This is a fun one. This is on drugs and alcohol. Drugs and alcohol is kind of a crazy, I'll just give it a couple of minutes, people will come back in, even though we're going to keep on going. So, a little bit of questions about the test, as Mike said. Know the basics. They're supposed to test on the handbook. Do they have some things from the old handbook still in there? Possibly. I wouldn't spend a lot of worry about it, because if there's a lot, let me know and I'll go back and scream and yell, because I did that when I took the test, but again, that was back in March. So, I'm sure they didn't have time to pull things off. But if their new guidance has nothing about a two-month wait after an MOI, they shouldn't be asking questions on that. And theoretically, the test is validated. So, if you have a lot of people who do well and fail certain questions, you've got to go back and think these are bad questions rather than bad test takers. So, again, I think a lot of it, as long as you give it a good effort, you're not going to be perfect. I didn't get a perfect test. Mike, you didn't get a perfect test either, did you? Close. No, I was not. And I'm dying to know what one I missed, because I'm not happy about that. Yeah, I mean, there are a couple others that I'd like to intervene, because I don't really think if I do a lot of work with nerve innervates, what part of the leg anymore. I don't do that work. And it's like, I don't remember. Is it really relevant? Quite honestly, no, it's not relevant in my mind, whether you certify somebody where the nerve root goes to. And quite honestly, I mean, keep in mind, I've been doing this forever. I probably only did a few things before I took the test. I did not study that hard for it, and I did not. So, there wasn't a lot of trick-me, trick-me stuff on there. So, if you're doing the GITs every day, then what would be the first thing to do? The recommendation, read the new handbook, read the periodic training, be real aware of the regulations that are on the new handbook, and you should do fine. It really is, don't look for a trick, don't look for a trick question, because they're not meant to be trick questions. If they're trick questions, the answer is, there are people who are taking this test who have, are board certified in five specialties. There are people who are not board certified in anything and are not physicians, and they're meant to be able to pass the test reasonably as well. So, I remember on the very first test I took, it was, you have a person who comes in, and this is back with the smoking, but they're a smoker with shortness of breath, in your office on three asthma meds or COPD meds, what would you do? Well, I would do a PFT. The right answer was, refer them to a specialist for a regional evaluation, you know, only because of what you do. So, don't think about, well, based on all of my training, kind of a more, it's not meant to be really super hard. All right, we have a whole lot on drugs and alcohol, all of 88, page 88 through page 94, the rest of it really doesn't say a whole lot. So, a lot of this is focused more on the drug and alcohol testing piece, and some illegal drugs, and not a whole lot about the medications, which were mostly covered in psych. Those are the most common medications we're going to have issues with. And then, of course, we have the cardiac meds and pulmonary meds we mentioned in there as well. So, this is a lot more of other stuff. Have you ever used tobacco? I can't recall anyone ever being disqualified for using tobacco, but it kind of is a throwback to the, if you smoke, do we do a pulmonary function test? That question is stupid. Do you currently drink alcohol? Of course, this is one of those no, no, no's, and if yes, it's once a week. Have you ever, ever, have you used, I remember, have you had or had, do you have an illegal substance within the past two years on that particular question, within the past two years? Just because they say yes doesn't mean it has to be disqualifying. Somebody who's smoked a joint a year ago is not an automatic disqualification. Really, get that assessment how you need it, and we'll talk about that. Have you ever failed a drug test or been dependent on an illegal substance? The answer yes, no, well, hard to figure that one out. Yes? Drivers don't consider marijuana to be illegal anymore. That's exactly correct. Say that again? Drivers do not, individuals do not consider marijuana to be illegal anymore because it is legal in their states, and that's one of the things we're going to talk about is that this exam is a federal exam. Federal use of drugs is considered whether it's legitimate or not. The regulation clearly says they cannot use a Schedule I substance. It is going to be a nightmare when, and I no longer think if, they reschedule marijuana, and if we have some time, I can give a little bit of insight of what's going on with that, but Mike is absolutely right. They don't consider marijuana illegal, so if they answer no, it doesn't necessarily mean that they