6

Summary Assessment: Conclusions and Recommendations

Prior to 1974, the Federal Aviation Administration (FAA) lacked a program to encourage pilots to seek treatment for substance use problems so they could return to work safely. With a grant from the National Institute on Alcohol Abuse and Alcoholism to the Air Line Pilots Association, International (ALPA), and in cooperation with the FAA and airlines, the Human Intervention Motivational Study (HIMS) was created to assess the viability of an occupational program for pilots with alcohol use problems. HIMS was intended to provide a comprehensive approach to treatment and recovery by emphasizing identification, intervention, diagnostic assessment, treatment, continuing care, and relapse assistance. The Flight Attendant Drug and Alcohol Program (FADAP) was established in 2010.

In response to a congressional mandate, this study committee was tasked with reviewing available information on HIMS and FADAP, including recommendations concerning possible changes to the programs and lessons provided for other drug and alcohol treatment programs in the transportation sector. As the committee began its work pursuing the areas of Congressional interest, there was a presumption advanced by the FAA and the Congressional sponsors of the study that HIMS and FADAP were model programs that could serve as the basis for other drug and alcohol treatment programs in the transportation sector. Early in the pursuit of the committee’s charge three observations became clear: (1) that the lack of information made available to the committee, for reasons described in Chapter 1, would limit the ability of the committee to execute the charge; (2) what information was available to the committee created uncertainty regarding the claims about the success of the programs in addressing

substance misuse among pilots and flight attendants; (3) that there was a dearth of current published research on substance misuse directly related to safety-sensitive professionals.

Therefore, the committee conducted a careful review of the science associated with modern evidence-based treatments for substance use problems and considered the unique circumstances that affect case identification and treatment approaches for people employed in general safety-sensitive professions. Although relying on indirect evidence about individuals in safety-sensitive professions, the committee could nevertheless, in its judgement, reasonably inform the management and implementation of programs for pilots and flight attendants. The committee conducted detailed analyses of data obtained on the FADAP. It also examined the publicly reported data from HIMS and assessed those data in light of what is known about the prevalence of substance use disorders among pilots and the processes for identifying pilots with such problems. This concluding chapter reviews the committee’s study approach and challenges encountered, followed by a summary of key findings across thematic areas that led to each of the committee’s conclusions and recommendations.

STUDY APPROACH AND PROCESS

After gathering information about the HIMS and FADAP histories and methods, the committee reviewed presentations and reports prepared by HIMS and FADAP and program administrators in an effort to assess program outcomes and determine the approaches to case identification and treatment in the context of the prevailing scientific evidence. To supplement and independently assess the findings from these sources of information, the committee requested access to HIMS and FADAP outcome databases for analyses by a statistical consultant hired for the study. Furthermore, the committee developed a tool for obtaining testimonials of the lived experiences of pilots and flight attendants experiencing substance misuse problems through a “Call for Perspectives” issued to pilots and flight attendants. Committee members and staff also attended annual meetings of the two programs, met with program administrators and stakeholders, and arranged for interviews of a small group of participants to gain additional first-hand qualitative information about the programs.

In reviewing the literature on the treatment of substance use disorders and consulting experts in the field, the committee documented the changes that have been taking place on the basis of the disease model of addiction. The methods employed by HIMS and FADAP could thus be compared with the state of the best practices for screening, assessing, and treating substance use disorders, while taking into account the special context of professionals in safety-sensitive occupations such as pilots and flight attendants.

During this process, the committee faced several challenges, particularly with respect to access to available data and other information, limiting its pursuit of the charge. The committee was nevertheless able to obtain enough information to reach a few conclusions about the two programs, leading to some limited recommendations on program improvements.

The remainder of this chapter presents a summary of the committee’s findings, followed by its conclusions and recommendations. The committee prioritized findings it viewed as most helpful to aligning the treatment services and overall administration and management of programs for pilots and flight attendants with current evidence on effective treatment for substance use disorders and considerations for safety-sensitive professionals. While the committee identified a few areas in which current practices are at odds with received evidence, it also identified areas where the programs align well with current thinking regarding best practices, such as HIMS’ and FADAP’s emphasis on peer networks to support recovery.

