Clinical Practice Guideline
Developed for the
Aerospace Medical Association
by their constituent organization
Overview: In alcohol abuse, alcohol consumption significantly impairs social, interpersonal, and/or occupational functioning. Alcohol dependence involves a pattern of repeated self-administration that usually results in tolerance, withdrawal, and compulsive drinking behavior. These disorders commonly develop between the ages of 20 and 40, and along with alcohol misuse are among the most commonly seen psychiatric issues encountered in aerospace medicine. Current psychiatric guidelines per DSM-IV-TR give criteria for diagnoses of alcohol dependence (303.90) and alcohol abuse (305.0) that colloquially define alcohol related problems.
Alcohol use disorders are difficult to detect and there is no one objective parameter that can be used to make the diagnosis. Therefore a flight surgeon or AME must be aware of and watchful for circumstances which can signal their presence, e.g., presence of alcohol on the breath or an elevated blood alcohol level during duty hours, an alcohol-related incident, such as a DUI or domestic incident, insomnia, hypertension, vague GI problems, and frequent minor injuries. Laboratory abnormalities such as elevations of MCV, GGT, ALT, AST, uric acid, triglycerides, or increased carbohydrate deficient transferrin (CDT) may be present. Chronic depression, irritability, and anxiety may indicate the presence of an alcohol use disorder, especially when they represent a change from a flyer’s normal personality. Objective screening tests (CAGE questionnaire, MAST, AUDIT, and McAndrew) are available for use by the flight surgeon or through the Mental Health Clinic. Recently the National Institute of Alcohol Abuse and Alcoholism has developed a single-question test for primary care doctors to replace longer questionnaires. This question asks, “How many times in the past year have you had (for men) 5 or more drinks or (for women) 4 or more drinks in a single day?” None of these make or confirm the diagnosis, but they can help evaluate the presence, extent, and severity of alcohol use problems.
In the military, whenever a flight surgeon suspects that any member has an alcohol problem he or she is required to inform that member’s commander, who must then take certain steps, consistent with that service’s policy. The risk for alcohol withdrawal must also be assessed immediately. Along with the usual medical evaluation, the workup should include an assessment for other psychiatric disorders, such as major depression, anxiety disorders, and personality disorders, for which alcoholics are at increased risk. Another substance use disorder and antisocial personality disorder (associated in young men with alcohol dependence) are the most common co-morbid diagnoses.
Recidivism is a primary concern for flight surgeons and AMEs when dealing with aviators and alcohol. Roughly one-quarter of alcohol abuse patients demonstrate relapse at 3 years, while alcohol dependence patients have demonstrated relapse rates of 41% at 2 years. Abstinence from alcohol is the preferred modality for preventing relapse in aviators. Abstinence has been associated with a lower risk for relapse when compared to low risk drinking. Some studies have shown that limited drinkers were four times more likely to relapse to unacceptable drinking levels than were those who reported total abstinence.
By 2013, DSM-V will replace the current DSM-IV-TR. Alcohol Abuse and Dependence diagnoses will be merged into a single diagnosis with graded clinical severity: Alcohol-Use Disorder (moderate & severe). The new diagnosis will combine existing criteria from both Alcohol Abuse and Dependence. Unfortunately, Alcohol Abuse and Dependence are used interchangeably in waiver submissions. Since Alcohol Abuse and Dependence have the same aeromedical waiver criteria, the merging of the diagnoses in DSM-V should be seamless to local flight surgeons and facilitate better waiver data management.
Aeromedical Concerns: A continuum exists ranging from normal social use of alcohol, through non-diagnosable alcohol misuse of aeromedical concern, to diagnosable alcoholism. As an alcohol problem progresses it often causes problems first at home, then in the social environment, and performance in the cockpit may be the last area to be noticed. One of the more vital roles of the flight surgeon is involvement with the squadron aircrew in their off-duty time and, in particular, participation in social and recreational activities where the use of alcohol often occurs.
Alcohol misuse presents hazards to aviation because of both acute and chronic effects on cognitive and physical performance. Acute alcohol intoxication and hangover, which can cause impairment in cognition, judgment, coordination, and impaired G-tolerance and nystagmus, are obviously incompatible with flying. Similarly alcohol withdrawal is a threat to flight safety due to anxiety, tremor, and the possibility of arrhythmia. Further, subtle cognitive impairment, manifesting as slowed reaction time, inattentiveness, difficulty in monitoring multiple sensory inputs, and difficulty making rapid shifts of attention from one stimulus to another, can occur after low doses of alcohol which would not cause intoxication. After moderate alcohol consumption, impairments can persist for many hours after the blood alcohol level has returned to zero and well beyond the 12-hour ‘bottle-to-throttle’ guidelines. Positional alcohol nystagmus, indicating impairment in vestibular function, can occur under G-load up to 48 hours after alcohol consumption. Heavy drinkers are at risk for arrhythmias ("holiday heart") for several days after drinking.
