Alcohol Use and Misuse in Aviation Medicine

Return to flying after alcohol use requires documented abstinence from problematic use, no sequelae from use, and normalisation of blood tests (LFTS, MCV and carbohydrate deficient transferrin (CDT))

dr thomas perkins, casa designated aviation medical examiner

Definition

This protocol refers to suspected or confirmed “problematic use” of alcohol such as:

  • Positive workplace test
  • DAME opinion
  • DUI within 5 years of application
  • Self-reported use and confirmatory blood tests (e.g. LFT’s / MCV and CDT)

Aeromedical Implications

Effect of aviation on condition

  • Hypoxia – increase cognitive decrement caused by alcohol

Effect of condition on aviation

  • Subtle incapacitation – impaired alertness / reaction / decision-making
  • Loss of situational awareness & vertigo
  • Distraction due to impaired concentration.

Approach to medical certification

Based on the condition

  • As per CASR 67.150 Table 67.150.1.5 and 1.6.
    • demonstrated abstinence from problematic use
  • no sequelae from problematic use
  • Normalisation of blood tests

Based on Treatment

  • As per CASR 67.150 Table 67.150.1.5 and 1.6, 2.5 and 2.6, 3.5 and 3.6. – currently undertaking or completion of appropriate course of therapy
  • no safety-relevant medications (benzodiazepine or naltrexone)

Demonstrated Stability

  • Abstinence or harm minimisation as per risk stratification
  • Blood parameters and breath testing
  • Sponsor reports
  • Surveillance plan from applicant and/or employer detailing intended alcohol use and monitoring by doctor, laboratory and sponsors

Risk assessment protocol – Information required

New cases

  • Fellow of the Australasian Chapter of Addiction Medicine specialist [FAChAM] for an assessment in regards to:
    • diagnosis
    • past and present alcohol consumption
    • current clinical status
    • physical and psychological sequelae/co-morbidities
    • LFTS, MCV and carbohydrate deficient transferrin (CDT)
    • treatment, response to treatment and side effects
    • prognosis
    • ongoing management plan
  • FAChAM follow-up report, where applicable following treatment intervention, demonstrating
    • abstinence from problematic use of alcohol and other substances.
    • freedom from the ill-effects of substance misuse
    • recent blood tests (LFT’s, MCV and CDT)
  • Consider Police report

Renewal

  • Fellow of the Australasian Chapter of Addiction Medicine specialist FAChAM for an assessment in regards to:
    • diagnosis
    • alcohol consumption
    • review of physical and psychological sequelae/co-morbidities
    • current clinical status and compliance with established goals and requirements
    • review of LFTS, MCV and carbohydrate deficient transferrin (CDT)
    • review of sponsor reports and tests as listed below
    • treatment, response to treatment and side effects
    • prognosis
    • ongoing management and surveillance plan

(NOTE: In certain circumstances, reports may be accepted from psychiatrists or other alcohol or addiction medical specialists. Prior agreement must be sought to avoid unnecessary expense and delays.)

  • 3 monthly LFT’s MCV and CDT
  • Random breath alcohol testing
  • Sponsor / peer / employer reports (as appropriate)

Indicative outcomes

The onus is on the applicant to demonstrate fulfilment of the regulatory requirements. Careful attention to the conditions requiring testing or reports by a particular date, is essential to give confidence that aviation safety is being maintained. Failure to submit tests and reports on time will be treated as indicators of possible relapse.

Favourable

  • Demonstrated absence of problematic use for a pre-defined period. This is usually a minimum of 12 months, and includes sponsor and clinical reports
  • Ongoing normal blood and breath-alcohol tests

Unfavourable

  • Problematic use
  • 2 relapses following diagnosis
  • Alcohol-related convictions: 3 or more
  • Abnormal blood or breath-alcohol tests
  • Complications of alcohol-use e.g. psychiatric, portal hypertension, varices, clotting etc.