The committee’s conclusions and recommendations are aimed at processes that can improve the HIMS and FADAP. Because HIMS and FADAP differ in important ways that have implications for how they are, and perhaps should be, designed and assessed, the issues related to each are discussed separately as warranted. Because the committee’s recommendations are intended to improve both program management and oversight, they are directed as appropriate to FAA (primarily through its Office of Aerospace Medicine, which is responsible for a broad range of medical programs and services for both the domestic and international aviation communities) and to Congress.

ALIGNING SUBSTANCE USE DISORDER PRACTICES AND POLICIES FOR HIMS AND FADAP WITH THE EVIDENCE BASE

The key functions that the committee sought to understand, and subsequently provide guidance on, related to the following questions: (a) How are pilots and flight attendants that misuse substances identified? (b) How do pilots and flight attendants that misuse substances and need treatment get engaged with treatment? (c) What is the content of treatment strategies employed by the two programs? And (d) How are flight attendants and pilots in need of follow-up care directed to appropriate and effective providers of care?

Before presenting the committee’s individual summary findings, conclusions, and recommendations, the following observations should be highlighted. First, ensuring public safety while providing support for employees needing treatment is an important consideration that applies to all professions that have a duty to serve and protect the public. Throughout this consensus study, the committee was cognizant of the precarious balance in

commercial aviation between ensuring public safety and meeting an obligation to help employees in safety-sensitive positions receive the treatment they need to address substance misuse and use disorders. The primary role and responsibility of FAA is public safety, and thus in many cases it could be reasonable to mandate different approaches to case identification and use of treatment settings than those common in care of the general population. The summary findings highlight some areas where employees could obtain better treatment for substance use disorders by aligning with current, evidence-based science while also minimizing risk to the public.¹

Second, the implementation of substance misuse programs for pilots and flight attendants is highly decentralized, which has implications for the FAA’s ability to track substance misuse and its treatment in pilots and flight attendants, and for the committee’s conclusions and recommendations As described in Chapter 2, FAA follows regulations from the U.S. Department of Transportation (DOT) issued to implement statutory provisions that authorize DOT agencies to provide substance use disorder programs in the different transportation modes. It is the policies and procedures of FAA, then, that create the operational frameworks for HIMS’ and FADAP’s local execution by the airlines and relevant unions.

Third, the implementation of effective programs depends on the ability to assess and monitor practices and outcomes for appropriate management and oversight.

The remainder of this section reviews the specific findings, conclusions, and recommendations developed by the committee, which are informed by key features of evidence-based practices drawn from Chapter 3 and summarized in Box 6-1. The committee observed departures from these practices in its review of HIMS and FADAP in certain key thematic areas. These areas include:

• diagnosis and case identification;
• 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.

The conclusions and recommendations are offered within each of these areas with the goal of identifying potential changes to HIMS and FADAP that could better align the programs with the current evidence base for substance use disorder programs and treatment. We reiterate that because published research on substance misuse among pilots or flight attendants,

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¹ While this report focuses on substance misuse prevention, intervention, and treatment to algin with the statement of task, the committee fully acknowledges that the FAA’s primary responsibility is ensuring the safety of the national airspace.

or even safety-sensitive professionals, is lacking, these conclusions and recommendations are based primarily on evidence from the robust literature available on the qualities of effective substance use programs in general that, in the committee’s judgement, are sufficiently generalizable across individuals and contexts to be able to reasonably inform the management and implementation of programs for pilots and flight attendants, while noting special considerations that could apply to the aviation context.

Diagnosis and Case Identification

The committee observed that current definitions for substance use disorders in the Code of Federal Regulations (CFR) do not always align with current science-based approaches to diagnosis. For example, the FAA’s

language and diagnostic criteria for differentiating between substance abuse and substance dependence (as defined by 14 CFR § 67.107 and reviewed in Chapter 2 of this report) are more restrictive than those in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]. The FAA also uses different blood alcohol content thresholds. This can lead to a pilot meeting the FAA definition of substance abuse or dependence but not the clinical DSM-5 criteria for a substance use disorder.

