And then that should work. OK. Lucky me. Psych and substance abuse is going to be something that's going to be challenging. OK. Active psychosis, of course, we're not going to approve them to drive, right? So we want to look at substantially comprised compromise judgment, attentional difficulties, suicidal behavior or ideation. That's going to become important. Personality disorder that repeatedly manifests by overt inappropriate acts. The guy running naked down the middle of the street is the one I think about. And then any of the medications, what are the side effects of the medications to control said disease? OK. So to be qualified, the driver has to be compliant with the treatment program, no disqualifying side effects, included a comprehensive evaluation by a mental health professional who understands the functions and demands of commercial driving. Good luck with that. For all the psychiatric diagnoses, let's function on the history and functional status, not on the specific diagnosis. Per the 2021 CDME guide, it is unlikely that drivers who are highly susceptible to frequent states of emotional instability, i.e., schizophrenia, affective psychosis, paranoia, severe anxiety, or depressive neurosis would satisfy the physical requirements. Just going to tilt it back so we can see your face. OK. It used to be these were hard stops, OK? But if you're going to certify somebody, yeah. It's affective psychosis. Yeah. Affective psychosis is on the hard note. Yeah. If they're actively psychotic, no, please don't give them a card. Right. So unlikely to be certified are the following, OK? If you are going to certify them, you're going to need, well, really, really large cojones. And that's my personal opinion. And you're going to need to provide a lot of information on why you're certifying them. Once again, I keep thinking about Naomi. Being famous is good. Being infamous is not good. And being the doctor that certifies somebody that goes out and drives a bus or a big vehicle and kills 20 people. Do you guys know what that is? No. So case by case, you're really going to ride herd with your mental health specialist. And it gives you a psychiatrist or psychologist, OK? So let's get somebody, even if all you're doing is a phone console. OK, when I first started giving this course, you had to see a mental health provider for this case. Now you don't. OK? Waiting period, there's no waiting period, OK? You can certify for a year. The etiology must be shown to be adequate, effective, safe, and stable. Now, once again, you want to understand what happens if these people don't get their medicine, OK? So this is the same. Don't, if they've got active psychosis, please don't certify them. And then any treatment side effects that interfere with safe driving, like somnolence, OK? Bipolar disorder. Number one cause of death in people that are diagnosed with bipolar. Suicide. So bipolar is, in my practice, I made anyone with a bipolar diagnosis see a mental health professional because medication has to be switched a lot. I really didn't want the risk. And like I said, number one cause of death is suicide. OK, so how long is this a real diagnosis, OK? Or was this given to them by erroneously 20 years ago? Or is this a real diagnosis? They need to be symptom-free following a non-psychotic major depression unaccompanied by suicidal behavior, OK? Number one cause of death, bipolar, suicide, OK? How long has the driver been symptom-free? Following a severe depression, or a suicide attempt, or a manic episode? What is their medication dosage? Are the medications causing any side effects of the driver? Is the treatment adequate, safe, stable, da, da, da, da, OK? OK, no longer. You can certify for a year. So recommend certifying if they're symptom-free. They've completed some kind of treatment program, so you're going to want to note from the person that's treating them and tolerates the treatment. Now, the treatment can't increase their sedation. And they're going to have to have, every time you certify, a complete evaluation by a mental health provider who understands the functions. And you're going to include that with your certificate. And you're going to include that with your stuff, OK? You're not going to write a loan on this. Even if all you're doing, because you're very rural, even if you've got an agreement with a mental health provider that you can talk to on the phone, OK? Because sometimes that's all we can get. So this is the same. So of course, if they have active psychosis, we don't want to certify them. And then any personality defects that are going to manifest as over-inappropriate acts, OK? So at least every two years, you need an evaluation by your mental health specialist, OK? And then you're supposed to advise the driver that if they have a manic or severe depression episode, that they self-report within 30 days. And please document that you've advised the driver, because I don't know about you, but I don't see a whole lot of drivers self-reporting. And then they're only certified every year. Depression. This is no longer available. I mean, we used to have waiting periods. Those are no longer in the standard. We, of course, if they're actively psychotic, we're not going to certify them. And then at least every two years, have a mental health