were lying or withholding information, and this is where the regulation gets a little specific. Physically qualified does not use a drug or substance identified in Schedule I or a narcotic, amphetamine, or other habit-forming drug. So that regulation kind of covers everything, that you can't use something that may be impairing. Now the exception is they don't use a non-Schedule I drug or substance except if it's prescribed by, now prescribed is an interesting word because technically cannabis is not prescribed. Now is, sesamate is, nabalone is, but medical marijuana as we think of it is not. By a licensed medical practitioner familiar with the driver's medical history, and he advised the driver the substance will not adversely affect their ability to operate the motor vehicle safely. So that's that second piece is, does the doctor know what they do? How does the healthcare provider say that they're safe to operate? Always a problem. Now it goes a little further and says, this is where we get the medical advisor criteria. Schedule I substances cannot be used. Period. End of story. So if the driver admits to chronic use of, current use of medical marijuana, that has to be disqualified. They cannot qualify a driver on medical marijuana. They can't qualify a driver on using recreational marijuana. Do you need to have an assessment done? Maybe. Can you do a non-federal drug test? Yes. So you can do a non-federal drug test. It is not a violation under the federal drug testing program. You do not have to report that to the clearinghouse. You do not have to have a SAP, a formal SAP evaluation, but you probably do want to have some kind of evaluation done before you consider qualifying them again. Now remember, we talked about stupidity testing. You know you're coming in for your commercial driver test. If you're periodic, you're not necessarily going to have a drug test unless the company does periodic drug tests with the commercial driver med exam. Some do, some don't. If you're a new hire, you may very well be having a drug test with the new hire commercial driver medical examination. Now when it comes to the other schedules, two to five, an examiner may qualify the driver if the treating provider says, hey, they're safe, they're not having any side effects. What do we do at this point when you use that 5,895 and ask for the information? If it's recreational, then it's not prescribed by a licensed healthcare professional, so that does not fit into that. If it's recommended by a licensed healthcare professional, that's where, again, it gets a little bit squirrely because it's not really prescribed because you can't really prescribe a non-FDA approved medication. And one of the ways to do that, of course, is to get information from this prescribing provider. And I do have the right number on that one. Okay. Medical examiner may request a non-Department of Transportation test. We already mentioned that. Use of this app is not required. It is not reported. It is not considered actual knowledge necessarily under the drug testing regulations. So what do we do about CBD? CBD has been a nightmare. There's a lawsuit that's coming to the Supreme Court where fortunately a driver is suing the CBD company, not the carrier. He tried suing the carrier and that failed miserably. But he's suing the CBD company under RICO Act because they were putting the workplace at risk because it wasn't properly labeled and they said there's no THC in there, but there was. Now, the important thing that people tend to forget is there's a by weight. This is not a, is there any there and there's 10 milligrams or five milligrams in this five, you know, whatever capsule. CBD is all kinds of formulations. It can be an oil, it can be an edible, it can be gummies, you know. It's a 0.3% by weight THC is what's permitted and that's under federal law. So if you take 0.3% in this little speck and 0.3% in this little speck and you keep on adding, you have a cumulative amount of THC to a point where if you take enough CBDs that's within the legal limit, do you think gummies, and you take enough of them, you're going to have the same number of amount of THC as you'll have in a joint. So it's not just a matter of is it mislabeled, which it is mislabeled because FDA isn't monitoring it. So does it have more THC than it's supposed to? Yeah, usually. And if not, we then have other issues which we'll mention in a minute. So the idea being CBD is one of those buyer beware. It's not regulated. You don't know what's in there and on top of that, how much of it are you using? Are you taking one gummy, two gummies, two brownies, five brownies, whatever you want to take. Okay. It is cumulative. For the Department of Transportation, this is where it gets really sticky. You should not disqualify a driver for taking CBD, but you should warn them that if you pop a positive on a drug test, it's a positive test. The fact that you're using CBD is not a valid explanation for the medical review officer and you will be treated as having had a positive test. So