It is understandable that for the sake of public safety, the primary duty written into its legal charter, the FAA may choose to apply additional considerations in defining what is acceptable substance use for the purpose of case identification. However, while full alignment with DSM criteria may not always be feasible without increasing significant operational risks, more consistent application of evidence-based diagnostic practices could better align treatment approaches with the current science.

Barriers to Early Help Seeking and Access to Affordable Treatment

Even when substance misuse treatment is available, there are often several barriers that keep aviation workers from accessing the services they need. These can come in the form of keeping individuals from even seeking help, due to concerns about employer retaliation, loss of employment, or general stigma related to substance use and mental illness. They may also be more structural barriers, such as lack of financial access or ability to pay for the treatment offered.

Some barriers are inherent to the context of the aviation industry, however, and public safety concerns may preclude their removal. But other barriers can be addressed by cultivating a climate that is supportive of employees’ overall well-being and participation in available programs where appropriate. For example, strict, nonconfidential reporting requirements for mental health and substance use disorders, and the subsequent

threat of employment consequences stemming from beginning treatment, can discourage and deter early treatment. Such requirements can especially affect flight attendants given their weaker employment attachments relative to those of pilots. Additionally, HIMS requires an open release of information (ROI) to be shared with them, allowing access to all records from a treatment episode. While this ensures that employees remain in compliance, it also discourages the initial disclosure of said information, as employees are concerned about losing their careers. Limiting ROIs or placing parameters on which information is shared could increase confidentiality of the employee during their treatment while ensuring a safe return to work. An ideal practice would be to encourage help-seeking by offering access to confidential, voluntary mental health and substance use treatment.

A significant barrier for pilots entering substance use disorder treatment is the unique medical certification requirements that pilots must meet. While HIMS does offer the prospect of a return to the flightdeck upon completion of treatment, identification of a co-occurring disqualifying condition places the pilot’s medical certificate and, in turn, the pilot’s career and livelihood at risk. The committee found a lack of opportunity for prevention or early intervention through confidential sharing of information about health and well-being. Aside from policies that have direct impacts on employment, developing policies that cultivate a climate of help-seeking and health-promoting environments can also contribute to reducing barriers to treatment. For example, creating a context that avoids stigmatizing people with substance use disorders supports voluntary reporting and early treatment, including use of specific nonstigmatizing language. Because screening for substance misuse and comorbid conditions during annual physical exams is known to help to identify misuse, and because existing screenings are yielding rates of 0.5 percent from aviation medical examiners (AME’s) annual examinations, when general screening rates are typically greater than 14 percent, attention is needed to make the AME screening more rigorous and reliable.

Additionally, a key component of an effective program is ensuring awareness of the program. Responses that the committee received from both flight attendants and pilots indicated that many are perhaps unaware of FADAP or HIMS until they have a serious substance use disorder. Without knowledge that the program exists, it will be difficult to get employees the help they need or have them be willing to come forward and be transparent about their concerns or situation.

Recommendation 2: The Federal Aviation Administration should ensure that mandated annual physical exams (e.g., aviation medical examiner examination) for all safety-sensitive professions require screening for substance misuse use tools that are validated for the population and setting.

Recommendation 3: While employment termination is a legitimate outcome if return-to-work policies are not met, the Federal Aviation Administration should ensure that airlines identify and remove features of their workplace substance misuse policies and procedures that are likely barriers to early identification and treatment, such as disclosures that are not likely related to performance in a safety-sensitive position, and consider opportunities to promote more fully early identification and treatment.²

• This committee recognizes the FAA’s expectation of complete transparency from pilots about their physical and mental health to ensure the safety of the public and the national airspace. We also recognize, however, that this requirement may lead pilots to avoid accessing care that is observable to the airlines and to the FAA, and/or lead to dishonest reporting on their Form 8500-8 to avoid jeopardizing their medical certification, and thereby their ability to fly. Such behavior, however, likely serves to increase the risk of adverse events. Thus, while we acknowledge that full implementation of the recommendation may not be immediately actionable until policies and procedures are in place to mitigate concerns about potential short-term risks to operational impairment, the recommended actions remain worthy of serious consideration by the FAA in meeting the ultimate goals of public safety and pilot health.
• As examples for implementation:
  • The FAA could consider not requiring the release of a pilot’s full record as part of medical certification. If concerns for disqualifying conditions are present for a particular pilot (e.g., suicidal ideation, psychosis, ADHD, bipolar disorder), a full release of records could still be required.
  • Because mental health issues co-occur with substance use disorders, the FAA could encourage pilots to confidentially (barring a diagnosis of a major disqualifying condition) seek early care for mental health issues, potentially through a limited waiver for Form 8500-8 or their airline’s EAP.

