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Safety Recommendation Details

Safety Recommendation I-14-001
Details
Synopsis: The use of over-the-counter (OTC), prescription, and illicit drugs is increasing in the US population. The National Transportation Safety Board (NTSB) is concerned about the possible safety implications of increased drug use in all modes of transportation. Yet, in most modes of transportation, data about drug use by vehicle operators is limited to a small proportion of operators and a short list of drugs. Aviation is the one mode in which the regulatory authority, the Federal Aviation Administration (FAA), routinely conducts extensive postaccident toxicology testing on fatally injured pilots. This study used the results from this testing to assess drug use in aviation. By assessing evidence of fatally injured pilots’ drug use prior to flying and the associated potential for impairment, this study addressed a serious aviation safety issue and a growing transportation safety concern.
Recommendation: TO THE FIFTY STATES, THE DISTRICT OF COLUMBIA, AND THE COMMONWEALTH OF PUERTO RICO: Include in all state guidelines regarding prescribing controlled substances for pain a recommendation that health care providers discuss with patients the effect their medical condition and medication use may have on their ability to safely operate a vehicle in any mode of transportation.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Intermodal
Location: United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14SS003
Accident Reports:
Report #: SS-14-01
Accident Date: 2/11/2014
Issue Date: 9/23/2014
Date Closed:
Addressee(s) and Addressee Status: Commonwealth of Kentucky (Closed - Acceptable Action)
Commonwealth of Massachusetts (Open - Acceptable Response)
Commonwealth of Pennsylvania (Open - Unacceptable Response)
Commonwealth of Puerto Rico (Open - Await Response)
Commonwealth of Virginia (Closed - Reconsidered)
District of Columbia (Closed - Unacceptable Action - No Response Received)
State of Alabama (Closed - Unacceptable Action - No Response Received)
State of Alaska (Closed - Unacceptable Action - No Response Received)
State of Arizona (Closed - Unacceptable Action - No Response Received)
State of Arkansas (Closed - Unacceptable Action - No Response Received)
State of California (Closed - Unacceptable Action - No Response Received)
State of Colorado (Closed - Unacceptable Action - No Response Received)
State of Connecticut (Closed - Unacceptable Action - No Response Received)
State of Delaware (Closed - Unacceptable Action - No Response Received)
State of Florida (Open - Acceptable Response)
State of Georgia (Closed - Unacceptable Action - No Response Received)
State of Hawaii (Closed - Unacceptable Action)
State of Idaho (Open - Acceptable Response)
State of Illinois (Open - Acceptable Response)
State of Indiana (Closed - Unacceptable Action - No Response Received)
State of Iowa (Closed - Acceptable Action)
State of Kansas (Open - Await Response)
State of Louisiana (Open - Await Response)
State of Maine (Open - Await Response)
State of Maryland (Open - Unacceptable Response)
State of Michigan (Open - Unacceptable Response)
State of Minnesota (Closed - Acceptable Action)
State of Mississippi (Open - Await Response)
State of Missouri (Closed - Unacceptable Action - No Response Received)
State of Montana (Open - Await Response)
State of Nebraska (Closed - Unacceptable Action - No Response Received)
State of Nevada (Open - Await Response)
State of New Hampshire (Closed - Unacceptable Action - No Response Received)
State of New Jersey (Closed - Unacceptable Action - No Response Received)
State of New Mexico (Closed - Unacceptable Action - No Response Received)
State of New York (Closed - Unacceptable Action - No Response Received)
State of North Carolina (Closed - Unacceptable Action - No Response Received)
State of North Dakota (Closed - Acceptable Action)
State of Ohio (Closed - Acceptable Action)
State of Oklahoma (Closed - Acceptable Action)
State of Oregon (Closed - Acceptable Action)
State of Rhode Island (Open - Acceptable Response)
State of South Carolina (Closed - Unacceptable Action - No Response Received)
State of South Dakota (Open - Acceptable Response)
State of Tennessee (Closed - Unacceptable Action - No Response Received)
State of Texas (Open - Unacceptable Response)
State of Utah (Open - Acceptable Response)
State of Vermont (Closed - Acceptable Action)
State of Washington (Closed - Unacceptable Action - No Response Received)
State of West Virginia (Closed - Acceptable Action)
State of Wisconsin (Open - Acceptable Response)
State of Wyoming (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: State of Alabama
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Alabama
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Alaska
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Alaska
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Arizona
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Arizona
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Arkansas
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Arkansas
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of California
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of California
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Colorado
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Colorado
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Connecticut
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Connecticut
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Delaware
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Delaware
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: District of Columbia
Date: 5/10/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: District of Columbia
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Florida
Date: 3/6/2018
Response: On March 30, 2016, Ms. Allison Dudley, then Executive Director, Florida Board of Pharmacy, responded to this recommendation via e-mail, writing that, in early 2016, the Florida legislature passed a bill requiring the Florida Department of Health to develop and distribute an educational pamphlet regarding pain management prescriptions, which would include information on safe vehicle operation when a person is using a controlled substance. On July 21, 2016, pending development and distribution of this pamphlet containing the recommended discussion, Safety Recommendation I-14-1 was classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: State of Florida
Date: 7/21/2016
Response: We note that the Florida legislature recently passed a bill requiring the Florida Department of Health to develop and distribute an educational pamphlet regarding pain management prescriptions. The department plans to include in this pamphlet information about the safe operation of any vehicle when the operator is using controlled substances. Pending development and distribution of this pamphlet containing the recommended discussion, Safety Recommendation I-14-1 remains classified OPEN—ACCEPTABLE RESPONSE.

From: State of Florida
To: NTSB
Date: 3/30/2016
Response: -From Allison M. Dudley, J.D., Executive Director, Board of Pharmacy, Department of Health, Division of Medical Quality Assurance: Thank you for your follow-up letter concerning the National Transportation Safety Board’s Safety Recommendations I-14-1 and 2. With regard to the first safety recommendation, the legislation I previously mentioned has passed. The legislation requires the Department of Health to create a pamphlet relating to controlled substances. When this pamphlet is developed, I will recommend that it include information about the safe operation of any vehicle when on controlled substances. With regard to the second safety recommendation, the Boards of Pharmacy, Nursing, Medicine and Osteopathic Medicine will place the draft article on the each board’s website. The mission of the Department of Health is to protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts. I hope this answers your questions and concerns. Please do not hesitate to call or write if you have any additional questions.