specialist evaluate them. And then advise the driver and document that you've advised the driver that they report any manic or severe major depressive episode within 30 days of onset. Only one year. It's my fault? Yeah. Yeah. If anybody's taking medicine for anything you need to think about, it's a one-year card. OK. So I've never gotten pushback. Employers know this is how this works. And the employers, they get a one-year card that employers have. Less than a one-year card, you may get crankiness. But one-year or two-year card is what they expect. And it's less than a year they can afford. They've got so many people that are diabetic, hypertensive, whatever, they don't even think about it. And it won't impact the trial. So personality disorder. So if that personality disorder is characterized by excessive aggression, impulsive behaviors, we're really going to have to look at them for a risk assessment. And we really want to decide whether or not we're willing to put ourselves on the line and let them drive. If they're medically unqualified, if the disorder is severe enough to have repeatedly manifested by overt acts, please document these, because they'll doctor show. Alcohol and drug dependency abuse are profound disorders that we see in personality disorders. And if those factors are present, we need to know that. There's no recommended waiting period. But you want to make sure they're safe and stable and all that good stuff. And you can only certify for a year. Schizophrenia used to be a hard no. It used to be one of those, they said, history of schizophrenia, never going to drive for FMCSA. They took that out. Okay. If you're actively psychotic, okay, you do not want to certify. If a person is hearing voices, we probably don't want to certify. If they're delusional or having hallucinations, we probably don't want to certify. If their anti-psychotic therapy is causing sedation and motor abnormalities, such as muscle, I don't know if any of you have dealt with any schizophrenics, but some of the anti-schizophrenic medication can cause some significant muscle rigidity and tremors. And it may impair their coordination to drive. And especially during initiation of medication and adjustment of dosage, you really want to be careful about certifying them to drive. It's unlikely that you're going to certify these people. Go ahead. The reason that this is happening, I think the reason this is happening, I've had a couple of these people show up and people, the treatment of schizophrenia is improving. And some of the people that are on the Depo meds, where they're getting a shot every six months, so they can't forget or not take it, they can do that for five years and they're doing okay. And that's the kind of patient that might be okay for this. And, you know, but you may want to say, well, what's the dosage in the world of new medicine? Oh, it's every six months, you're going to get six months on carbs. I a hundred percent want to know you got the shot. Right. Right. Because that's the risk of schizophrenia. The real risk is that people stop treating. Right. They stop taking their medicine. And if you've ever dealt with any homeless populations, a good majority of them are schizophrenic that are not taking their medication. On medication, they're wonderful, but at some point they just stopped taking it. So this isn't a two week cowbell dick you're talking about, it's something longer. There's some longer acting antipsychotics that work for some people. And I've seen a couple of younger people, one of them was trying to fly. Good luck with this. But again, this may be a problem, but his psychiatrist said he'd been doing great for five years in this treatment. He's doing great. He's like finished college and he was doing fine. Yeah. And so the treatment has really improved. Might be able to be certified. You get to decide how flexible you wanna be. So I wouldn't have a problem with someone that like Carl's talking about doing a six month card. If they're doing oral medicine, me personally, Dr. Clark, I'm not gonna certify him. There's too much literature and too much research that talks about a discontinuation of treatment and the bad things that happen. Okay. So these are not schizophrenia. Okay. So if your patient's been diagnosed with these, that doesn't fall under the same risks. Okay. Now of course you don't want them to be actively delusional. You don't want them to be actively psychotic, but a brief reactive psychosis is not disqualifying. And it may never happen again. If fully resolved. Right. If you stress a person enough, they're gonna have one of these. Okay. We're not perfect. We're human. So there are waiting periods for these. Brief reactive psychosis is six months. Schizophrenic form disorder is six months. And all other psychotic disorders are one year maximum. Once again, if they're not perfect, maximum certification one year, right? They need to complete a symptom-free waiting period. The, you've got to be in lockstep with their mental health provider. Okay. And they've got to tolerate treatment without disqualifying side effects. Okay. And you're gonna want that evaluation by the mental health provider. Hopefully that understands the functions and demands of commercial driving. Okay. Don't certify if they're actively schizophrenic. Okay. If