there's guidance in there from ODAPC. There's guidance from the FDA. It's referenced in the medical examiner handbook. A lot of examiners have these little CBD beware kind of flyers or different kinds of discussion points, but you've really got to make sure they understand. It is not an automatic disqualifier and that's, I think, one of the rememberings you've got to do. It's not a disqualifier, but ODAPC and CBD, they remind employer. ODAPC is the Office of Drug and Alcohol Policy and Compliance. That's the group that does, oversees the drug testing. DOT requires testing for marijuana, not for CBD. We test. Labeling is wrong. FDA has cautioned people. CSA has cautioned people. ODAPC is cautioning people. It is also currently illegal to market CBD by adding it to food or resistant dietary supplement. Under federal law, the problem is state laws are very different and the problems are in some states. Georgia, for example, you can have up to 5% THC in a low THC, high CBD product. So that 5% is going to add, you know, 5 milligrams, I'm sorry, is going to crank up a whole lot faster. That was actually 5%. So yeah, that's going to be the real big problem. The other issue we're running into is that those who are selling CBD in order to enhance the psychoactive nature of it are dusting it, spraying it, adding whatever, Delta 8 and Delta 10, which are also psychoactive cannabinoids. So from a safety perspective, cannabis CBD is really scary. I was kind of on the side talking about this, but I figured it means we have a little extra time. I will go to my soapbox a little bit. And rescheduling it will put it in a really big problem because as an agency, the Department of Transportation, our department, is only able to test for Schedule 1 and 2 drugs. So if marijuana goes to Schedule 3, it will not be on the drug panel, even though all the agencies say, we're going to keep testing, we're going to keep testing. By federal regulation, they cannot. What ACOM and several other organizations that I've been working with lately have been trying to do is say, hey, we're not in favor or opposed to having marijuana at Schedule 3. We just want to make sure all the unintended consequences from a workplace safety perspective are reviewed, appreciated, and addressed first. Right now, we can say it to somebody, you may not use oxycodone when on duty or subject to duty. If it becomes a Schedule 3, it's going to be that much harder to marijuana because how long does it stay in the system? It depends. What's the product? Where's the product coming from? How are you ingesting it? Are you ingesting it by an edible? Are you smoking it? Are you vaping it? Are you using it with oils or anything else? So it's not like any other drug. It's not like alcohol. And I know I have discussions with some colleagues is when I drink two shots of whiskey that is by, you know, X proof, you kind of have an idea. You can kind of extrapolate how long that person's going to be under the influence. We don't have that option or that ability with cannabis at this point in time. So bottom line is for the commercial drug or medical exam, if the person is using medical cannabis because it's a scheduled substance, it cannot be permitted, they cannot be qualified. Recreational, not even a question. Schedule 2 through 5 medications can be qualified if with discussion with the treating provider, the treating provider has determined it will not impair and the medical examiner agrees with them because it's your name on that medical certificate. So that's medications in like about a five second nutshell. Reminds everybody CBD and it's over and over again. Take the wording from these slides. Take the handout that is in your syllabus. Just talk to your examiners, talk to your employers. It's really important that everyone understands that we don't care where you got your THC in your system. If it's positive, it's positive. If you're prescribed by a doc, you can't be certified. So I just want to get some clarity in the role between MRO and a commercial drug or medical examiner. Two different people. Understood. My question is, you get this person that comes in and says, I have smoked marijuana, and then you just say, look, don't smoke again. Are you saying you can't clear that person if you're not doing the drug test? MRO is over here. Ignore it. They come into your office and they admit that yes, they smoke marijuana. How often? When was the last time you smoked? A month ago. You can do a drug test if you choose to. A non-DOT drug test, should you choose to. You may decide to qualify them or you may decide not to qualify them. What I would generally do though is, why are you using it? Oh, it's medical. It's been prescribed. That's my trigger to say, nope, sorry, no. The reason being is you're using it to treat a medical condition. What medical condition are you using it to treat? You can't be taking it to treat that medical condition, so what else are you going to do? Go back to your provider and work with them to get something else that you can be treated