From: NTSB
To: State of Florida
Date: 3/11/2016
Response: We note that Section 465.024, Florida Statutes, warns pharmacists, health care practitioners, and patients about the negative effects that controlled substances may have on a patient’s ability to safely operate a vehicle and that, during the 2016 Florida legislative session, Senate Bill 1378 was introduced to address safety issues concerning controlled substances. If this bill becomes law, the Florida Department of Health would be required to develop and distribute a written educational pamphlet relating to controlled substances that includes precautions regarding pain management prescriptions. Ms. Dudley’s e-mail indicated that, if this bill becomes law, the Florida Department of Health would ensure that the pamphlet includes safety precautions concerning the operation of a vehicle while using controlled substances. We remind you that, to satisfy our recommendation, such a discussion should address operating a vehicle in any mode of transportation. Pending the state of Florida’s completing these actions, Safety Recommendation I-14-1 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Florida
To: NTSB
Date: 1/27/2016
Response: -From Allison M. Dudley, J.D., Executive Director, Board of Pharmacy, Department of Health, Division of Medical Quality Assurance, State of Florida: Thank you for your letter to Governor Scott regarding the recommendations of the National Transportation Safety Board (NTSB). As Executive Director for the Board of Pharmacy (Board), the entity that regulates the practice of pharmacy in Florida, I have been asked to respond. Thank you for sharing the NTSB’s recommendations with the Board. The state of Florida has long recognized that controlled substances may impact a patient’s ability to safely operate a vehicle. Section 465.024, Florida Statutes warns pharmacists, health care practitioners and patients of these potential negative effects and provides in pertinent part… “It is declared that the unrestricted use of certain controlled substances, causing abnormal reactions that may interfere with the user’s physical reflexes and judgments, may create hazardous circumstances which may cause accidents to the user and to others, thereby affecting the public health, safety, and welfare. It is further declared to be in the public interest to limit the means of promoting the sale and use of these drugs.” Additionally, during the 2016 Florida legislative session, Senate Bill 1378 was introduced to address safety issues concerning controlled substances. If this bill becomes law, the Florida Department of Health would be required to develop and distribute a written educational pamphlet relating to controlled substances that includes precautions regarding pain management prescriptions. If this bill ultimately becomes law, the Department would ensure that the pamphlet includes important safety precautions concerning the operation of a vehicle while using controlled substances. The mission of the Department of Health is to protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts. Again, thank you for sharing you’re the NTSB’s recommendations. If you have any additional questions, please do not hesitate to contact me.

From: NTSB
To: State of Florida
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Georgia
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Georgia
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Hawaii
Date: 7/2/2018
Response: We note that at its April 12, 2018, meeting, the HMB determined that its pain management guidelines address this recommendation; therefore, it does not plan to revise or amend them. According to the guidelines, when opioid analgesics are prescribed for pain management, the prescriber and the patient need to create an informed consent agreement, and, while creating this document, the physician should discuss the risks and benefits of controlled substance use with the patient. These guidelines include a document titled “Informed Consent for Opioid Prescribed Pills,” which has a series of statements the patient must initial, including When I take these pills, it may not be safe for me to drive, operate machinery, or take care of people. If I feel sleepy, confused, or impaired by these pills or other drugs, I should not do things that may harm others. Although we believe this statement would be more responsive to our recommendation if it addressed operating a vehicle in any mode of transportation, we also believe that by including both driving and operating machinery in this statement, the HMB has satisfied Safety Recommendation I-14-1. On December 30, 2015, Ms. Awakuni Colón wrote us that the Hawaii Board of Nursing (HBN) had adopted the American Nurses Association (ANA) Code of Ethics. Her letter pointed out that the code’s “right to self-determination” at Interpretive Statements 1.4 explains that self determination is the philosophical basis for informed consent in health care, and that patients have the moral and legal right to determine what will be done with their own person. On March 11, 2016, we replied that medical prescribers possess significantly more knowledge than patients about the impairments associated with medications and medical conditions. The purpose of Safety Recommendation I-14-1 is to ensure that medical prescribers have provided patients with adequate information about the dangers of operating any type of vehicle while using medication. We do not believe that Interpretive Statements 1.4 of the ANA Code of Ethics adequately addresses this issue, nor do we believe that providing a patient with important medical information regarding risk constitutes an infringement on the patient’s right to self-determination. We note that at its April 5, 2018, meeting, the HBN discussed our March 11, 2016, and March 6, 2018, letters regarding this recommendation. The HBN disagrees that the ANA Code of Ethics does not address Safety Recommendation I 14 1 and does not plan to take any further action. Ms. Awakuni Colón’s May 25, 2018, letter did not provide any information about where the ANA Code of Ethics discusses prescribers providing patients with information about the risks of operating an automobile or any other type of vehicle while using a medication. We believe that such information from the prescriber is needed for the patient to provide informed consent. Ms. Awakuni Colón also said that the HBN posted the following documents on its website: • Guidance Statement—Pharmacist’s Corresponding Responsibility When Dispensing Controlled Substances • Checklist for Prescribing Opioids for Chronic Pain • Exclusionary Formulary for Advanced Practice Registered Nurses Granted Prescriptive Authority We reviewed these documents and did not find anything about a prescriber informing a patient of the risks of operating any type of vehicle when using a medication, even if it is taken correctly and as prescribed. Although the HMB has satisfied the recommended action, the HBN has not and does not plan to do so. Consequently, Safety Recommendation I-14-1 is classified CLOSED--UNACCEPTABLE ACTION.

From: State of Hawaii
To: NTSB
Date: 5/25/2018
Response: -From Catherine P. Awakuni Colon, Director of Commerce and Consumer Affairs: At its April 5, 2018 meeting, the Board of Nursing ("Board") discussed the March 6, 2018 letter from Robert L. Sumwalt, Ill, Chairman of the NTSB, stating that the Board's reference to the American Nurses Association ("ANA") Code of Ethics, specifically the code's "right to self-determination" is "irrelevant to Safety Recommendation 1-14-1." The Board disagreed with the Chairman's determination of the Board's reference to the ANA Code of Ethics. As the regulatory agency for the practice of nursing in this State, the Board is responsible for ensuring the safe practice of nursing and therefore determined that reference to a section of the ANA Code of Ethics was relevant. In March 2016, the Board developed a memorandum in response to the NTSB's November 2015 letter from former Chairman Christopher Hart. This memorandum that was posted on the Board's web page on March 1, 2016, a copy of which is attached, includes reference to the NTSB article. In addition, the Board, in its efforts to continually provide information and guidance to their nurses, also posted the following information: • Guidance Statement - Pharmacist's Corresponding Responsibility When Dispensing Controlled Substances; • Checklist for Prescribing Opioids for Chronic Pain; and • Exclusionary Formulary for Advanced Practice Registered Nurses Granted Prescriptive Authority. The safe prescribing of any medication that impacts the mental or physical state of an individual patient is and should be a concern for any prescriber, thus the Board will continue to provide nurses as much information and guidance so that they can ensure the safety of their patients.