they've got active psychosis, if they've got prominent negative symptoms, and if they're doing overt inappropriate acts. Those are not someone you want to be driving a lethal weapon. Okay. Psychotic disorders, you wanna, at least every two years, they should have an evaluation and clearance for commercial driving from a mental health specialist, such as a psychiatrist or psychologist who understands the functions and demands of driving. You're supposed to advise the driver that if they have a manic or severe major depressive episode they're supposed to self-report within 30 days. Please document this. Okay. You can do it. Yeah. So alcoholism. Now we all know alcoholism is a disease and the recidivism rate is very high. That's gonna be important. The SAP, which is not you, okay, determines that alcoholism exists. Once again, not you. Okay. Driver is not qualified to drive a commercial vehicle while he has a diagnosis of alcoholism. And the ultimate responsibility rests with the motor carrier, not you. Okay. The motor carrier is supposed to ensure that the driver is medically qualified and determine whether a new medical examination should be completed, not you. Okay. Alcoholism. When an interstate driver tests positive for alcohol, once again, not you, okay, or controlled substances under part 382, the driver is not required to be medically reexamined or to obtain a new medical examiner certificate. Okay. Not you. You don't even know about it. Provided the driver is seen by a SAP, not you, who evaluates the driver and does not make a clinical diagnosis of alcoholism. So Joe Bob shows up at work drunk and they test him and he's like way over the limit. Okay. And they find out he's been drinking a quart every day and it's been going on since his wife left him. Not sure if she left him because he was drinking a quart a day, but anyway. But if they don't diagnose him with alcoholism, they can't drive drunk, but if they don't have the diagnosis, you're not even going to know about it. Okay. If the SAP provides the driver with documentation, the driver returns to work. Once again, you're nowhere in this scenario. Okay. No waiting period is recommended. Don't certify a driver until the driver has successfully completed counseling and or treatment. Now I've had this happen to me. I had a driver come in and he had a note where he failed a drug test and I have no note from the SAF. He can't certify. He's, I've got to have that note from the SAF, okay, that says this is, it's not a problem. Yes, he failed, you know, he went to Colorado where it's legal to have marijuana and we're going to wait out that period because he can't have a positive test and return to driving, okay. So if distant use of use, you're going to talk about the medical conditions, recent use, you're going to want a SAF recommendation. Recommend to certify no residual disqualifying physical impairment from their drug use, successfully completed counseling and or treatment per the SAF and no current disqualifying alcohol related disorders. I mean, they don't have the Pharisees and, you know, all the other things that go on. Okay, don't certify if they're an active practicing alcoholic, okay. Current alcoholic illness or non-compliance with DOT alcohol conduct guidelines, okay. An alcohol-related unstable physical condition and if they've not met their return to duty requirements, you can't certify ongoing, and this is really important because you'll, number one, you'll see it again and number two, it will walk through your door. If they're going through a 12-step program like Alcoholics Anonymous, that is for maintenance of recovery and is not disqualifying. Maintenance of, you're going to see this again, okay. You may decide that you want more testing. Just one quick thing on alcohol that I got back at one time. In the questionnaire, you may ask, do you use regular alcohol? And I have had very honest driver and he would mark yes. So that's an example of where in your discussed yes answers and when I asked him, he had a beer every Saturday during the games. So I had not explained it because he told me that and when the employer or somebody had seen, it said yes and it hadn't been explained. I got pushback. So just to be aware. So if they yes, then explain how much, okay. I have a beer every Saturday. I have a glass of wine every Friday, you know, explain it or you're going to get pushback. Okay, let's talk about drug abuse. Okay. Which is now made really, really interesting because marijuana is legal in a lot of places. It's not legal federally. So, and you're going to see this both on the exam and in your office. Okay. If they're positive, they will not drive. Period. End of discussion. Can't certify them. I don't care, you know, what they're coming in with. Okay. So THC, they're still currently testing for it. They're testing for a lot of things right now. You'll see a lot of stuff show up. Just know that THC is a really long half-life and it may be months, months before it's out of their system. Cocaine, amphetamines, methamphetamines, codeine, morphine, one to two days has been the longest research has ever shown that these have been still in the system. Cocaine is supposed to be really rapidly metabolized. So I'm a retired colonel and we used to have to stand at the gate