Medical Work-up: The work-up for an aeromedical waiver needs to include a complete history of all alcohol-related problems. Labs need to include a blood alcohol level, CBC with MCV, GGT, ALT, AST, triglycerides, and CDT. The report should also address work performance, peer relationships, family and marital relationships, psychosocial stressors, attitude toward recovery, abstinence, AA or other approved alcohol recovery program attendance, and a mental status examination. For first-time waiver requests, there should be documentation from the alcohol treatment program. Most military waiver requests will require a signed letter promising to remain abstinent. Some authorities may also require mental health examinations while in aftercare.
Air Force: Alcohol abuse and dependence are disqualifying for all classes of aviation in the US Air Force, to include FC IIU (UAS operators). These conditions may be waived by MAJCOM/SGPA for a period of no greater than three years.
Army: Current or history of alcohol abuse or dependence is considered to be disqualifying according to Army Regulation 40-501 Standards of Medical Fitness. This regulation considers alcohol misuse to be different from abuse and dependence, but it also may be considered disqualifying. Disposition and treatment is discussed in AR 600-85 Alcohol and Drug Abuse Prevention and Control Program. There are two Aeromedical Policy Letters related to this: SUBSTANCE-RELATED DISORDERS: ALCOHOL ABUSE OR DEPENDENCE, and ALCOHOL-RELATED DISORDER, NOS (ALCOHOL MISUSE).
The aeromedical concerns of the Army are the same as those stated for the USAF. Applicants are usually not granted an exception to policy. Waiver for rated personnel is possible if the patient: (1) maintains unqualified acknowledgment of the alcohol abuse disorder, (2) successfully completes the appropriate treatment program, (3) remains abstinent for 90 days without need for medication, (4) maintains satisfactory participation with documentation in an organized alcohol recovery program (AA, Rational Recovery, etc.) 3-5 times per week for the first 90 days of recovery and then 1-3 times per week thereafter for a period of 5 years total. Noncompliance: Continued denial of an alcohol problem and refusal to abstain from alcohol following treatment are grounds for permanent termination from aviation duties. Any relapse requires resubmission for waiver. Waivers for relapses with further outpatient and/or residential treatment are rarely granted.
Navy: Flight Surgeon must submit grounding physical to NAMI Code 342. Waiver is possible 90 days after the patient has:
1. Successfully completed OUTPATIENT or INTENSIVE OUTPATIENT treatment.
2. Maintained a positive attitude and an unqualified acknowledgment of his alcohol disorder.
3. Remained abstinent without the need for Antabuse-type medications.
4. Complied with aftercare requirements post-treatment during the 90 days
Consult Navy Waiver Guide for further details
Civilian: Substance dependence and abuse are two of the Federal Aviation Administration’s (FAA) specifically disqualifying conditions. This means that if one has one of these diagnoses, they are disqualified and must gain medical certification through the Authorization for Special Issuance, i.e. waiver, process. If one is diagnosed with these conditions policy requires that they must remain substance-free for two-years. There are ways an airman may obtain medical certification sooner than that.
The FAA has several ways that it attempts to determine whether an airman has a drug or alcohol problem. One way is medical history question 18.v., which asks the airman if he/she has ever been arrested, convicted or had an administrative action against them as a result of alcohol or drugs. Another way occurs when an airman signs Block #20 of the medical history, where they are giving the FAA permission to perform a comparison with the National Driver Registry Computer System. A positive “hit” from this system leads to a review of their response to Block 18.V. and if a negative response is encountered, legal action against the airman and medical certificates occurs. An airman regulation, 61.15 (e), mandates that any airman who has an arrest, conviction or administrative action against them for alcohol or drugs to report this to AMC-700 (Security Division at the FAA’s Aeronautical Center in Oklahoma City, Oklahoma). The airman is in addition also expected to report this action on their next medical examination.