From: State of Hawaii
To: NTSB
Date: 4/26/2018
Response: -From Ahlani K. Quiogue, Executive Officer, Hawaii Medical Board: Regarding your email dated April 24, 2018, and the following inquiry: It appears to me from the Medical Board’s deliberations described in your message that no further action in response to I-14-1 is planned, and therefore we should close I-14-1. Is that correct that you regard your action as having satisfied the recommendation, and no further action is planned? Yes, the Hawaii Medical Board believes that it has satisfied the I-14-1 recommendation based on its Guidelines, the requirements set forth in Hawaii Revised Statutes §329-38.5, and the “Informed Consent for Opioid Prescribed Pills”, which was attached to my email dated April 23, 2018. Further, while this was not specifically addressed at its meeting on April 12, 2018, the Hawaii Medical Board’s administrative rules also contain a provision for informed consent, specifically Hawaii Administrative Rules §16-85-25, includes general standards for categories of information for informed consent. I have included the following language for your consideration: (a) Except as provided in subsection (b), where standards of medical practice indicate that a health care provider should provide the patient, or the patient’s guardian, with information prior to obtaining consent for proposed medical or surgical treatment, or for a diagnostic procedure, information satisfying the following categories shall be supplied to the patient or the patient’s guardian: (1) The condition to be treated or the suspected existence of which is the indication for a diagnostic procedure; (2) A description of the proposed medical or surgical treatment or diagnostic procedure; (3) The intended and anticipated result; (4) The recognized alternative treatments or diagnostic procedures, including the option of not providing treatment or performing the diagnostic procedure; (5) The recognized substantial risks of serious complication or mortality associated with the proposed treatment or diagnostic procedure, with the recognized alternative treatments or diagnostic procedures, and with not undertaking treatment or diagnosis; and (6) The recognized benefits of the proposed treatment or diagnostic procedure, of recognized alternative treatments or diagnostic procedures, and of not undertaking treatment or diagnosis. (b) The disclosure of information required by subsection (a) may be withheld if in the judgment of the health care provider the information would be detrimental to the patient’s mental or physical health, or not in the best interest of the patient, provided that such action is consistent with general standards of medical and surgical practice. Lastly, regarding the NTSB Safety Recommendation I-14-2 as it pertains to the Board of Nursing and Board of Dental Examiners, I am attaching for your review the boards Memorandums dated March 2016 and April 2016, for your review. Based on these attachments, it appears that both boards included the NTSB article as well as the recommendations. Does this satisfy that requirement? Please let me know and I will pass your response on to those boards. Thank you for your continued efforts in working with the State of Hawaii.

From: State of Hawaii
To: NTSB
Date: 4/23/2018
Response: From Ahlani K. Quiogue Executive Officer Hawaii Medical Board Department of Commerce & Consumer Affairs Professional & Vocational Licensing Division: Thank you for your patience in awaiting a response. At its April 12, 2018 meeting, the Hawaii Medical Board (“Board”) reviewed the NTSB’s correspondence regarding its Safety Recommendations I-14-1 and -2, and determined that it will not amend and/or revise its Pain Management Guidelines (“Guidelines”). I have attached for your review its Guidelines. It is the Board’s belief that the following language from its Guidelines clarify its expectations of physicians and patients when opioid analgesics are prescribed for purposes of pain management and also addresses the NTSB’s comments/concerns as relayed in its initial correspondence dated November 12, 2015, and most recent email from you dated March 22, 2018: Section III: Practice Guidelines for Chronic Pain Management Informed Consent and Agreement for Treatment – The physician should discuss the risks and benefits of the use of controlled substances with the patient, persons designated by the patient or with the patient’s surrogate or guardian. Medical Records – The physician should keep accurate, current and complete medical records. Elements considered for completeness may include, but are not limited to the following: 5. Discussion and documentation of risks, benefits and alternatives; 6. Results of treatment(s) provided (changes in pain intensity and character, interference with activities of daily living), and management of side effects. Compliance With Controlled Substance Laws and Rules – To prescribe, dispense or administer controlled substances, the physician must be licensed in the state and comply with applicable federal and state laws. Instead, the Board directed me to: (1) post on its webpage, as a separate document and/or addendum to its Memorandum dated March 2016 (attached), the article entitled “Evidence that Pilots are Increasingly Using Over-the-Counter, Prescription, and Illicit Drugs”; (2) refer you to Hawaii Revised Statutes section 329-38.5 (https://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0329/HRS_0329-0038_0005.htm), which required the Department of Health to create and place on its website a template for informed consent and requirement for written policies; and (3) provide you a copy of the of “Informed Consent for Opioid Prescribed Pills” (attached), which contains a statement that a patient must review, understand, and accept regarding the possible hazards of driving, operating machinery, etc. while taking opioids. With regard to number 1, prior to making any changes to the content on its webpage, please note that its Memorandum dated March 2016, includes not only the Safety Recommendations I-14-1 and -2, but it also includes the “I-14-2 DropIn” language or what we initially assumed was the article the NTSB wanted posted. If there is another article you would like us to include online or if we completely misunderstood your directive, please let me know. Thank you for your attention to this matter. Should you have any questions, please let me know.