with that makes that condition stable and controlled. What if they just go and see their friends and go see music? That's recreational. Bye. So when they come into their... But again, you've got to... When they admit it, they do recreational, you just qualify. You've got to do an assessment. And it's up to different examiners. Some have a very low threshold. I smoked marijuana a month and a half ago and they disqualified. We have others that will come in. They'll say, yeah, I smoked at my buddy's party last Saturday night. I know I shouldn't be doing it. We'll make you a drug test. And if they test negative, we may say, okay, that's fine. Examiners may do that. So it really depends on the situation. You've got to really ask the questions. The question might be, okay, well, when you smoke that marijuana... Again, I'm just throwing some ideas out there, so this is all about taking history. When you smoked that marijuana two months ago, were you a driver? If so, for who? How old were you? Were you under age for the state? So again, you can't pigeonhole this. You can't pigeonhole this. Again, right now your role is as medical examiner. It's no different, and this is where a lot of people are saying we've got to go with marijuana and we will have to go if it becomes Schedule 3, is are you taking it at a time where you are impaired? Because we can say, I take oxycodone. Oxycodone extended release is going to be in the system for a damn long time. Do we disqualify every single driver who's taking oxycodone? No. One of the things with cannabis is to some extent we've got to get used to treating it not that different than any other impairing medication, whether we do it now or we do it a month from now, or two years from now. But they cannot be taking it. Your job is to tell them you cannot be taking it. You can use CBD, but it's at your own risk. I'm doing it for a medical condition. Well, how do I know that medical condition is safe and stable? So again, it's not an absolute yes or no, but it's, you know, I'd have a pretty low threshold to testing them. And, you know, if they're in a situation, and again, this is one of the big arguments that a lot of the groups are using, saying, well, if they use it on Friday night and they're not working again until Monday, are they still having it in their system? Probably not. You know, especially if they're infrequent users. Now, that's the reason why the drug test might come in handy, because if they're frequent users and they're five days out, they're going to pop a positive anyway. If they really haven't used it in over a week, two weeks, and they use it rarely, now you do know you're negative this time, but you're going to be in a random testing pool. And you're also going to be in a pool that if you have to have anything that leads to reasonable suspicion or reasonable cause, you're going to get tested. So you may have dodged your bullet this time. But... When can they come back for it? Up to you. And that's specifically in the handbook, that there is no specific waiting period after use of a substance, a legal substance or otherwise. So they come back in a week and... Again, that is up to the examiner to decide what is their problem. Are they saying, I'm taking this for my anxiety? Work with your doctor. What are you taking now? I'm not taking anything. Well, a week later, I'm not sure your anxiety is well enough controlled to certify you, because you've been taking marijuana for a month, or two, or ten. How long have you been on that? So there's a lot of pieces you've got to make that decision. It's not a good answer, but it has to be an individual assessment. But there's no rules for when they can come back? There's no rule for anything on when they can come back. I mean, cardiac, neurologic, you know, nothing. It's really up to the examiner. So again, what we're talking about, you know, this is scheduled substances. No current medical use, you may not certify them if they admit to using a Schedule 1 substance. So if they admit to using it, you start as a no, but then it's a find out of when did they last use, why did they use, how did they use, and get that information. Schedule 2 through 5, Schedule 2, high abuse potential, but you've really got to evaluate, again, the when, the where, the how, the why. And you may certify, make that final decision. You can use the alternate, the optional medication form. 3 and a 5, low potential for abuse, but still may be arrest for impairment. Now, here's another issue. Suboxone, because of a really poorly worded response. Shantix was the same thing, which was then withdrawn. Suboxone, naloxone, naltrexone, any of those combinations do not automatically preclude certification. Neither does methadone. Methadone used to be part of the advisory criteria and somehow snuck its way up into part of the regulation. Methadone is not disqualifying. Suboxone is not automatically disqualifying. You need to have information from the treating provider, the medical examiner makes the final decision. What's important? Would