Pain Management and Commercial Driving

[MCHAD]

I'd like some opinions.  Lets say you have a 60 year old patient present for a DOT CDL physical exam. The patient reports to the Medical Assistant doing check-in/vitals that the only medications they take cyclobenzaprine, hydrocodone 10/325, and meloxicam "Only as Needed" for chronic pain.  The MA looked the patient up prior to provider seeing them on the prescription monitoring website and finds that the patient consistently fills prescriptions every month for Hydrocodone 10/325 #120 as well as Morphine Sulfate 30mg #60 for the last year.  This patient currently holds an active CDL which they report is used "occasionally" to help with agricultural work when asked if she actively uses the CDL, but mentioned that they were thinking about applying for a job as a school bus driver to the front desk employee. 

DOT regulations state that in order for a patient with prescriptions for chronically taken narcotic medication to qualify medically for a CDL a written letter from the prescribing provider needs to be provided indicating that the medication will not impair their ability to safely operate a commercial vehicle.  If this letter is provided by the prescribing provider the DOT medical examiner may but does not have to clear the patient for Commercial driving.

What would you do?

 

[narcan]

I'm not attaching my name and medical license to someone who fills 180 narcotic tablets a month but only claims to take them as needed for pain. It doesn't matter if this person uses their CDL occasionally or not. There's no such thing as a CDL that you can only use on Saturdays.

If the patient truly needs that degree of narcotic medication to function, then unfortunately working in a job that requires a CDL should not be in their future.

Pass on the business and let someone less scrupulous sign off on their DOT physical. Would you want this person driving your kids around?

[sas5814]

Not in a million years would I sign off on someone taking those meds having a CDL. Imagine him dragging 60k pounds down the highway at 75 MPH or driving a fuel tanker, much less a school bus. Just nope... he needs to find something else to do. Life is unfair but DOT physicals are done in the interest of public safety not making jobs for drivers.

[GetMeOuttaThisMess]

We had a similar situation about a decade ago on Interstate 75 north of Dallas where a trucker went across the median and took out a family.  Evidence showed multiple controlled substances as being prescribed for this individual as I recall (I know at least one).  One of the first folks that LE wanted to talk to was the provider who signed the DOT certificate.

[Guest UVAPAC]

100% disqualify.

After years of fighting/arguing with my SP's, we no longer qualify drivers on opioids or benzos.

[MCHAD]

Thanks for the responses, this is exactly how I feel about this situation, I’ve been accused in the past about being overly cautious...but I really don’t think it’s overly cautious at all. 

[narcan]

There are certain things which are hard stops, and this is one of them.

[Reality Check 2]

Also look at the underlying condition requiring narcotics and whether or not narcotics are really the answer or an added complication. Spinal stenosis, radiculopathy, cervical fusion, etc. In all likelihood there is an underlying condition that is not conducive to safe driving with the narcotics as the cherry on top - on fire, rolling downhill at high speed....

I would never certify that person - ever.  

Many times it is easier to point out the condition and its limitations requiring meds - puts the pieces together for denial with some logic instead of just railing the narcotics - and YES, they are a problem. 

The listed pt is on 100 MED and that is just wrong for noncancer pain. Shouldn't be driving a personal vehicle much less a schoolbus.

Public safety first and always. Stick to the rules.

[rev ronin]

What everybody else said.  Although, I might consider asking the prescriber for a letter, and if he or she writes one, forward it to the medical board with an accompanying complaint of unprofessional behavior...

[mgriffiths]

As everyone else has said...but I will add, if a patient tells me they take narcotics PRN for pain...they're prescription is immediately discontinued by me, or at minimum is weaned and I tell them bluntly that we are starting the weaning process.  All get frustrated/angry/whatever, a few have never come back, many I have had success with - it's worth the fight...but it's ANNOYING every time.

[narcan]

15 minutes ago, mgriffiths said:

As everyone else has said...but I will add, if a patient tells me they take narcotics PRN for pain...they're prescription is immediately discontinued by me, or at minimum is weaned and I tell them bluntly that we are starting the weaning process.  All get frustrated/angry/whatever, a few have never come back, many I have had success with - it's worth the fight...but it's ANNOYING every time.

You mean in the context of getting them qualified to get a CDL?

[mgriffiths]

This is for any patient.  Narcotics are not for PRN pain.

[RWMondak]

On 11/25/2017 at 3:39 AM, MCHAD said:

I'd like some opinions.  Lets say you have a 60 year old patient present for a DOT CDL physical exam. The patient reports to the Medical Assistant doing check-in/vitals that the only medications they take cyclobenzaprine, hydrocodone 10/325, and meloxicam "Only as Needed" for chronic pain.  The MA looked the patient up prior to provider seeing them on the prescription monitoring website and finds that the patient consistently fills prescriptions every month for Hydrocodone 10/325 #120 as well as Morphine Sulfate 30mg #60 for the last year.  This patient currently holds an active CDL which they report is used "occasionally" to help with agricultural work when asked if she actively uses the CDL, but mentioned that they were thinking about applying for a job as a school bus driver to the front desk employee. 