From: State of Hawaii
To: NTSB
Date: 3/20/2018
Response: -From Catherine P. Awakuni Colon, Director, Department of Commerce and Consumer Affairs: This is in response to your letter dated March 6, 2018, addressed to Governor David Ige, regarding the issuance of the National Transportation Safety Board’s (NTSB) Safety Recommendations I-14-1 and -2 to the State of Hawaii on September 23, 2014. The Recommendations were a result of the NTSB’s safety study, Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment. Please be advised that the Hawaii Board of Pharmacy, Board of Nursing, Board of Dental Examiners, and the Hawaii Medical Board will review your most recent letter at their March, April, and May meetings respectively, to address your dissatisfaction with my letter dated December 30, 2015. For your additional information, the aforementioned boards will discuss, among other things: 1. Specific to the Board of Nursing, your opinion that its adoption of the American Nurses Association Code of Ethics “right to self-determination” statement is “irrelevant to Safety Recommendation I-14-1, and that medical prescribers will likely possess significantly more knowledge than patients about impairments association with medications and medical conditions... [The NTSB] does not believe that Interpretive Statements 1.4 of the American Nurses Association Code of Ethics adequately addresses this issue, nor do we believe that providing a patient with important medical information regarding risk constitutes an infringement on the patient’s right to self-determination.” 2. Specific to the Hawaii Medical Board, amending its Pain Management Guidelines per your recommendation(s). As you may be aware, these guidelines are just that, guidelines, which provide general information for both physicians and patients to ensure appropriate and safe prescribing of opioid analgesics for purposes of managing pain. This document in no way is to be used as a document to address a specific profession, such as pilots. 3. Whether the boards will be publishing not only the guidelines on their websites, but also the “sample article” to satisfy Safety Recommendation I-14-2. Please be advised that neither I, nor the boards’ offices received your response dated March 11, 2016, and, thus, one can presume that we did not receive the “sample article” either. As the Director of the Department of Commerce and Consumer Affairs, it is my goal, as well as my staffs’, to ensure compliance with both Hawaii State and federal laws, while maintaining the regulatory boards’ autonomy to carry out their legislative mandate to ensure the safety of the consumers of the State of Hawaii. Please feel free to contact us again should you have any questions.

From: NTSB
To: State of Hawaii
Date: 3/6/2018
Response: A December 30, 2015, letter from Ms. Catherine P. Awakuni Colon, Director, Department of Commerce and Consumer Affairs, said that the Hawaii Board of Nursing had adopted the American Nurses Association Code of Ethics. The code’s “right to self-determination” at Interpretive Statements 1.4 explains that self-determination is the philosophical basis for informed consent in health care, and that patients have the moral and legal right to determine what will be done with their own person. On March 11, 2016, we replied that this statement is irrelevant to Safety Recommendation I-14-1, and that medical prescribers will likely possess significantly more knowledge than patients about the impairments associated with medications and medical conditions. The purpose of Safety Recommendation I-14-1 is to ensure that medical prescribers have provided patients with adequate information about the dangers of operating any type of vehicle while using medication. We do not believe that Interpretive Statements 1.4 of the American Nurses Association Code of Ethics adequately addresses this issue, nor do we believe that providing a patient with important medical information regarding risk constitutes an infringement on the patient’s right to self-determination. Ms. Awakuni Colon’s letter also said that the Hawaii Medical Board adopted the American Medical Association’s Code of Medical Ethics, which requires a physician to provide competent medical care, and that the Hawaii Medical Board considered competent medical care to include a discussion of the risks and benefits of prescribing medications. Further, she wrote that the Medical Board adopted pain management guidelines in 2006 for physicians’ reference in providing a quality medical practice. In our March 11, 2016, reply, we asked you to confirm that these pain management guidelines recommend that health care providers discuss with patients the effect their medical conditions and medication use may have on their ability to safely operate a vehicle in any mode of transportation. If the guidelines do not include that specific recommendation, or if the recommendation is limited to only automobile driving, we said that the Hawaii Medical Board needed to revise the guidelines to satisfy Safety Recommendation I-14-1. Pending such revisions for each profession with prescribing authority in the state of Hawaii, Safety Recommendation I 14 1 was classified OPEN--ACCEPTABLE RESPONSE. We have not received any further information from you regarding this recommendation since Ms. Awakuni Colon’s letter. Please tell us whether the Hawaii Medical Board has reviewed its guidelines and determined that they satisfy the recommendation or has revised its guidelines accordingly. Please also inform us whether other boards for professions with prescribing authority in Hawaii have issued guidelines to satisfy this recommendation.

From: NTSB
To: State of Hawaii
Date: 3/11/2016
Response: We note that the Hawaii Board of Nursing has adopted the American Nurses Association Code of Ethics. The code’s “right to self-determination,” at Interpretive Statements 1.4, explains that self-determination is the philosophical basis for informed consent in health care, and that patients have the moral and legal right to determine what will be done with their own person. We are unclear of the relevance of this statement to Safety Recommendation I-14-1. Medical prescribers will likely possess significantly more information and knowledge than the patient about the impairments associated with medications and medical conditions. The purpose of Safety Recommendation I-14-1 is to ensure that the medical prescriber has provided adequate information to a patient about the dangers of operating a vehicle (any type of vehicle) while using the medication. We do not believe that Interpretive Statements 1.4 of the American Nurses Association Code of Ethics adequately addresses this issue, nor do we believe that providing a patient with important medical information regarding the risk constitutes an infringement of the patient’s right to self-determination. We also note that the Hawaii Medical Board adopted the American Medical Association’s Code of Medical Ethics, which requires a physician to provide competent medical care. We further note that the Hawaii Medical Board considers competent medical care to include a discussion of the risks and benefits of prescribing medications and that the Board adopted Pain Management Guidelines in 2006 for a physician’s reference in providing a quality medical practice. Please confirm that these Pain Management Guidelines include a recommendation that health care providers discuss with patients the effect their medical condition and medication use may have on their ability to safely operate a vehicle in any mode of transportation. If these guidelines do not include this specific recommendation, or the recommendation is limited to only automobile driving (as opposed to vehicle operation in any mode of transportation), we ask that the Hawaii Medical Board revise these guidelines to satisfy Safety Recommendation I-14-1. Pending revisions that satisfy Safety Recommendation I-14-1 for each profession with prescribing authority in the state of Hawaii, Safety Recommendation I-14-1 is classified OPEN--ACCEPTABLE RESPONSE.

From: State of Hawaii
To: NTSB
Date: 12/30/2015
Response: -From Catherine P. Awakuni Colon, Director, State of Hawaii, Department of Commerce and Consumer Affairs: This is in response to your November 12, 2015 letter to Governor David lge regarding the NTSB Safety Recommendations 1-14-1 and 1-14-2, issued on September 23, 2014. Hawaii's Board of Pharmacy, Board of Nursing, Board of Dental Examiners, and the Hawaii Medical Board have placed or will be placing these recommendations on their respective meeting agendas for the months of December and January. The recommendations also will be placed on the webpages of these boards under "Important Announcements" for our licensees and the public to view. In addition, a copy of your letter will be shared with the Hawaii Department of Public Safety, Narcotics Enforcement Division ("DPS-NED"). DPS-NED is the agency that registers practitioners who prescribe controlled substances and narcotics in the State. For your information, the Hawaii Board of Nursing has already adopted the American Nurses Association Code of Ethics for Nurses. The Code of Ethics for Nurses with Interpretive Statements 1.4 (The right to self-determination) states in relevant part: Self-determination, also known as autonomy, is the philosophical basis for informed consent in health care. Patients have the moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed judgment; ... The Hawaii Medical Board, likewise, adopted the American Medical Association's Code of Medical Ethics, which also requires the physician to provide competent medical care. The Hawaii Medical Board considers competent medical care to include a discussion of the risks and benefits of prescribing medication and, in 2006, adopted Pain Management Guidelines for a physician's reference in providing a quality medical practice. Please feel free to contact us again should you have any questions.