If an airman has a single alcohol offense within five years and their breathalyzer test is 0.15 of greater the Aerospace Medical Certification Division (AMCD) requires them to have a substance abuse evaluation by an individual trained in such assessments. If the airman refuses alcohol testing requested by the arresting officer, they must also have a substance abuse evaluation. If on this single “driving while intoxicated” offense a testing result of 0.20 or greater is obtained the FAA considers this evidence of tolerance and will deny the airman’s medical certification. Two alcohol or drug offenses within 10 years requires a substance abuse evaluation, a written explanation by the airman of the two events, a current copy of their State driving record, and they must also provide copies of the police report and court documents. Three or more offenses in a lifetime are considered equivalent to substance dependence and the airman is immediately denied and is required to provide a written explanation of the events, a copy of their State driving record, copies of police and court records, and undergo substance abuse psychiatric and neuropsychological evaluations. The reasoning behind the requirement for both seeing a psychiatrist and a clinical psychologist are to see what each specialist opines as a diagnosis. Many times one disagrees with the findings of the other and consultation is obtained from a FAA consultant to “break the tie”.
In the FAA one only need to demonstrate one of the following to be diagnosed with substance dependence: (1) manifestation of withdrawal symptoms, (2) increased tolerance, (3) impaired control of use, and (4) continued use despite damage to physical health or impairment of social, personal, or occupational functioning.
The other ways that the FAA can determine whether an airman has a problem with alcohol or drugs is through its Industry Drug and Alcohol Testing Program mandated under Title 49 Code of Federal Regulations (CFR) Part 40 and 14 CFR Part 120. The program is managed by the Drug Abatement Division (AAM-800) is located at FAA Headquarters building in Washington, D.C., and consists of a headquarters element and drug abatement investigators at each of the nine FAA Regional Medical Offices.
The Industry Drug and Alcohol Testing Program covers a variety of aviation industry personnel; however, with respect to pilots, it only covers those actively working in positions requiring first and second-class airmen medical certificates. In addition it covers non-FAA air traffic controllers with second-class airmen medical certificates. Individuals may be tested randomly or for reasonable suspicion while working or on duty. Testing may also be performed during the pre-employment process. Should someone test positive, their airman and medical certificates are revoked emergently. Most of the major air carriers have a program known as the Human Intervention and Motivation Survey (HIMS) to get these airmen into active rehabilitation and recovery. This program, which started in the mid 1970’s, requires the airman to attend an inpatient alcohol and drug-treatment facility, seek aftercare, attend Alcoholics Anonymous or some other similar recovery group, obtain a sponsor and be closely followed by a specially trained FAA Aviation Medical Examiner (AME) and their airline for two to five years. Once again, the airman is required to maintain “total sustained abstinence” from the substance (s) they were using. Failure to do so results in their Authorization for Special Issuance to be withdrawn until they can again demonstrate their determination to remain sober.
In the past several years the FAA has begun to treat the third-class airmen much like the professional pilots having them seek out a HIMS AME and being closely monitored.
Air Force: The majority of aviator waiver recommendations for alcohol related diagnoses are managed through base and command level interaction; ACS in-person evaluation is seldom required. Review of AIMWTS data in 2010 showed 344 individuals requesting waivers for alcohol abuse and 217 individuals requesting waivers for alcohol dependence, for a total of 561 aviator cases. There were 24 FC I/IA cases, 159 FC II cases, and 378 FC III cases. Within the FC II category, 6 were initial certification cases, and within the FC III category, 87 were for initial certification. Of the 24 FC I/IA cases, 14 were disqualified with the most recent AMS; of the 159 FC II cases, 31 were disqualified with the most recent AMS; and of the 378 FC III cases, 122 were disqualified with the most recent AMS. Many of the aviators in the pool of 561 had multiple aeromedical summaries for alcohol-related diagnoses. There were some who were disqualified and later waived, some waived and later disqualified, and a few who were disqualified, waived and then disqualified again.
Army: Over a recent two year period there were 1,741 unique rated aircrew encounters filed in the Army Aeromedical Epidemiological Data Repository. Among these there were thirteen coded for alcohol abuse and six for dependency. Two aviators were suspended in each of these two groups.
Navy: Not available at this time
Civilian: There are currently 779 first-class, 693 second-class and 1,310 third-class airmen issued with a history of alcohol dependence.
ICD 9 codes for alcohol abuse and dependence
American Psychiatric Association : Substance Abuse Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), Washington, DC: American Psychiatric Publishing; 2000:191-295.
American Psychiatric Association DSM-5 Development. Alcohol-Use Disorder. Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=452.
Jones DR. Aerospace Psychiatry. Ch. 17 in Fundamentals of Aerospace Medicine, 4th ed. Lippincott, Williams and Wilkins, 2008.
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Prepared by Drs. Ray Clydesdale and Dan Van Syoc