Air Force Waiver Guide


Alcohol Abuse and Dependence (May 10)



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Alcohol Abuse and Dependence (May 10)



I. 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 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.
Whenever a flight surgeon suspects that any Air Force member has an alcohol problem he or she is required by AFI 44-121 to inform that member’s commander, who must then take certain steps, including referral for an Alcohol & Drug Abuse Prevention & Treatment (ADAPT) Program evaluation. 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 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.
II. 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.
III. Waiver Considerations.
Alcohol abuse and dependence are disqualifying for all classes of aviation in the US Air Force, to include FC IIU. These conditions may be waived by MAJCOM/SGPA for a period of no greater than three years.

Table 1: Waiver potential for alcohol abuse or dependence.


Flying Class (FC)

Waiver Potential

Waiver Authority

ACS review/evaluation

I/IA

Maybe

AETC


Maybe*

II and III, untrained

Maybe

AETC


Maybe*

II and III, trained

Yes

MAJCOM


Maybe*

IIU

Yes

AFMSA


Maybe*

GBC/ATC

Yes

MAJCOM


Maybe*

SMOD

Yes

AFSPC


Maybe*

† All aviators with a history of alcohol abuse or dependence must remain abstinent, provide documentation of successful treatment and after-care follow-up, and must not take any psychiatric medications.



*ACS evaluation or review is at the discretion of the waiver authority.
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 Feb 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.
IV. Information Required for Waiver Submission.
These conditions may be waived by MAJCOM/SGPA for a period no greater than three years. In order to be considered for waiver, three conditions must be met: 1) individual must have successfully completed treatment (defined below) as determined and documented by the MTF Alcohol & Drug Abuse Prevention & Treatment (ADAPT) program treatment team; 2) the individual must comply with post-treatment aftercare program requirements (also defined below). Flight surgeon participation in both the ADAPT treatment team meetings and aftercare follow up is required; and 3) the individual must have a positive attitude and unqualified acknowledgement of his/her alcohol disorder.
Treatment Program Requirements: Individuals will have successfully completed treatment when the following conditions are met: 1) They meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for early full remission of substance dependence or no longer meet diagnostic criteria for substance abuse; 2) The treatment team determines, based on DSM criteria, individual’s progress towards agreed-upon goals and/or issues as stated in the treatment plan; and 3) They remain abstinent without the need for medication.
Post-treatment Aftercare Program Requirements: 1) The individual must remain abstinent without the need for medication: 2) document participation in an organized substance use aftercare program (e.g., Alcoholics Anonymous-(AA), or other program approved by the MTF ADAPT Program Manager), and 3) meet with the designated professionals for the following specific timeframes:
Table 2: Post-treatment Aftercare Requirements

Professional/Meetings

First Year

Second/Third Year

Fourth Year

Flight Surgeon

Monthly

Quarterly

Annually

ADAPT

Monthly

Monthly

N/A

Psychiatrist, Psychologist, or Social Worker

Annually

Annually

N/A

Organized Alcohol Aftercare Program

3x weekly

1x weekly

Recommended (not required)


Notes:
1. The flight surgeon has primary responsibility for collecting and submitting the required documentation for waiver submission. The ADAPT representative documents substance use aftercare program attendance. Temporary modification of aftercare program requirements because of operational demands must be documented by the flight surgeon.
2. Initial waiver may be requested after ―treatment program completion and successful completion of 90 days in the post-treatment aftercare program.
3. Unsatisfactory Progress in Aftercare Program: Failure of a member to acknowledge his/her alcohol problem, to abstain from alcohol, or to comply with all aftercare requirements is medically disqualifying. The following pertain to any individual who fails to remain abstinent or otherwise not comply with all aftercare program requirements: Ground the member and arrange for re-evaluation by flight surgeon and ADAPT provider to determine potential for re-treatment. If member is determined to have potential for re-treatment, follow the initial waiver and aftercare program processes. If member is determined not to have potential for re-treatment, an AMS must be submitted for permanent disqualification. A second waiver request for substance use disorder may be considered in accordance with initial waiver requirements, but requested no sooner than 12 months from the last date that non-compliance with the post-treatment aftercare program was documented. Second waiver requests are considered on a case-by-case basis only, and waiver authority for these individuals is AFMSA/SG3P.
4. As part of the waiver package, the individual states in writing that they understand the waiver is valid, only if total abstinence from substance is maintained, and that a verifiable break in abstinence, once the waiver period has begun, is considered medically disqualifying. This written statement, kept in the medical records, must be accomplished at the initial waiver request, and re-accomplished each time a waiver renewal is requested.
5. ACS evaluation is not routinely requested in cases of alcohol use disorders, but such an evaluation may be requested through the MAJCOM if an aviator’s flight surgeon and/or commander desire it, particularly for a second opinion. In such cases, a summary of all evaluations (ADAPT Program, medical, and Life Skills) done during the initial workup, a report from a mental health evaluation done within three months of waiver package submission documenting the absence of co-morbid psychiatric pathology and cognitive impairment (e.g. WAIS-R), an aeromedical summary containing salient laboratory values, and required aftercare documentation should be submitted.
The aeromedical summary for initial waiver for alcohol abuse or alcohol dependence should include the following:

A. Aeromedical summary containing a physical and 2 sets of laboratory values (BAT, CBC with MCV, GGT, SGOT, SGPT, triglycerides, and CDT). Labs should be collected at treatment initiation and just before waiver submission. The summary 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 mental status examination.

B. Copy of alcoholism treatment program summary (first time only).

C. ADAPT statements documenting aftercare and AA or other approved alcohol recovery program attendance.

D. Copy of annual psychiatrist/psychologist examination while in aftercare.

E. Letter of recommendation from individual’s commanding officer.

F. Copy of signed abstinence letter (Initial and renewal waiver requests must have a signed abstinence statement included as an AIMWTS attachment). In the abstinence letter, the individual states in writing that he or she understands that, if granted, the waiver is valid only if total abstinence from alcohol is maintained. A verifiable break in abstinence once the waiver period has begun is medically disqualifying. The abstinence letter should be signed and dated immediately upon the individual expressing intent to return to flying status.
Note: There is no formal waiver provision for FC I/IA and initial FC II or FC IIU. If the waiver authority deems it appropriate, a waiver may be considered on a case by case basis only.
The aeromedical summary for waiver renewal for alcohol abuse or alcohol dependence should include the following:

A. Aeromedical Summary - interim history since last waiver.

B. Flight surgeon summary of any interim alcohol-related therapy to include ADAPT and laboratory results as above drawn at time of AMS.

C. Consultations from any providers evaluating member for alcohol problems or assessing them for history of same.



D. Copy of signed abstinence letter (Initial and renewal waiver requests must have a signed abstinence statement included as an AIMWTS attachment). In the abstinence letter, the individual states in writing that he or she understands that, if granted, the waiver is valid only if total abstinence from alcohol is maintained. A verifiable break in abstinence once the waiver period has begun is medically disqualifying. The abstinence letter should be signed and dated immediately upon the individual expressing intent to return to flying status.


ICD 9 codes for alcohol abuse and dependence

305

Alcohol Abuse

303.9

Alcohol Dependence


V. References.
1. 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.
2. American Psychiatric Association DSM-5 Development. Alcohol-Use Disorder. Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=452.
3. Air Force Instruction 44-121, Alcohol and Drug Abuse Prevention and Treatment (ADAPT) Program, 2001.
4. Air Force Instruction 48-123, Aerospace Medicine Medical Examination and Standards, 2009.
5. Jones DR. Aerospace Psychiatry. Ch. 17 in Fundamentals of Aerospace Medicine, 4th ed. Lippincott, Williams and Wilkins, 2008.
6. Yesavage B. Hangover effects on aircraft pilots 14 hours after alcohol ingestion: a preliminary report. American Journal of Psychiatry, 1986; 143: 1546-50.
7. Dawson DA, Goldstein RB, and Grant BF. Rates and correlates of relapse among individuals in remission from DSM-IV alcohol dependence: a 3-year follow-up. Alcohol Clin Exp Res, 2007; 31: 2036-45.
8. Watson CG, Hancock M, Gearhart LP, et al. A comparative outcome study of frequent, moderate, occasional, and nonattenders of Alcoholics Anonymous. J Clin Psychol, 1997; 53:209-14.
9. Vaillant G and Hiller-Sturnhofel S. The Natural History of Alcoholism. Alcohol Health Res World, 1996; 20:152-161.
10. Henry PH, Davis TQ, Engelken EJ, et al. Alcohol-induced performance decrements assessed by two link trainer tasks using experienced pilots. Aerospace Medicine, 1974; 45:1180-89.
WAIVER GUIDE

Updated: Feb 2010

Supersedes Waiver Guide of Nov 2006

By: LtCol Valerie Johnson (RAM 10) and Dr Dan Van Syoc
CONDITION:



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