From: NTSB
To: State of Hawaii
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Idaho
Date: 8/10/2018
Response: On March 28, 2018, the Idaho Board of Medicine satisfied its portion of this recommendation by posting revisions to its Guidelines for the Chronic Use of Opioid Analgesics on its website. On May 14, 2018, we said that for you to fully satisfy this recommendation, the Idaho Board of Nursing, which had not yet responded to this recommendation, also needed to revise its guidelines for nurses with prescribing authority. Ms. Evans wrote that the Board of Nursing would publish an “Update from the Board of Nursing” in the August 2018 issue of RN Idaho, the quarterly publication of the American Nurses Association chapter for Idaho (ANA Idaho). This update would include a paragraph encouraging nurses to “routinely discuss with patients the effect their diagnosed medical conditions or recommended and prescribed drugs might have on their ability to safely operate a vehicle in any mode of transportation.” We point out that these are not the prescribing guidelines that are the subject of Safety Recommendation I 14-1. On June 12, 2018, we asked Ms. Evans which of the following three possibilities applied in Idaho: • Nurses in Idaho with prescribing authority use the Idaho Board of Medicine’s Guidelines for the Chronic Use of Opioid Analgesics • For nurses with prescribing authority in Idaho, there are no prescribing guidelines for opioids • There are other guidelines used by nurses with prescribing authority in Idaho We did not receive an answer, so we followed up on June 22, 2018, to confirm that Ms. Evans had received our inquiry. We pointed out that if nurses with prescribing authority in Idaho use the Board of Medicine’s Guidelines, or if there were no prescribing guidelines for nurses in Idaho, then the state of Idaho had satisfied Safety Recommendation I-14-1. We asked that Ms. Evans send us any guidelines used by nurses with prescribing authority in Idaho so we could review them to determine if they contained the recommended discussion between prescribers and patients. If the guidelines did not contain that, we recommended that they be revised to do so. We have not received a response from Ms. Evans, nor have we been able to find any prescribing guidelines on the Idaho Board of Nursing’s website. Please tell us if nurses with prescribing authority in Idaho follow any guidelines when prescribing controlled substances for pain. Pending the answer to that question, Safety Recommendation I 14 1 remains classified OPEN--ACCEPTABLE RESPONSE.

From: State of Idaho
To: NTSB
Date: 6/5/2018
Response: -From Sandra Evans, MAEd, RN, Executive Director, Idaho Board of Nursing: The Idaho Board of Nursing has taken the following steps to address Safety Recommendations I-14-1 and -2, as requested in your letter addressed to C. L. Otter, Idaho Governor, dated March 4, 2018: 1. Included a paragraph encouraging nurses to “routinely discuss with patients the effect their diagnosed medical conditions or recommended and prescribed drugs might have on their ability to safely operate a vehicle in any mode of transportation”, and inviting nurses to visit www.ntsb.gov to “learn more” in the “Update from the Board of Nursing” to be published in the August 2018 issue of RN Idaho . RN Idaho is the quarterly publication of ANA Idaho, a constituent of the American Nurses Association for Idaho’s licensed registered nurses. The publication is mailed quarterly to the nearly 30,000 licensed practical, registered and advanced practice registered nurses licensed in Idaho and can be accessed online at www.idahonurses.org. 2. The sample NTSB news article, “Evidence that pilots are Increasingly Using Over-the-Counter, Prescription and Illicit Drugs”, is cited in the above article and will be posted to both the Board of Nursing’s website at www.ibn.idaho.gov as well as the ANA Idaho website at www.idahonurses.org. 3. The August “Update from the Board of Nursing” includes the link to the above sample article. Please let me know if additional information is needed.

From: NTSB
To: State of Idaho
Date: 5/14/2018
Response: We note that on March 28, 2018, the Idaho Board of Medicine placed on its website revisions to its Guidelines for the Chronic Use of Opioid Analgesics that satisfy this recommendation. The Idaho Board of Nursing, which has not yet responded to this recommendation, also needs to revise its guidelines for nurses with prescribing authority. Pending the Board of Nursing revising its guidelines as recommended, Safety Recommendation I-14-1 is classified OPEN--ACCEPTABLE RESPONSE.

From: State of Idaho
To: NTSB
Date: 3/28/2018
Response: -From Anne K. Lawler, JD, RN, Executive Director, Idaho State Board of Medicine: We added the I-14-2 Drop-in to our most recent newsletter, which was e-mailed to all of our licensees today. Attached is a copy. The article appears on page 3. In addition, I added the language along the lines of what you sent from Oregon in two places in our Opioid Policy, attached. You will see it in the top group of bullet points on page 9, which is the recommended Informed Consent language, and again on the top of page 10, which is the safety warnings that are recommended to be provided to the patient. We will re-upload this new version of the Opioid Policy to our website this afternoon. Thank you for your guidance on these points.

