ‘intermediate’ severity alcohol-related history - neither severe (above) nor minor (below) - should be assessed as not meeting the medical standards. The application shoud be referred for further consideration via the statutory flexibility (AMC) process.
• Such applicants with an ‘intermediate’ severity alcohol-related history may in exceptional circumstances be assessed as meeting the medical standards. 
• Care is essential in making such an assessment and an ME considering this action should have a long-term medical involvement with the applicant and their alcohol problem and should liaise directly with CAA Medical Officers beforehand.

Relatively minor

• Applicants with a history of relatively minor alcohol problems (e.g. a single drink drive conviction, or demonstrated occasional only excessive binge drinking consumption pattern), who have effectively managed the problem and successfully complied with all medical surveillance obligations, may be assessed as having a condtion that is not of aeromedical significance, thus meeting the CAA medical standards.

Other drugs: Considerations

A wide range of recreational drugs, legal and illegal, are available and used within the wider community. For example the 2012 / 2013 Ministry of Health drug use survey identified over 10% of the adult population as self-reporting the use of cannabis during the previous 12-months, with 6% of those users reporting harmful effects on work, studies or employment opportunities, and 8% reporting mental health harm due to cannabis use.⁶ That same survey identified approximately 1% the adult population as self-reporting the use of amphetamines during the previous 12-months.⁷ The previous nationwide drug use survey,⁸ which did not consider synthetic cannabinoid use, identified approximately 15% of adults as using cannabis during the previous 12-months followed, respectively, by stimulants (including methamphetamine) 3.9%, ecstasy 2.6%, LSD and synthetic hallucinogens 1.3%, prescription sedatives 1%, injected drugs 0.3%, and opiates 0.1%. The rapid emergence of use of synthetic cannabinoids is of grave concern given their potency and difficulties in detecting them.

'It is totally unacceptable for anyone in a safety-critical transport role, such as a pilot, to be working while impaired by a substance, whether legal or not', Chief Commissioner John Marshall QC told a media briefing.

CAA considers the use of other recreational drugs to be totally unacceptable, even when abstaining at times of duty. This is because of the multiple pyscho-social consequences and circumstances usually associated with drug use.

Other drugs: Information to be provided

On the first occasion that an applicant presents with a history of drug use.

• A point of contact screening drug test;
• A laboratory confirmatory drug test in case the point of contact drug test in non-negative;
• A Ministry of Justice report or equivalent, on the first occasion that an applicant presents with a history of use of psychoactive recreational drug use;
• A detailed written description by the applicant of their use of drug over time.

Other drugs: Disposition

• A first time applicant with a remote history of drug use (more than five years), no evidence of addictive behaviour (drug, medication, smoking, alcohol), a negative point of contact drug test and no other red flag, may be considered as not having a condition that is of aeromedical significance, thus meeting the medical standards.
• A first time applicant with a history of drug addiction, recent or prolonged use of drugs, multiple drug use, or a recent non-negative drug test may not be considered as meeting the medical standards. The application to be processed via the statutory flexibility (AMC) process.
• An applicant, who has been previously been issued a certificate and continues to comply with ongoing surveillance obligations should be considered as having a conditon that is of aeromedical significance unless a previous AMC has concluded that the condition is no longer of aeromedical significance. The applicant should be considered under the flexibility process. If none of the surveillance results raises additional concerns, the applicant is likely to be issued a medical certificate. Surveillance is likely to decrease over time.
• An applicant, who has been previously been issued a certificate and who has failed to comply with medical surveillance obligations, or returns a non-negative drug test, or if some other feature raises additional concerns should not be issued a certificate or an extension of the certificate. The CAA medical team should be advised immediately and no CAA medical certificate should be issued or extended. The application should be processed via the statutory flexibility (AMC) process or declined.

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¹ New Zealand Transport Accident Investigation Commission Annual Report 2014 – 2015 (F.7 ANN)

² New Zealand Transport Accident Investigation Commission Final report, Aviation inquiry 12-001 Hot-air balloon collision with power lines and in-flight fire, near Carterton, 7 January 2012.

³ New Zealand Transport Accident Investigation Commission Watch List ‘Substance use: regulatory environment for preventing performance impairment’ accessed online at Substance use: regulatory environment for preventing performance impairment(external link) on 16 February 2016.

⁴ New Zealand Health Protection Agency alcohol.org.nz ‘Alcohol Quick Facts’.

⁵ World Health Organization. WHO Expert Committee on Problems Related to Alcohol Consumption: Second report. Geneva: WHO. 2007.

Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, & Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. The Lancet, 373(9682), 2223 - 2233. 2009.

Business and Economic Research Limited (BERL) Report to: Ministry of Health and ACC, Costs of Harmful Alcohol and Other Drug Use. BERL ref #4577. July 2009.

Connor J, Kydd R, Shield K, & Rehm J. Alcohol-attributable burden of disease and injury in New Zealand: 2004 and 2007. Research Report commissioned by the Health Promotion Agency. Wellington: Health Promotion Agency. 2013.

Law Commission. Alcohol in our lives: an issues paper on the reform of New Zealand’s liquor laws. Wellington: Law Commission. 2099.

⁶ New Zealand Ministry of Health. 2015. Cannabis Use 2012/13: New Zealand Health Survey. Wellington: Ministry of Health.

⁷ New Zealand Ministry of Health. 2013. Amphetamine Use 2012/13: Key findings of the New Zealand Health Survey. Wellington: Ministry of Health.

⁸ New Zealand Ministry of Health. 2010. Drug Use in New Zealand: 2007/08 New Zealand Alcohol and Drug Use Survey. Wellington: Ministry of Health.