AINsight: Pilots Beware of Prescription Opioids

 - March 29, 2018, 12:53 PM

Drug and alcohol testing for all DOT “safety sensitive” positions has been in place since 1991, and for the FAA specifically through protocols in FAR Part 120. Safety-sensitive functions in aviation include pilots, flight attendants, air traffic controllers, dispatchers, maintenance personnel, and a few others.

Part 121 and 135 pilots are subject to drug and alcohol testing. Testing is performed pre-employment (drugs only), random, post-accident, reasonable cause, and return to duty (after prolonged absence). Ongoing additional testing can also be done through certain special issuance medical programs for pilots in remission from drug and/or alcohol abuse or dependence. For most routine screening, drug testing is done through urine samples and alcohol testing through breathalyzers.

Until recently, this included testing for amphetamines/methamphetamine (with MDMA, or Ecstasy, added in 2010), marijuana, cocaine, phencyclidine (PCP), and opioids (codeine, heroin, and morphine). Marijuana is still a federal drug of abuse; the FAA has no tolerance for its presence in any drug testing or by prescription in states where medical or recreational marijuana has been approved.

Effective January 1, the Department of Health and Human Services (HHS) mandated that the FAA add prescription opioids in routine urine drug testing. This includes the most common semi-synthetic compounds: hydrocodone, oxycodone, oxymorphone, and hydromorphone. Thus, prescription narcotics such as Vicodin, Percocet, Norco, Lortab, and others, are now part of the urine drug screen.

These newer additions are legal medications with appropriate medical indications. Yet pilots could face action against their medical certificates, pilot certificates, or potentially both as a result of testing positive for them.

Understanding that there is an “opioid crisis” in the U.S., HHS felt it was important to screen for them routinely. However, there are many challenges in making the system well defined and fair in its enforcement.

Herein lie some of the dilemmas, and to its credit the FAA worked hard with HHS to anticipate and minimize potential problems. That said, there are still no ironclad protocols on how to evaluate and confirm a positive test result, and how then to deal with the results.

All positive test results always first go to a medical review officer (MRO). The MRO’s job is to obtain all pertinent information, including whether a “valid” prescription had been issued to the pilot.

What constitutes a valid prescription? What constitutes a pilot violation or true positive result? The discretion on these decisions is given to the individual MRO. To date, there hasn’t been sufficient time to enact formal education protocols to provide standardized and consistent decision-making criteria to MROs.

In the case of methamphetamine, there aren’t going to be any acceptable explanations, so that’s an easy one for the MRO. But what about Percocet? A pilot might very well be prescribed this medication after surgery or for a host of other reasons. FAR 61.53 reminds the pilot to be smart about this, and not to fly when the medical condition or medications might interfere with flight safety. This is certainly a nebulously worded regulation.

If you have just had oral surgery, for example, and need a few days of pain relief, then it’s sensible not to fly. But when can you fly? FAR 61.53 essentially leaves that up to the pilot, if there are no formal regulations that are controlling.

Basically, when the pilot can perform all flight duties and is no longer impaired from the procedure or from the pain-relief medication, he/she is good to go. Sounds simple. But how long should the pilot wait to fly after taking Percocet, for example?

Unfortunately, there is not yet any specific guidance for prescription opioids, even though they are now being tested for in urine. To be conservative, most of the people I interact with in the drug/alcohol program “recommend” waiting at least 72 hours after taking a pain medication before flying—as long as the pilot is otherwise feeling airworthy, of course. That should provide sufficient time for most people to fully metabolize the compound, providing a negative test result.

The MRO is not permitted to question the treating physician’s judgment in providing the opioid prescription. However, what does the MRO do in the case of a pilot who had some medication “left over,” and then used it months later for another similar (or perhaps different) medical condition?

Again, there are no absolute guidelines here yet. The MRO could consider that a positive test, at his/her discretion, if the pilot was deemed to have “self prescribed” the recent use of the opioid, even though the medication was obtained legally via an appropriate prescription earlier. This pilot, therefore, could potentially face certificate action for taking a medication that was legally and appropriately prescribed. For the time being, the best advice to pilots is to obtain a current prescription for the medication.

Regarding opioids that are “left over,” consider a word of caution: until there are adequate precedents, be wary of taking an opioid without a current prescription. What are the criteria for “current?” Until there are either standardized protocols or precedents, no one can answer that question.

Sound judgment by the pilot includes self-grounding until the medical condition has improved and a reasonable time period has elapsed since taking any prescription opioid.

The FAA and MROs are put in a challenging position as this policy evolves. This will be a learning process for everyone. Do yourself a favor and use prescription opioids wisely and only through a valid prescription.

Dr. Sancetta is a former DC-10 captain with 11,000 flight hours. He has worked as a Senior AME since 1993 and is appointed as AME Consultant to the Federal Air Surgeon.