Summary

Substance use disorders are prevalent in the United States. The National Institutes of Health define a substance use disorder as “a treatable mental disorder that affects a person’s brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or [prescription] medications.” (National Institute of Mental Health, n.d.). National estimates suggest that about 15 percent of the population age 18 and older has a substance use disorder, more than two-thirds of them an alcohol use disorder (SAMHSA, 2021). For the purposes of this report, the committee defined substance misuse¹ as substance use that is problematic from a health, policy, or regulatory perspective, even when it might not meet the diagnostic threshold of a substance use disorder. Substance misuse also includes using substances in inappropriate settings, such as the workplace, or in high doses (McLellan, 2017). The prevalence rate of substance misuse among pilots and flight attendants is uncertain, due to the limited validated data that are available. The general view held both in the literature (Modell & Mountz, 1990; Porges, 2013) and by the Federal Aviation Administration (FAA)^2,3 is that the prevalence rate potentially lies in the

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¹ Although not a universally adopted term, the committee chose to follow the precedent of the Department of Health and Human Services, the Centers for Disease Control and Prevention, and the Surgeon General in using “substance misuse” in this report to describe a broad spectrum of substance use that could be considered problematic from a policy or regulatory perspective despite not meeting the diagnostic threshold of a substance use disorder.

² Flight Attendant Drug and Alcohol Program (FADAP) staff response to the Committee-issued questionnaire, August 2022.

³ HIMS staff response to the Committee-issued questionnaire, August 2022.

range of 8 to 15 percent, which is roughly comparable to the range in the general population.

The job of commercial airline pilots is not like other jobs. Pilots are entrusted with people’s lives while operating a complex machine that engages all neurocognitive domains. Pilots must be prepared to respond rapidly, both cognitively and physically, to altered circumstances in jet aircraft traveling at high speeds in an environment susceptible to rapid change. Flight attendants too must be prepared to respond quickly and effectively in high pressure situations that can change abruptly.

Ensuring that pilots and flight attendants who need treatment for substance misuse are excused from their duties to receive effective treatment is critical for both aviation safety and the health and well-being of pilots. That requires commitment from the government, the employer, the airlines, and the affected individuals. Substance misuse can have a wide range of negative consequences on a person’s life, adversely affecting physical and mental health, relationships, finances, and careers. For many reasons, it is in the public interest to help people obtain effective treatment for their substance misuse and return to work. Otherwise, society faces safety risks and the potential loss of highly skilled pilots and trained flight attendants from the commercial airline workforce.

Established in 1974, the Human Intervention and Motivational Study (HIMS) is a program that coordinates the identification, treatment, return to work, and monitoring of pilots who misuse substances. Similarly, the FADAP, created in 2010, supports flight attendants who misuse substances or have a substance use disorder. Endorsed by the FAA, airlines, and employee unions, both programs seek to ensure aviation safety and preserve the careers of these critical airline workers.

This study, which was sponsored by the FAA in response to a congressional mandate, reviews available evidence and program information on HIMS and FADAP. When it began, a key goal of the study was to identify policies and practices from the two programs that could be relevant and helpful to improving the drug and alcohol programs of other transportation modes. It was also understood, however, that the review could surface needed improvements in HIMS and FADAP, or perhaps point to areas where assessments and evaluations need to be strengthened to improve the effectiveness of the two programs. See Box S-1 for the complete statement of task.

STUDY APPROACH

To conduct the study, the National Academies of Sciences, Engineering, and Medicine appointed a 12-member committee consisting of experts in program evaluation, state regulation of safety-related professions, health economics, and the clinical disciplines (psychiatry and psychology) relevant

to the evaluation and treatment of people with substance use disorders in the airline workforce and other safety-sensitive occupations. At the study outset, the committee assembled information on the histories of the programs and their methods. The committee learned that prior to 1974, the FAA lacked a rehabilitative program to encourage pilots to seek help with recovery and remission to return to work safely. With a grant from the National Institute on Alcohol Abuse and Alcoholism, the Air Line Pilots Association, International (ALPA), in cooperation with the FAA and airlines, created HIMS as a prototype occupational substance use program for pilots. HIMS was intended to provide a comprehensive approach to rehabilitation and recovery by emphasizing identification of pilots misusing substances, diagnostic assessment, treatment, continuing care, monitoring, and relapse assistance. FADAP was created for flight attendants after HIMS had been in place for pilots for more than 35 years.

After gathering information about the HIMS and FADAP histories and methods, the committee reviewed presentations and reports prepared by HIMS and FADAP administrators to assess program outcomes and determine the content of program activities. To supplement and independently assess the reports from the programs, the committee requested access to HIMS and FADAP databases that included more detailed information on treatment and outcomes. The committee intended to conduct analyses that would provide a more complete and detailed description of the work and outcomes produced by the programs with the aid of a consultant hired for the study. In order to obtain more qualitative information on the, lived experiences (a “Call for Perspectives”) of pilots and flight attendants, some of whom may have participated in the programs, the committee developed a tool for eliciting such information. Committee members and staff also attended annual meetings of the two programs, met with program administrators and stakeholders, and arranged to interview a small group of participants to gain additional, first-hand qualitative information about the programs.