Pilot and Controller Information

  • The hazardous and problematic use of alcohol has been associated with aviation accidents
  • For pilots and controllers who have problematic use of alcohol, the most successful treatment has resulted from abstinence from all alcohol use. For this reason, certification may be possible when pilots and controllers demonstrate abstinence
  • The best way to demonstrate abstinence is through objective evidence of abstinence and careful attention to monitoring
  • Problematic use of alcohol is associated with serious medical problems quite apart from the hazard to aviation activities..

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.Last modified: 5 September 2018

Attention Deficit Hyperactivity Disorder in Aviation Medicine

“ADHD needs to be in full remission, off stimulant medication for a minimum of 6 months after the completion of treatment.”

dr thomas perkins, casa dame and aviation medical officer

Effect of condition on aviation

  • Premature and ill-considered actions
  • Restlessness and excess of movement causing distraction
  • Impaired split attention affecting multi-tasking and situational awareness

Approach to medical certification

Based on the condition

  • In full remission

Based on Treatment

  • No safety-relevant medication such as stimulants

Demonstrated Stability

  • Absence of symptoms for a minimum of 6 months after treatment completed. (Reflects DSMIV diagnostic criteria)

Risk assessment protocol – Information required

New cases

  • Copies of medical records from date of diagnosis to the present
  • Copies of records from Medicare detailing consultations and prescription of medications
  • An up to date assessment by the treating paediatrician or psychiatrist if available detailing:
    • History of condition
    • Precise confirmation of the diagnosis with reference to DSM-IV criteria
    • Co-morbidities, including drug and alcohol use
    • Requirement and response to treatment
    • Current clinical status with respect to DSM-IV criteria
    • Current functional status, with reference to collateral information if available from school, family, workplace etc.
  • Completion by the paediatrician/psychiatrist and the chief flying instructor of the  ADHD and autism spectrum disorder instructor’s questionnaire form 420 (PDF 617.14 KB) regarding symptoms in the context of and noting the implications to both the normal day to day life and the conduct of aviation. Attached questionnaire
  • Copies of academic records and employment history
  • Copies of traffic infringements and criminal records
  • Copies of any special investigations performed such as QEEG or neuropsychological testing
  • Follow-up plan
  • Previous specialist reports if available

Renewal

  • May be subject to annual review by an appropriate specialist on a case by case basis.

Indicative outcomes

Favourable

  • Stable off medication for at least 6 months and satisfactory reports
  • Instructor questionnaire and annual specialist reports for 5 years following cessation of treatment. After 5 years consideration of removal of surveillance requirement.

Unfavourable

  • Recurrence of symptoms
  • Stimulant medication

Pilot & Controller Information

  • Any recurrence must be reported to the DAME

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Disclaimer

The clinical practice guidelines is provided by way of guidance only and subject to the clinical practice guidelines disclaimer.Last modified: 5 September 2018

What Makes A Good CASA DAME Report?

It goes without saying that good reporting in Aviation Medicine is the mainstay of quality in reporting and outcomes

Dr thomas perkins, aviation medical officer and casa dame

To assist CASA’s consideration of applicants where there is doubt about ability to meet the required medical standard, DAMEs should avoid vague descriptive terms in their reports. Expressions such as ‘brief’, ‘infrequent’, ‘mild’, ‘some’ or similar convey no meaningful information. CASA recommends the “8W mnemonic”.

  1. What 1: What happened? (Detail signs and symptoms that led to the consultation, procedure performed etc).
  2. What 2: What were the sequelae?
  3. When 1: What were the dates and frequency?
  4. Where: What body part was affected? (Left or right, upper arm/forearm etc).
  5. Why: Why was a procedure performed?
  6. Who: Who was involved? (Who carried out a procedure/made an assessment/is undertaking follow-up, etc).
  7. What 3: What is the prognosis?
  8. When 2: When and at what frequency is follow-up planned?

Where specialist opinions are requested, these questions should be asked in the referral letter.

Once all necessary information has been received, full details of the case are considered, and where required may be considered by a Complex Case Management (CCM) panel composed of CASA’s aviation medicine practitioners. When appropriate, this panel may be supplemented by clinical or other specialists, or additional advice and reviews may be required by this panel. A determination on the case will then be made and the applicant notified of the result.

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