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² After a prepublication version of the report was provided to the FAA, this section was clarified to accurately reflect FAA’s authorities.

• • The FAA could update Form 8500-8 to be more encouraging of treatment-seeking by not requiring the dates and reasons for mental health visits and asking whether the pilot has sought mental health care (yes/no).

Financial Barriers

In addition to policies and culture, the decentralized structure of HIMS and FADAP results in great variability in the financial costs faced by aviation workers, with flight attendants usually facing greater liabilities that serve to create barriers to care. Although goals and FAA special issuance authorization standards are consistent, the program implementation varies among airlines. Pilots employed by major carriers with robust collective bargaining agreements and union support will often be provided with stronger financial support. Smaller carriers with more limited budgets may leave pilots with much more limited financial protection for mandated treatment and required evaluations and limited financial support during the medical leave.

Flight attendants are more likely than pilots to have limited funding sources to pay for treatment. Moreover, the decision of a flight attendant to go into treatment extends beyond the actual expenses incurred in treatment. Most flight attendants are treated in residential care programs, which in addition to being a high-cost modality results in extended absence from work and income loss.

Allowances and Encouragement for Individualized Treatment

Currently, regardless of diagnosis, HIMS and FADAP emphasize 30 days of residential treatment over individualized treatment plans based on multidimensional assessment. While that is consistent with American Society of Addiction Medicine (ASAM) best practice recommendations for professionals in safety-sensitive occupations and treatment practices for physicians involved with physician health programs, other effective, more flexible, and less costly treatment modalities may be more appropriate. For some, 30 days of residential treatment may not be adequate. Level-of-care placement decisions are insufficiently linked to the severity of illness and individual circumstances. The benefits and risks of any medical treatment must be weighed before the treatment proceeds; this principle applies, of course, to the use of medications for addiction treatment in the context of professionals working in safety-sensitive occupations. However, it is unclear what process the FAA and other oversight organizations for pilots, flight attendants, and other professionals in safety-sensitive occupations use to evaluate and mitigate the risk associated with medication for addiction treatment.

Furthermore, although many mutual help groups exist, Alcoholics Anonymous (AA) is typically the most researched and has the most evidence on its impact on outcomes. HIMS and FADAP continue to recommend AA engagement specifically for their participants. However, that decision may alienate some employees given AA’s spiritual nature and undertones.³ Some evidence shows that other mutual help groups can be just as effective as AA, and other research has shown that social connections with like-minded peers and the adaptive, community-based system they provide are often responsible for treatment benefits.

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³ Captain Dave Fielding, British Airways, presentation to the committee, November 1, 2022, that included an overview of substance use disorder and mental health support systems in UK aviation as a comparison to HIMS.

The following elements should be considered in implementing the recommendation:

• A determination of the severity of disease and treatment recommendations should be made by addiction experts using the ASAM dimensions and should include collateral information. Assessment should include consideration of what puts someone at higher risk (e.g., onset of use, family history of substance use, trauma history) and objective measures of substance use and screening for co-occurring physical and mental health conditions.
• Treatment recommendations, including level of care and length of stay, should be based on the severity of the disease and individual circumstances, not dictated by a required 30 days of residential treatment.
• Aeromedically significant deficits are of significant concern for pilots and the safety of the airspace. Current science indicates that there are medication-assisted treatment (MAT) options that could provide significant benefit to preventing relapse while posing minimal risk for impairment, particularly with appropriate medication selection and monitoring, and as a result of the required neurocognitive evaluations for pilots involved with HIMS. The FAA has a model for successfully and safely introducing lifesaving mental health medications that improve the safety of the airspace; they should explore how this could be adapted for MAT.
• Aftercare planning should, at minimum, include peer support and offer nonspiritual options beyond AA, while being transparent on the depth of the evidence base for these different voluntary involvement programs.