you want a driver who's second on, you know, Dorojevic, has a patch, maybe even has an insulin, a morphine pump? Well, what's the person's underlying condition that's causing them to need that much pain control? If they have that much pain, then maybe they really shouldn't be doing a heavy, medium to heavy job to start with. Does this medication impair them? So again, just because it's not prohibited, it doesn't mean it's a good idea to certify them. Person's taking oxycodone, oxycontin, send it, release, twice a day. Would you certify that driver? Probably not. So why are these things any different? What is the underlying condition? What is the substance use disorder? Have they been totally controlled? Have they had any problems? People relapse. Have they been 10 years on it? Maybe they're fine. Have they been less than that? Maybe they're not. So it has to be that assessment. And again, what is the job? What is the situation? From this perspective, you're certifying them as a commercial driver medical examiner to do any job that may be required for any company. Non-scheduled drugs, FMCSA doesn't have any specific criteria. Get input from the treating provider. Final input is the medical examiner. And as you asked, there's no mandatory waiting period after disclosed drug use. So it's when you feel comfortable bringing them back, just like if they said, I've used it a month ago, I've used it two months ago, I've used it six months ago, I used it a week ago. There's no absolute time at which you say, stop, no, other than I smoked before I came in for the exam. That's a pretty good no. Kind of like I'm having a heart attack while I'm sitting here for my exam. You wouldn't certify that person either. So where are we going back to this? More than they can't do it while they're a commercial driver. Well, again, is this a new hire or a current hire? No current employee. Current employee is a different situation. They're coming back in and they're getting further recertification. That's a whole different thing. I'm thinking new hire. If they're a new hire, maybe. But if they tell you, you know, I'm a current driver, I'm a recertification, and I smoked pot a week ago, no. That's a whole different situation. I'm thinking new hire because hopefully the current employees are not that stupid. And that would be kind of a stupidity test to say, are you using illegal drugs? They may not think of marijuana as illegal, but if they're a current driver, they know it's illegal. So, yes, a lot of- At least they were honest. True. Even if they were stupid, they were honest. Absolutely. So considerations, you know, is information available from the prescribing medical practitioner? What are the side effects that are present? Does the person have any side effects or symptoms of substance abuse disorder? And has the treatment for these non-scheduled one substances been shown to be effective, stay stable, and so forth? This is our optional medication form. You know, I think it's great because it asks, what medications are they taking? What are you prescribing? What are other providers prescribing? Are they having any side effects? And do you feel that they're safe? And then this is where they have that, you know, the medication form gives us all along, talks about driving, talks about transporting passengers, hazardous material. I like to highlight things before I give it to the treating provider to make sure they understand this is a safety-sensitive, cognitively-demanding job. And then just more of this, what medical conditions are being used? And then I just threw these up because I thought they were kind of fun. You know, this medications and dosages you prescribe. We're really looking for the hydrocodone, but adenoviral diazepam, hydrocodone, and then we keep on going down. What problems are being treated? Chronic pain syndrome, seizure disorder. What? You know? So these forms, and this is a really old one that people have made on their own. A lot of clinics used to use them. You never know what you're going to find. So patient medical conditions, or I think there's somebody else's signature on that. So, and then, of course, you get the medication list, and you see they're also on Capra, which they forgot to tell you. So when you're using your medication-optional form, you may find out things that were forgotten that may be significant. Again, you got to use clinical judgment. Oh, I forgot to tell you that I take diphenhydramine as needed, or I take chlorphenidramine, or I take one of those. Does it really matter, you know, or is it one of those, well, Benadryl, well, you really shouldn't be taking this while you're driving. I'm not sure I would ding somebody and not qualify them for something like that. But again, you got to use your judgment. And this was another one I loved. Paris takes morphine sulfate-extended release in oxycodone on a daily basis. First prescription written back in 18. Done very well on his current regimen. Been on it for years. Has been accident-free on the job. Perfectly fit for