DOT regulations state that in order for a patient with prescriptions for chronically taken narcotic medication to qualify medically for a CDL a written letter from the prescribing provider needs to be provided indicating that the medication will not impair their ability to safely operate a commercial vehicle.  If this letter is provided by the prescribing provider the DOT medical examiner may but does not have to clear the patient for Commercial driving.

What would you do?

 

I have specialized in Occupational Medicine for more than 23 years and have been a PA for 32 years. This issue is a common occurrence in my practice. It is IMPERATIVE that the prescribing physician / provider submit a statement that she / he feels that the individual is safe to operate a commercial vehicle while taking these medications.  I have a form letter that I send for most of the situations which require additional documentation such as this. At the very most, I give a 45 day "hold" on signing the medical certification.  
I explain to the examinee that Federal Regulations  and the safety of driver and the public are my guidelines. If the prescriber submits a letter explaining why an opiate is required and that they will monitor the use, the very most I will give is a ONE YEAR certification. However, I will notate this and keep the letter on file. This must be done at every interval, whether the medical certificate is issued for 90 days or one year. Most of the time, the prescriber weans the driver from the opiate and the issue is resolved.

 

[Guest UVAPAC]

1 hour ago, RWMondak said:

I have specialized in Occupational Medicine for more than 23 years and have been a PA for 32 years. This issue is a common occurrence in my practice. It is IMPERATIVE that the prescribing physician / provider submit a statement that she / he feels that the individual is safe to operate a commercial vehicle while taking these medications.  I have a form letter that I send for most of the situations which require additional documentation such as this. At the very most, I give a 45 day "hold" on signing the medical certification.  
I explain to the examinee that Federal Regulations  and the safety of driver and the public are my guidelines. If the prescriber submits a letter explaining why an opiate is required and that they will monitor the use, the very most I will give is a ONE YEAR certification. However, I will notate this and keep the letter on file. This must be done at every interval, whether the medical certificate is issued for 90 days or one year. Most of the time, the prescriber weans the driver from the opiate and the issue is resolved.

 

So out of curiosity....

 

You have a driver on percocet or vicodin 3-4x daily for chronic lower back pain.  The driver gets a note from his orthopedist or primary care physician stating that he is stable on the medication, and that they feel it is safe for the patient to operate a commercial motor vehicle.  You document the person denies all side effects, and issue them a 1 year card...

 

3 months later the driver gets into an accident, resulting in fatalities.  They run a breath alcohol and a toxicology report, as MANDATED in these situations.  Toxicology report comes back positive for opiates.  The injured file a lawsuit that the driver was taking medications that impaired judgement, reaction time, cognition.  

You go to court... the lawyer says... "sir/madam are you a physician assistant?"

You:  "Why yes I am"

Lawyer:  "Are you trained in pharmacology, and understand the risks of opioid use?"

You:  "Why yes I do."

(Lawyer approaches the stand and hands you bottle of vicodin/percocet.)  "Please read me the sticker affixed to the bottle."

You:  "CAUTION USE OF MOTOR VEHICLE OR MACHINERY.  MAY CAUSE CNS IMPAIRMENT.  MAY CAUSE DROWSINESS."

Lawyer:  "And you do understand despite PCP/Ortho signing off, ultimately you are responsible for certifying this driver, and you are the occupational medicine specialist?"

You:  "Yes I do."

 

How do you defend yourself?  How do you sleep at night knowing the school bus of kids crashed and that it could be directly related to your patient's impairing medication?  How do you prove it was not the cause of the accident?

What if it is snowing, and they argue reaction time was delayed due to opiate?

What if they are changing the radio station, and they argue the drivers judgement was impaired?

 

I would never do it.  Even if god himself wrote the patient the letter stating they can safely drive.  

 

[sas5814]

You go to court... the lawyer says... "sir/madam are you a physician assistant?"

 

From personal experience in an unrelated matter what they tend to say is "so....you aren't a DOCTOR are you?"

I had, because I do have a PhD, the fun of saying "yes I am a doctor" and waiting while him and his flunky shuffled papers trying to figure out how this simple question went off in the ditch.

That said I am on your side. On my signature chronic narcotic or benzo users don't get cleared for just that reason. 

[MCHAD]

So, ultimately myself and the other provider that is DOT certified told our office manager we aren’t comfortable passing this individual even if they had a letter from pain management.