From: State of Idaho
To: NTSB
Date: 3/6/2018
Response: -From Anne K. Lawler, JD, RN, Executive Director, Idaho State Board of Medicine: Thank you for following up regarding Safety Recommendations I-14-001 and -002. As former Executive Director of the Board of Medicine, Nancy Kerr, stated in her September 23, 2014 e-mail, she included an article regarding the NTSB Safety Recommendations in the 2014 third quarter newsletter, attached. This article is found on the top right of page 3 of the newsletter and included a link to the NTSB website for further reference. In addition, the Board continues to provide its licensees and the public up to date guidelines from the CDC and the Federation of State Medical Boards regarding the prescribing of controlled substances for pain. Please see the Board’s webpage with these policies, procedures, and guidelines at the following link: https://bom.idaho.gov/BOMPortal/BoardAdditional.aspx?Board=BOM&BureauLinkID=320 The “Board of Medicine Guidelines for the Chronic Use of Opioid Analgesics,” the second link on this page, was just updated recently, to incorporate the CDC Guidelines for Prescribing Opioids for Chronic Pain. These guidelines reinforce prescriber communication with patients regarding safe use of controlled substances for pain in all circumstances. Further, the Board of Medicine is actively participating in the Idaho Opioid Misuse and Overdose Strategic Plan 2017-2022 group through the Idaho Office of Drug Policy. The 5-year vision of this group is for “A safe and healthy Idaho free of opioid misuse and untreated opioid use disorders.” I am happy to share the NTSB Safety Recommendations with this group to share with prescribers, as well. Please let me know if you have updated information you would like the Board of Medicine to provide to its licensees and I will include that information in the quarterly newsletter that I am preparing currently for e-mail distribution to our licensees and for posting on our website. Please let me know if you would like additional information. -From Alex J. Adams, PharmD, MPH, Executive Director, Idaho State Board of Pharmacy: The Idaho Board of Pharmacy featured the attached article on the homepage of our website from 2015-2016: https://web.archive.org/web/20160121162939/http://bop.idaho.gov:80/

From: NTSB
To: State of Idaho
Date: 3/6/2018
Response: The only information that we have received regarding your state’s response to these recommendations was a September 23, 2014, e-mail from Ms. Nancy Kerr, then Executive Director, Idaho State Board of Medicine; however, Ms. Kerr’s e-mail did not describe your plans to address Safety Recommendation I-14-1. On November 3, 2014, we said that, pending details of Idaho’s plans to satisfy Safety Recommendation I-14-1, it remained classified OPEN--AWAIT RESPONSE.

From: NTSB
To: State of Idaho
Date: 11/3/2014
Response: Because Ms. Kerr did not describe your plans to address this recommendation, it remains classified OPEN—AWAIT RESPONSE pending our receipt of those details.

From: State of Idaho
To: NTSB
Date: 9/23/2014
Response: -From Nancy M. Kerr, RN, M.Ed., CMBE, Executive Director: Thank you, will include a reminder in next quarter’s newsletter. You may also wish to send a copy to the Board of Nursing (Nurse Practitioners are independent in Idaho).

From: NTSB
To: State of Illinois
Date: 5/15/2018
Response: We note that, under the Illinois Controlled Substances Act, dispensers of pain medications, typically pharmacists, are required to affix a label to medication containers with directions for use and cautionary statements. We further note that, under the administrative rules associated with the Illinois Pharmacy Practice Act, prior to dispensing a prescription to a new patient, a new medication to an existing patient, or a medication with a change in dose, strength, route of administration, or directions for use, a pharmacist is required to verbally counsel the patient on common severe side and adverse effects, how to avoid them, and what to do if they occur. Although we appreciate the value and benefits of these requirements, they do not address Safety Recommendation I-14-1 because pharmacists and dispensers are not prescribers. Further, medication labels are not the same as prescribers discussing with patients the effect their medical conditions and medication use may have on their ability to safely operate a vehicle in any mode of transportation; in fact, our investigations have found that these labels are ineffective. On January 13, 2000, we issued Safety Recommendation I-00-5 to the US Food and Drug Administration (FDA), recommending that the FDA revise labels on medication containers to address our finding that medication label warnings regarding vehicle operator impairments were vague, confusing, and did not effectively inform patients about proper precautions. The FDA did not take the action that we recommended. In our 2014 study issuing Safety Recommendation I 14 1, we concluded that current written and oral communications do not effectively inform patients about the risks their medical conditions and drug use may pose to operating a vehicle in any mode of transportation. In addition to the activities described above, we further note that the IDFPR is amending the administrative rules related to the Medical Practice Act to include implementing the “Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain” developed by the Federation of State Medical Boards. This policy will require any physician prescribing controlled substances to establish an informed consent and treatment agreement with the patient. The policy will require that the physician discuss the risks and benefits of the treatment with the patient, and that the informed consent document contain information about the medication’s potential side effects, such as cognitive and motor skill impairment (which would affect driving and other tasks). The amendments to the administrative rules related to the Medical Practice Act may address this recommendation if the informed consent specifically addresses both driving and operating a vehicle in any mode of transportation. We have found generalized warnings, such as to use caution when operating heavy machinery, to be ineffective if they do not specifically include vehicle operation. To ensure that the amendments address the issues in our recommendation, on April 11, 2018, we e-mailed Ms. Masiello our 2014 study and a note about where to find the basis for the recommendation. To fully satisfy this recommendation, the amendments will need to apply to all medical professionals with prescribing authority; typically, that includes physician assistants and advanced practice registered nurses in addition to physicians. Pending revisions to the administrative rules that apply to all medical professionals with prescribing authority in Illinois, Safety Recommendation I-14-1 is classified OPEN--ACCEPTABLE RESPONSE.

From: State of Illinois
To: NTSB
Date: 4/6/2018
Response: -From Dina M. Masiello, General Counsel, Illinois Department of Financial and Professional Regulation: Currently any health care professional in Illinois who prescribes pain mediation, i.e. a controlled substance, is subject to the Illinois Controlled Substances Act ("Act"). Under the Act, dispensers are charged with dispensing controlled substances in good faith by prescription "and he or she shall affix to the container in which such substance is sold or dispensed a label indicating the directions for use and cautionary statements, if any, contained in any prescription." 720 ILCS 570/312(f). Further, IDFPR is in the process of amending the Administrative Rules related to the Medical Practice Act to include the implementation of the "Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain" ("Policy") as authored by the Federation of State Medical Boards. The Policy requires that any physician licensed to administer controlled substances must establish informed consent and a treatment agreement. Specifically, the Policy requires that the physician discuss the risks and benefits of the treatment plan with the patient and that informed consent documents contain the following: The potential risks and anticipated benefits of chronic opioid therapy. Potential side effects (short and long-term) of the medication, such as cognitive impairment. The risk of drug interactions and over-sedation. The risk of impaired motor skills (affecting driving and other tasks). See Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain, https://www.azdo.gov/Files/FSMBPainMgmt.pdf Moreover, pursuant to the Administrative Rules regarding the Illinois Pharmacy Practice Act, prior to dispensing a prescription to a new patient, a new medication to an existing patient, or a medication that has had a change in the dose, strength, route of administration or directions for use, the pharmacist shall provide verbal counseling to the patient, which includes counseling on "common severe side effects, adverse effects, or interactions and therapeutic contraindications that may be encountered, including their avoidance and the action required if they occur." 68 IAC 1330.700. Thus, the related Illinois Acts and Rules as well as the anticipated implementation of the Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain require that health care professionals advise patients of any side effects associated with use of a controlled substance, such as cognitive impairment or impaired motor skills and other adverse effects.