safety-sensitive duty on this regimen. Yeah, it's like I always would say, most of the drivers' first fatal crashes are their last. And I get a little bit concerned when I see stuff like this. And then we have the final one. A person is physically qualified to drive if they have no current clinical diagnosis of alcoholism. It is not the AA definition of what's an alcoholic. Always an alcoholic, nor does it mean somebody is sitting in your office having a beer while you're having the exam. So when it says it's current alcoholic disease, it is not fully stabilized. And when in remission, the examiner may certainly qualify them if they have information that they are stable and controlled. They may use a non-DOT drug test, or breath alcohol test in this case, to see if they come in. Again, if you're coming for your commercial driver medical exam, and you blow a positive, and you're not working, that's a stupidity test. Key thing, if you happen to have gone for lunch and had a Manhattan while you were at lunch, and I'm looking at Mike, because he knows it's my drink of choice, and then you go for your commercial driver medical exam, that's not really fair if I'm not working. So again, there's certain times that you can test. This is a non-regulated test, so you've got to use some common sense on this. You may want to have somebody who has substance abuse professional training, but you're not required to use a real-life SAP. You may request that information, as I mentioned, and the medical examiner makes the determination. Do they have a current diagnosis? You don't need an evaluation, and if remission, you can certify. Good old, you know, does the person use alcohol? How often do they use it? What do they put down? What's the frequency and volume? And remember, always double it at least. Do they have a current clinical diagnosis? We talked about what that means. Drug and alcohol testing overseen by the Office of Drug and Alcohol Policy and Compliance, ODAPC. This is only relevant, the federal drug testing, to those who count CDLs in most cases. So you have that 10,000, 26,000-pound, you know, gross vehicle weight rating vehicle I talked about earlier. 10,000 to 26,000 pounds. Does it need a CDL? Does it need a drug test? Above 26,000, they don't. You may conduct a pre-employment drug test concurrently with the commercial driver medical exam, federal, regulated. You generally would not be conducting a periodic drug test with the commercial driver recertification exam. Back in the olden days, they were doing recertification exams, drug tests. That went away many, many years ago. So at this point, the only time you might possibly do a federal drug test when someone's for a recertification exam is if it just so happens that they were scheduled for their recert and they got pulled for a random on the same exact day. Doesn't, it probably shouldn't happen very often. ODAXI's website's there, you should know about that. What medications disqualify a driver? Da, da, da, da, da, doesn't list any of them, okay? So remember, there are no really disqualified, unless any substance such as, you know, schedule one substance, and it doesn't talk about, seizure medication, we've talked about that, and methadone's not there anymore. And technically, insulin does, unless they meet the alternative insulin standard. Yeah. Doctor wants me to be in a program, smoking cessation meds, it's up to you, and talk to the treating provider. Can the driver be disqualified for using a legally prescribed medication? The answer is yes, yes, and definitely yes. And again, this is where you have to work with the treating provider. Is that medication safe? Is the underlying condition safe and stable? Can a driver be qualified by using Provigil? The answer for that is, of course. Can I hear a yes? You know, it really depends on, are they stable? What is it being used for? Is it being used because they have narcolepsy? Then probably not. Is it being used for insufficiently treated substructive sleep apnea? Well, why can't they be better treated? Is it being used for Parkinson's disease? Well, what about the Parkinson's disease? So again, it depends. If there's a legitimate reason, and things are relatively controlled otherwise, you can use it as long as you're following it closely. Does the legalization of marijuana, so basically every marijuana question, the answer's going to be it cannot be used and destroyed. Whether it's in-country, out-of-country, in-state, out-of-state, marijuana cannot be used as adult use, and it cannot be used as a Schedule I recommended medication at this point. Alcoholism, if the driver admits to alcohol use and based on responses, may the examiner require additional information? And the answer is yes. I like this question because I kind of wrote it. But look at the date. The date was in 2014. We need to have a question like this for some reason, and Elaine said, try to write something up. Interstate driver test positive for alcohol. Controlled substance must be medically examined. Remember, MRO and drug