Use of Evidence-Based Criteria in the Selection of Treatment Programs

Each airline has substantial autonomy and discretion in the treatment options it chooses to offer under the auspices of HIMS and FADAP. Although several airlines engage the same treatment programs or models of treatment, local discretion results in providing a range of inconsistent treatment options. While such variation is not necessarily a problem, the justification for the selection of treatment programs is not clearly set forth. One consideration is the differences in the ability of different airlines—from major carriers to smaller, regional carriers—to provide financial incentives and support for effective treatments. As discussed previously, the committee acknowledges that the different levels of financial support offered by the airline would need to be addressed to ensure more widespread involvement and participation in HIMS and FADAP.

In implementing this last recommendation, the key features of evidence-based practice previously mentioned in Box 6-1 should be considered when establishing criteria for the selection of effective substance use disorder treatment programs for transportation professionals.

QUALITY OF DATA AND DATA ANALYSIS FOR PROGRAM MANAGEMENT AND DECISION-MAKING

In its review, the committee encountered several areas where information is lacking that is necessary for the adequate assessment of program functions and performance. Effective programs depend on the ability of the FAA and Congress to assess and monitor practices and performance in the services of appropriate management and oversight. As detailed in Chapter 1, the committee experienced challenges with accessing data and uncovered evidence that raised concerns about the quality of data available to the FAA about the programs, suggesting potential limitations on the quality and comprehensiveness of data available to Congress and the FAA for them to fulfill their management and oversight roles.

HIMS and the FAA make claims about the success of the program that could not be substantiated by the committee, and the committee’s review of reports available to the public raised concerns about important elements of the program that could not be addressed with available information. In several instances data pointed to failure of processes that are inconsistent with claims of success. The lack of meaningful referral based on the annual medical examination of pilots noted earlier is a case in point. ALPA, the administrator of HIMS, acknowledges that the database is limited in its ability to produce advanced insights,⁴ which seems inconsistent with many public statements on the HIMS website that include findings from data on HIMS. As an example of an important issue that could not be fully examined, the committee was unable to discern to what degree there is unmet

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⁴ For more information, see Appendix D.

need and the potential reasons for it. It appears, from the data available, that a sizable portion of pilots likely to have a substance use disorder do not access treatment through HIMS. Alternatively, pilots who need and are seeking treatment may be accessing it outside of the federally mandated system of treatment and return-to-work requirements. HIMS treats roughly 1.5 percent of pilots, yet by HIMS’ own unconfirmed estimates the prevalence rate among pilots for having a substance use disorder is between 8 and 12 percent, which would be lower than the 13 to 15 percent derived from the research literature.⁵ The troubling implication of this is that the FAA and Congress have limited visibility of the degree to which pilots with substance misuse problems are being treated.

Likewise, the FADAP has major gaps in addressing substance misuse and substance use disorders for many flight attendants employed by U.S. commercial airlines. The analysis of the FADAP database highlighted data quality issues that limited the committee’s ability to assess program operations. Specifically, many flight attendants were lost to follow-up tracking and fewer than half of expected flight attendants were captured in the data, because data from some major airlines were missing. This resulted in clear geographic distortions and likely demographic distortions relative to the overall population of flight attendants.

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⁵ https://himsprogram.com/

• for data collection and to include specific post-treatment outcome measures and follow-up assessments to ensure that more complete data are collected.
• In the service of reviewing overall program effectiveness, deidentified data records that HIMS and FADAP collect should be able to be linked to the DOT’s testing database and easily exported to allow more useful and transparent reporting to Congress and any other delegated independent auditors, a process that includes anonymization of data.⁶
• HIMS and FADAP should be required to report to the FAA how they are analyzing and using the data they collect to inform internal program improvements and external customer satisfaction in compliance with EO 13642 and EO 14058. For example, HIMS should consider adopting FADAP’s practice of compiling and publishing an annual, detailed database report.

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⁶ After a prepublication version of the report was provided to the FAA, this section was edited to clarify the specific database and note the type of data records.