From: NTSB
To: State of Illinois
Date: 3/6/2018
Response: In an October 16, 2014, letter, Erica J. Borggren, Acting Secretary, Illinois Department of Transportation, said that the Illinois Department of Transportation does not have regulatory responsibility over the guidelines regarding prescribing controlled substances, nor does it publish newsletters or other routine forms of communication for licensed health care professionals. Ms. Borggren forwarded a copy of our recommendations to Dr. LaMar Hasbrouck, Director, Illinois Department of Public Health. We have not received any further information from you regarding actions to satisfy these recommendations, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response. Please tell us what actions you have completed or planned to satisfy the recommendations, which remain classified OPEN--AWAIT RESPONSE.

From: NTSB
To: State of Illinois
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: State of Illinois
To: NTSB
Date: 10/16/2014
Response: -From Erica J. Borggren, Acting Secretary, Illinois Department of Transportation: Thank you for your letter of September 23, 2014 to Governor Pat Quinn regarding 1-14-1 and -2 (Drug user trends in Aviation; Assessing the risk of Pilot Impairment). Governor Quinn has asked that we respond. The Illinois Aeronautics Act prohibits operation of an aircraft "while under the influence of intoxicating liquor or any narcotic drug or other controlled substance" (620 ILCS 5/43d). However, the Illinois Department of Transportation does not have regulatory responsibility over the guidelines regarding prescribing controlled substances as outlined in recommendation I-14-1, nor do we "publish newsletters or other routine forms of communications with licensed health care professionals" as outlined in recommendation I-14-2. Therefore, the Director of the Illinois Department of Public Health, Dr. LaMar Hasbrouck, has been copied on this letter, and we will forward your recommendations to him.

From: NTSB
To: State of Indiana
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Indiana
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Iowa
Date: 8/7/2018
Response: Our May 30, 2018, letter pointed out that action was needed by the Iowa Board of Nursing to satisfy this recommendation. We mentioned that the Iowa Professional Licensure Board acceptably addressed this recommendation by sending a printed reminder with the recommended information to all newly licensed physician assistants in Iowa and to physician assistants biennially when they renew their licenses. We note that the Iowa Board of Nursing is taking similar action for its nurses with prescribing authority in Iowa. This action satisfies Safety Recommendation I-14 1, which is classified CLOSED--ACCEPTABLE ACTION.

From: State of Iowa
To: NTSB
Date: 6/26/2018
Response: -From Kathleen R. Weinberg, MSN, RN, Executive Director, State of Iowa Board of Nursing: I am responding to the request by the National Transportation Safety Board in response to Safety Recommendation I - 14 - 001, per the suggestion of Mr. Marcus I reached out to the Iowa Physician Assistant's Board. They provided me with the language they send out to newly licensed providers who have the authority to prescribe. We will be adding the below language to the information sheet sent to all newly licensed Iowa advanced practice nurses: " The National Transportation Safety Board reminds you to remember to routinely discuss with patients the effect a person's diagnosed medical conditions or prescription medications may have on his or her ability to safely operate a vehicle in any mode of transportation." We have also put this statement in our newsletter which is mailed electronically to all Iowa licensed nurses and on our website. I am hoping this will satisfy meeting the recommendation. Mr. Marcus stated that the PA board satisfied the recommendation with the above similar language. Thank you.

From: NTSB
To: State of Iowa
Date: 5/30/2018
Response: We previously said that the Iowa Board of Medicine and the Iowa Professional Licensure Board, which licenses physician assistants, had satisfied this recommendation, and that action was needed by the Iowa Board of Nursing to complete Safety Recommendation I-14-1. We note that the Iowa Board of Nursing established an advanced registered nurse practitioners (ARNPs) advisory committee that revised section 655 Iowa Administrative Code (IAC), chapter 7, “Advanced Registered Nurse Practitioner.” We further note that the Iowa Board of Nursing is currently in the rulemaking process for these revisions. We reviewed the proposed changes to section 655 IAC, chapter 7, but we did not find anything that addressed the recommended discussion between a patient and the prescriber. We contacted Ms. Weinberg and provided information on actions taken by other states that satisfied this recommendation. She replied that she was consulting with an ARNP in her state to consider standard language prescribers might use to satisfy this recommendation. We point out that the Iowa Professional Licensure Board satisfied this recommendation by sending a printed reminder with the recommended information to all newly licensed physician assistants in Iowa and to physician assistants biennially when they renew their licenses. Pending similar action by the Iowa Board of Nursing for ARNPs with prescribing authority, Safety Recommendation I-14-1 remains classified OPEN--ACCEPTABLE RESPONSE.

From: State of Iowa
To: NTSB
Date: 3/19/2018
Response: -From Gerd Clabaugh, Director, Iowa Department of Public Health: This letter is in follow-up to the correspondence that was sent to Governor Reynolds, dated March 6 2018, in which it was stated that the National Safety Transportation Board had not yet received any information regarding the recommendation that was made to the Iowa Board of Nursing in May 2016, concerning guidelines for ARNPs who prescribe controlled substances. In response to your request, please find a letter from Kathleen Weinberg, MSN, RN, Executive Director of the Iowa Board of Nursing, outlining what steps are being taken by the Iowa Board of Nursing's ARNP Advisory Committee, to comply with the National Transportation Safety Board's Safety Recommendation 1-14-1. Should you have any questions or concerns, please feel free to contact me.