testing are two separate pieces. They are not required to be re-examined. They need to meet all the return to work and SAP requirements, but not necessarily a new commercial driver medical exam. There's a number of medical expert panel reports, all in red, not on the test, not for official guidance. You may want to look at them. I think you probably should, just to get an idea of what's been going on in 2006 and 2014 in ACOM practice guidelines, but are you required to follow them? No. Should you follow them as a requirement? No. Should you consider them? Probably be aware of them, at least as a start. FAA has a very nice document called Do Not Issue, Do Not Fly. It's not something you should be following absolutely, but it's a really good document. It talks about these are medications that probably should not be permitted in someone who's flying a plane. Is flying a plane and driving a truck similar? Maybe, you know, especially during takeoff and landing, during that in-between time, it's a little different safety concern. It talks about the interval, the dosage interval, in which you might want to avoid taking a certain medication. So again, this is something you may want to look at and may want to consider. Again, advise them to read the label warnings. I mentioned that earlier on. If it says don't drive until you know how it affects you, then don't drive until you know how it affects you, and maybe a bit time beyond that. The FTA also has a prescription over-the-counter toolkit. It's actually a bit out of date by now, but it's, again, another good idea for a company, if you're working for a company that needs policies. They had a number of policies from different transportation, trucking and trucking companies that, you know, again, might be useful to look at and some training material as well. And that's the end of Module 9. So, questions? I have two little pearls. So, Natalie mentioned, and of course it's in the handbook, that examiners could consider doing a non-federal test as part of your evaluation. Tread lightly. That test is now regulated by state and local law, and you may not be able to obtain testing for certain things because of state and local law, depending on where you live, and it may get even more complicated if the driver lives in one state, is headquartered in another, and is doing a job in a third state. Tread carefully. I typically, and this is, again, my opinion, it's not gospel, it's not writ. If I have a question about whether a driver has a drug or alcohol problem, I refer them to a specialist, and I might ask them to do one as part of their evaluation to see whether the driver has a drug or an alcohol problem, because then that drug test is being used for medical reasons, not for a fitness for duty evaluation. They're two separate scenarios. So, that's one pearl. Tread carefully. Not saying you can't do it. And if asked on a test, yep, you can. It's permitted. Then the other thing is, I will use the do not fly guideline of when I'm counseling drivers about medications that may be impairing, and when we have those shared decision-making discussions, that five times the dosing interval or five times a half-life is a useful tool, because sometimes drivers are on these medications and they have never been counseled by the person prescribing them how it may affect their job, whether they're a commercial driver, or a firefighter, or a linesman, or a pilot. I have people I see all the time, and they're like, well, why didn't my primary tell me that I shouldn't take that and drive a small bus? So, it's a very useful tool because it's easy for them to understand. Again, there's resources to look for, okay? It's just, yeah. But again, whether it's five times, whether it's two times, whether it's four, it's things to look at and consider. Let me just ask this question on the do not fly. I know they don't, so that's a guideline to help you make some decisions. It's a guideline that's applicable for individuals who are airmen, okay? It is not applicable for FMCSA. No, but I understand where he's coming from, is that if it makes sense to me. Again, for this course, for this course, and I said in the beginning, that's why I'm trying to bring this discussion back in. For this course, you can use other tools to decide what you want to base your decision on. This is based on your professional judgment and your training, and these are resources that we included for you to look at, for you to read, for you to interpret, not for us to discuss because it's not part of the FMCSA examination. Even as far as the state law, and Dr. Berniking is right, that when you do a drug test on a non-federally regulated situation, you do have to be aware of local requirements. However, our course today, FMCSA is recommending that if you are not sure, now how you would get that done may be different based on what state you're working in. So that's, you know, the problem, but again, this is the course, this is what we're teaching you today. Yes? I realize you're going to say it depends, but I want