and point people out that they would drug test. That was what they did on active duty. And it was like usually a Friday or Saturday night. That's all the random. Yeah. I love doing that. Anyway, so, but I would get positives for cocaine. Okay. What do you get from an MRO? A negative, a non-negative, a refusal to test, and test canceled. Okay. Now people can refuse to test, but if it is in their job description that says they must test. All of our drivers have to. Right. But in routine MRO work, you can refuse to test, but if you sign something that says you will be tested, they can fire you without cause. Okay. If a driver refuses to test, they must be removed. If the driver has a positive drug test, they must be removed. Okay. And to return to safety, safety sensitive duties, the driver must be evaluated by a SAP, which is not you. Comply with the SAP recommendation. Once again, not you. So, so, so hold on. Just, I just, you keep saying this. I just want to clarify this. As a physician, you can become a SAP. If you want to live in this world, that is an option. I don't recommend it. If you're going to be the examiner, but there are some people that want to do MRO and SAP and do that for big companies. That's okay. Physicians are going to take the class and get certified, but we're going to assume that you're not, maybe you've not dived into the world that deeply and you're going to let a SAP, a SAP do the SAP work. Right. So in, in order to go back to work, you have to have a negative drug test. Okay. Not a big deal for everything, but THC because everything is usually out of your system, except THC. And I've had, I can't probably five or six cases come in that are two to three to four months out and are still positive. Just depends on the, remember THC lives in your fat. And if you're a typical Texan, you get some extra fat. Okay. So no specific recommended timeframe for waiting. You should not certify the driver for the duration of the prohibited drugs in use. And a second examination must show the driver is free from the prohibited drug, i.e. negative drug tests and has completed the rehab that's been ordered by the SAP, which mostly should not be you. This is one of those few areas that you can certify for two years. Don't, don't, I personally don't agree with it, but the book answer is two years. And you may see this again because this is an outlier. If it's, if it's, if it's old drug use, that might be very reasonable. If it's recent drug use, that probably won't be true. Yep. So you're going to certify if the driver has no history of drug use, no residuals, and for proof of a successful completion of return to duty requirements. Now I've had more than one person come into my office trying to get me to return them to duty without a SAP letter. Can't do it. I explained it to them and they're like, but, but, but, but I'm like, go to your SAP, get a letter from them. I'm more than happy to do your physical. Other than that, I can't do it. Okay. Don't certify if controlled substance use, marijuana, any other habit forming drug for which the exception guidelines do not apply. Methadone is a hard stop. It's one of the very few ones that's still left. Okay. Doesn't matter. They got a note from their provider that says they've been using it forever and they almost stable. Methadone is a hard no. Okay. Note the 12 stuff programs. They are maintenance and are not disqualifying. Very important. You will see that again. So, so let me just stop for a second. Stay away from drug testing. When is it, when would you as the, as the CDME not certify somebody for drug use? They don't have a letter from the SAP. Well, no, so that's, that's, that's, that's drug testing stuff. When would you not certify somebody because of drug use? It's part of your exam. They report that they use drugs. Right. Exactly. So the two things I would, I would see methadone for that sounds like they'll tell you, I've never had anybody walk in and say, Oh yeah, I use cocaine. I've never had anybody do that, but they will come and tell you about methadone. That's a prescribed medication. They'll also tell you about the medical marijuana. Right. Those are two hard notes. And so they admit to drug use in your office and tell you about it. That's a fail. Current drug use. I should be careful. Okay. Or is that the Suboxone count as maintenance of recovery or is that treated like methadone? No. Well, okay. So this is, so I think we said this yesterday, but if you're, if you're months and months out, if you've been at least six months on your Suboxone, you're probably safe to drive. So I wouldn't worry about that too much. Assuming it's prescribed, it's just, they picked on methadone specifically because it was the only drug at the time, 30 years ago, when they made up the regulation. And so that's the one that's in the regulation and they kept telling us they were going to add Suboxone to that regulation, but that never happened. And I don't, at this point, I suspect it will not. So that, that, so yeah, if there were any medication for maintenance, that's okay. As long as it's not methadone. Does that answer your question? And they're on a stable dose. They've been on it for a while. Like my cutoff for chronic opiates and Suboxones and opiate is six months. If they're not, they need to