In order to put the processes and approaches of the HIMS and FADAP in context, the committee reviewed the robust literature that has emerged over the past few decades on methods to treat and support people who have misuse substances and have substance use disorders. In reviewing this literature and consulting experts in substance use disorder treatment, the committee documented the changes occurring in treatment based on the disease model of addiction. The methods employed by HIMS and FADAP could thus be compared with the state of the clinical science and practice for screening, assessing, and treating professionals with substance use disorders in safety-sensitive occupations. Additionally, the committee focused on examining the evidence base behind alcohol use disorder treatment because alcohol was the most frequent substance being misused in the aviation industry. The same general principles (to varying degrees) apply to all substances with addiction potential, including misused prescription drugs and opioids.

In pursuing this study plan the committee encountered several challenges, particularly with respect to HIMS. Notably, the committee’s effort to undertake an independent analysis of the workings of HIMS was hindered by a lack of access to program records and testimony from pilots on their lived experience. Repeated requests to share de-identified program outcome data with one professional statistician, even with assurances of confidentiality and under the oversight of the National Academies’ Institutional Review Board, were denied by HIMS administrators. Other efforts to ensure protection of the data, including conduct of the analysis by HIMS staff, were rebuffed. Moreover, the committee never received indications that ALPA-HIMS widely circulated the committee’s “Call for Perspectives”

tool for gathering lived experiences among pilots, foreclosing this assessment mechanism.⁴ The result was that the committee obtained just nine responses from pilots. The administrators of FADAP, by comparison, circulated the “Call for Perspectives” to flight attendants and garnered more than 1,000 responses. The committee was successful in holding follow-on qualitative interviews with flight attendants. In contrast, the committee did not receive information on meaningful participation by pilots in this phase of the study. The committee invited pilots to the study’s sole public workshop, but the invited pilots were advised not to participate after having discussions with their union representatives and airline senior staff. In the absence of a range of perspectives from pilots who had participated in HIMS, the committee could obtain the views of only two pilots, both ALPA members with HIMS leadership positions either at the national or airline level. In the case of FADAP only, the committee was able to commission the work of an independent consultant to help analyze program records, flight attendant survey results, and the qualitative interviews of several flight attendants who had either participated in FADAP directly or provided insights into the state of substance use within the profession. Unfortunately, the FADAP data were an incomplete reflection of the population of flight attendants, and a large share of participants were lost to follow-up and therefore outcome data were incomplete.

Unable to fully execute its original study plan, the committee was nevertheless able to reach a number of conclusions about the two programs, leading to recommendations on how to increase the reach and effectiveness of the two programs. These recommendations are summarized next.⁵

SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS

The committee sought to understand the two programs’ efforts on prevention and treatment by seeking answers to three questions: (1) How are pilots and flight attendants that misuse substances identified? (2) How do pilots and flight attendants that misuse substances and need treatment get engaged with treatment? and (3) How are flight attendants and pilots in need of follow-up care directed to appropriate and effective providers of care?

Three overarching observations informed the committee’s recommendations.

First, the committee was cognizant of the precarious balance in

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⁴ After a prepublication version of the report was provided to the FAA, text was changed here and throughout the report to reflect that what was previously termed a survey was in fact a “Call for Perspectives.”

⁵ For an overview of each chapter and appendix, see Chapter 1.

commercial aviation between ensuring public safety and honoring the obligation to help employees in safety-sensitive positions receive the treatment to address their misuse of substances. The primary role and responsibility of the FAA is public safety, and thus it is reasonable for it to mandate more restrictive standards for substance misuse among its workers than are mandated for the general population. The committee found areas where the treatment arranged by HIMS and FADAP was not consistent with treatments grounded in evidence-based science where it appears possible to realize better outcomes while minimizing risk to the public. These areas include approaches to diagnosis and case identification, removal of barriers to early help-seeking and access to treatment, allowances and encouragement for individualized treatment, and use of evidence-based criteria in the selection of treatment programs.

Second, the implementation of substance misuse programs for pilots and flight attendants is highly decentralized, creating challenges for determining how to take the recommended actions that would align the programs with evidence-based practices.

Third, the implementation of effective programs necessarily depends on the ability to assess and monitor practices and outcomes for appropriate management and oversight. As described in Chapter 1, the committee experienced challenges with accessing data about the programs. Based on its review of the publicly reported data and the program data received from FADAP, the committee also developed concerns about the type and quality of data available to the FAA and the Congress that those bodies need to fulfill their management and oversight roles.

The committee’s detailed conclusions and recommendations can be found in Chapter 6.

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