to know what factors go into your thinking practically when you're seeing people coming in with opioid prescriptions and how you're weighing that. What are they taking? What else are they taking? How long have they been taking it? What's the frequency of taking it? What else are they taking as an adjunct to that regular medication? You know, it's really, it's not a single question, yes, no. And what is the half-life of it? Are they able to avoid taking it when they're on duty or subject to duty? Again, if they're employed by one company, they'd be working for a different company, maybe working for one where they're on call. It's, if we would disqualify every driver who's taking a benzo, an antidepressant, an anxiolytic, basically a narcotic, because narcotics includes all of these drugs, we wouldn't have very many drivers on the road. And it really has to be that individual, what do I feel? What are they taking it for? How have they been taking it? How long have they been taking it? Newly prescribed, I'd be a lot more concerned. They've been taking the same medication, the same dose for five to 10 years, probably a lot less concerned. I would also go ahead and use that optional medication form if I don't really know and have the treating provider weigh in. Am I shifting the responsibility? No. But I'll use that when it is the, eh, I could go either way. And, again, a lot of the medication, there wasn't guidance in the old handbook either. So that's one area that hasn't changed. And you can ask that question, and I get asked that question all the time. There is no, you're going to get, again, 10 examiners in a room asking that question. You're going to get 10 different answers, essentially, and they're all going to be, they all, none of them are illegal. They're all going to be an option for you to do it. So this is where it goes back to, use those tools, take a good history, consider the job description of the physician that they're, you know, which they gave you in the handbook. Can they do those things that are required to do of a commercial driver? Because that's the job description you're looking at in light of using these medications. And, again, it ultimately funnels down into your clinical situation, unfortunately. And there's one more piece, which is your risk tolerance. There were a lot of examiners who say, I know it's really unlikely, which is true, that there's going to be a problem. And I know that I, like this guy, I think he has a really good story. He's given me all the information I've asked for. He's been very cooperative. I'm comfortable doing this. Others are saying, nope, this person has, you know, it's only two times the dosing interval. He can't avoid it because he's taking it while he's working. I'm not certifying them at all. The truth is, just like with sleep apnea, most of the individuals who are on these meds will not have any kind of problem, whether it's a big crash or a near miss. And if we start taking it, much as, you know, I think you've got to be critical of everybody out of work who is a minimally increased risk of something bad happening, we wouldn't have a safety-sensitive workforce, especially nowadays, where if you look, almost everyone's taken Xanax to some shape or form, often as needed. And maybe their condition is controlled, because maybe they do fine, except in certain situations. And there's drugs, I mean, you're talking about drugs, too, that are, you buy them at the counter, and they impair you, and people use them all the time. Yeah. All the time. Safe doesn't mean legal, or legal doesn't mean safe. And again, you have to, you know, and I'm sorry if we sound like broken records on this, it really, there is, if there's one message that I could drive home to you all, you have to treat each person as an individual, you have to consider them as an individual, and you have to give them the information you need to make that decision. And whether that be medical records, using some of these optional tools that we've provided for you today, like the medical panel reports, the do not fly list, whatever, those are all things for you to consider. Are they required? Again, no, they're not, and we've kind of brought that home today, and hopefully you understand that. But a lot of this is designed to help trigger you to consider all the ramifications, and second and third order effects, but at the end of the day, you have to use your clinical judgment, and for examiners that are not comfortable with that, and I know quite a few that are not, they really shouldn't be doing this. I wanna do one final, I'm gonna go to the next section, then we can wrap up some more questions, because May has, but the other thing is, look at the PDR. If the medication has a 30% risk of sedation, then maybe that's not a good one to be using on a regular basis. I mean, I see lots of people on gabapentin, and that bothers me more than most others. So if really, you know, especially, is the dose stable or not? I don't know.

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