be on it for at least six months before I will find them safe to drive. Does that answer the question? I hope so. Okay. Here we go. Okay. So you have the option to certify them for less than two years, but you can go two years. Scenario one, driver taking antipsychotic medication. You ask why? And they indicate they were diagnosed with schizophrenia as a teen and have been using the medication since. They see a psychiatrist and have done well. A note from their psychiatrist says they've been stable for 18 years and are fit to be a commercial driver. What's your decision? So the old answer was not to certify. The new answer, tough. If they're on oral medication, I personally would not certify. If they're on a shot that's given every six months, I'd probably give them a six-month guard. Scenario two, 43-year-old male who self-identifies as an alcoholic reports the date of his last drink eight years ago and that he participated in AA most weeks and will increase his attendance during stressful periods. No evidence of current alcohol use. Certificate decision. What are you going to do? You can give them a two-year. That's the book answer. Okay. Scenario three, patient with ADHD treated with medications. Psychotic episode two months ago. Was hospitalized. Medications adjusted. No psychotic symptoms since. Certification decision. Two months out from a psychotic episode should be at least six months. And you're going to want a written opinion from the psychiatrist that's treating them. Okay. Bipolar patient, well-controlled, stable medication, eight years. Certification decision. One year. Stable on treatment. Some of these do not, it doesn't pass the sniff test, but this says the book answer is one year. Scenario five, 38-year-old male for recertification. Last, about five years ago. Was using opiates for several years. Now in a medical assisted treatment program. Her note from medical director has been on Suboxone for 18 months. Stable dose. No drug test problems. Attends weekly counseling and frequent groups doing well. So actually the literature supports the stable dose and then being on the same dose for a long period of time, greater than six months, means that these people are more likely to be a good issue. Okay. Versus what, you know, your automatic is no, no, no, they're on opioids, but because they've been on a stable dose, we're going to say yes. Now you could issue six months to a year. The episodic use of opioids are more of a problem than the stable recurring dose that's used every day. Okay. I'm much more concerned about someone who, Oh, I've got some back pain and took his wife's Vicodin. Okay. Hey, it's a federal, it's a federal no, no to take someone else's medicine and episodic use leads to a lot more problems. Questions from the, from virtual land. I don't know how to do those. I'm going to let you do that. Yes. You know, we can't diagnose an alcoholic, but if a driver comes in and says, I'm drinking most nights of the week, more than the criteria that's in the DSM, can you do a non-certify and further evaluate that substance abuse? Yes, you can recommend they be evaluated, but you're not allowed to make the diagnosis. But you can not certify them based on what you put. You can do determination pending. Yeah. And if you, you, okay. I I'm staying away from DSM, anything five, six SP, whatever the new one is. If you think somebody has more drinking than what is a normal amount, if they drink it at a wedding four times a year, I don't care. They can have their beer on Saturdays at the game. I don't care about that, but be able to drink every day reliably. I said, what happens if you miss it? What happens if you don't, if you're an alcohol and they start, they get jittery that I'm not certifying that person they're symptomatic alcohol until proven. Otherwise I realized I don't make psych diagnoses, but they're not called. They have not called issue until proven otherwise. Did we answer the chat question? I know I'll, I was going to pop up as soon as we got back to wherever I could see them. Okay. I know there were like four chat questions that we haven't seen yet. Okay. How are we in terms of we are, we have one and a half, we have two to go. We'll be fine. Okay. Um, so that question was answered. So I think it's just this one question. How to determine is it has out active alcoholism, basically somewhere with the elevated BAL. So if they haven't activated blood alcohol level, then they're an active alcoholic and they're, they're not safe to drive. If they drink on a regular basis. Um, and especially if they report being symptomatic when they don't get to drink, they're an alcoholic and they're alcohol dependent and that's not okay. And it's not, it's not the, you know, yes, I'm George. I'm an alcoholic. That's not the, that's not the diagnosis we're going for. We're going for current alcohol use. Um, that is practicing alcoholic. Um, so more than four drinks a day or probably more than four drinks would definitely be a concern. And it may, and it might be less than that. And it really depends on how that, if I really, the thing that really gets me is symptoms if they're, if they're not using.

commercial driving

psychiatric certification

substance abuse

mental health evaluation

treatment compliance

schizophrenia

drug testing