From: State of Iowa
To: NTSB
Date: 3/12/2018
Response: -From Kathleen R. Weinberg, MSN, RN, Executive Director, State of Iowa Board of Nursing: I have been asked by Gerd Clabaugh, the Director of the Iowa Department of Public Health to respond to the letter dated March 6, 2018 to Governor Kim Reynolds. The Iowa Board of Nursing established an ARNP advisory committee in 2016. The committee has completed its work on revising 655 IAC, Chapter 7 - Advanced Registered Nurse Practitioner and the rules have been approved by the Board of Nursing, Noticed for Intended Action and are in the rule making process. In the revisions to Chapter 7, rules have been promulgated to include standards of practice of controlled substances. Please find the proposed rules below: 655-7.6(152) Standards of practice for controlled substances. In addition to the following standards of practice for treating a patient described in rule 655-7.5(152), an ARNP who prescribes or administers a controlled substance shall practice in accordance with the following: 7.6(1) The health history shall include a personal and family substance abuse risk assessment. 7.6(2) The health record must include documentation of the presence of one or more recognized indications for the use of a controlled substance. 7.6(3) An ARNP is encouraged to utilize a treatment agreement if continuously prescribing one or more controlled substances. 7.6(4) Prior to prescribing a controlled substance, an ARNP should review the patient's information contained in the PMP database. 7.6(5) Throughout the course of the patient's treatment, the ARNP shall provide ongoing education that includes, but is not limited to, the risks of using a controlled substance, information regarding addiction, physical dependence, substance abuse, and tolerance. 7.6(6) An ARNP shall maintain an active DEA registration and an active CSA registration to dispense, prescribe, or administer controlled substances. 7.6(7) An ARNP shall not prescribe a controlled substance to the ARNP's self or to a family member unless the prescribing occurs in a clinical setting when an emergency situation arises and when there is no other qualified practitioner available to the patient. I would also note that there is proposed Iowa legislation which would mandate the Board of Nursing, along with other Boards which regulate prescribers, to require continuing education hours for ARNPs who prescribe opioids. This continuing education would also reinforce the ARNP to educate their patients of the potential risks that are associated with the use of controlled substances.

From: NTSB
To: State of Iowa
Date: 3/6/2018
Response: In a February 12, 2016, letter, Mr. Gerd W. Clabaugh, Director, Iowa Department of Public Health, described that shortly after this recommendation was issued, the Iowa Board of Medicine initiated rulemaking to require physicians to discuss with patients the effects their medical conditions and medication use may have on their ability to safely operate a vehicle in any mode of transportation. However, several physicians and health care organizations argued that a mandated requirement was not necessary because it is standard practice for physicians and pharmacists to discuss with patients the effects of any prescribed medications, including pain medications. As a result, the Board of Medicine discontinued the rulemaking, instead issuing a press release to draw attention to our study and its findings. Mr. Clabaugh also said that the Iowa Professional Licensure Board sends all newly licensed physician assistants, optometrists, and podiatrists in Iowa a printed reminder that includes the information we recommended, and this reminder is also sent to those professionals biennially when they renew their licenses. Finally, Mr. Clabaugh said that, although the Iowa Board of Nursing did not have guidelines regarding Advanced Registered Nurse Practitioners (ARNPs) prescribing controlled substances, it had established an ARNP advisory committee that was to develop guidelines for controlled substance prescriptions that will be written in administrative rules. On May 18, 2016, we commended the Board of Medicine for issuing its press release following the widespread opposition to the proposed regulation. We also said that the reminders sent by the Professional Licensure Board satisfied Safety Recommendation I-14-1 for that organization. Pending the ARNP advisory committee’s guidelines directing that, when prescribing controlled substances for pain, an ARNP discuss with patients the effect their medical conditions and medication use may have on their ability to safely operate a vehicle in any mode of transportation, Safety Recommendation I-14-1 was classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: State of Iowa
Date: 5/18/2016
Response: We note that, shortly after this recommendation was issued, the Iowa Board of Medicine initiated rulemaking to require physicians to discuss with patients the effects their medical conditions and medication use may have on their ability to safely operate a vehicle in any mode of transportation. However, the Board of Medicine received several comments from physicians and healthcare organizations that a mandated requirement was not necessary, as it is standard practice for physicians and pharmacists to discuss with patients the effects of any prescribed medications, including pain medications. As a result, the Board of Medicine discontinued the rulemaking, instead issuing a press release to draw attention to our study and its findings about potential risks posed by prescription medications and a patient’s medical condition when the patient operates a motor vehicle in any mode of transportation. This press release is available on the Board of Medicine’s website and is included with mailings to new licensees. We disagree with the letters and comments that the Board of Medicine received opposing the proposed regulation. In our study, we found that current written and oral communications are not effectively informing patients about the risks their medical conditions and drug use may pose when operating a vehicle in any mode of transportation. The recommended discussion is between the prescriber and the patient, not the pharmacist and the patient, because we believe the prescriber is in a better position to discuss this issue and effectively counsel the patient to avoid dangerous activities while using the medication. We also point out that we have found the labeling required by the Food and Drug Administration (FDA) warning of the dangers of operating a vehicle while using an impairing medication to be insufficient, and we have recommended that the FDA address this concern (Safety Recommendation I-00-5). To date, that recommendation remains open. We commend the Board of Medicine for issuing its press release following the widespread opposition to the proposed regulation. However, Safety Recommendation I-14-1 recommends that the prescriber-patient discussion bring to the patient’s attention that his or her medical condition and medication use could affect the operation of a vehicle in any mode of transportation, not only the operation of a motor vehicle, as the press release emphasized. Accordingly, we recommend that any future, related communications from the Boards of Medicine or Nursing emphasize the risks associated not only with motor vehicle operation, but also with the operation of other types of vehicles, including buses, trucks, boats, airplanes, and rail locomotives of all types. We further note that the Professional Licensure Board?which is responsible for physician assistants, optometrists, and podiatrists in Iowa?sends to all such newly licensed professionals a printed reminder that includes the information we recommend, and that this reminder is also included with the information sent when members of these professions receive their biennial license renewal. These reminders satisfy Safety Recommendation I-14-1 for the Professional Licensure Board. Although the Iowa Board of Nursing does not currently have guidelines regarding the prescribing of controlled substances by an Advanced Registered Nurse Practitioner (ARNP), it has recently established an ARNP Advisory Committee. One of the goals and initiatives of this committee is to develop guidelines for the prescribing of controlled substances that will be written in administrative rules. Pending the development of those guidelines with a recommendation that, when prescribing controlled substances for pain, an ARNP discuss with patients the effect their medical condition and medication use may have on their ability to safely operate a vehicle in any mode of transportation, Safety Recommendation I-14-1 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Iowa
To: NTSB
Date: 2/12/2016
Response: -From Gerd W. Clabaugh, Director, Iowa Department of Health: Governor Branstad has asked me, as Director of the lowa Department of Public Health, to respond to your letter to him, dated November 12, 2015, requesting information regarding the State of Iowa's response to NTSB Safety Recommendations 1-14-1 and 1-14-2, relating to the prescribing of controlled substances by lowa licensed healthcare providers, and recommendations from NTSB regarding healthcare provider communication to patients who also operate vehicles while on these medications. The recommendations emanate from a study Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment. Attached to this cover memorandum you will find more detailed information from the Directors o f t he following licensing boards in lowa: Medicine, Nursing, Dental, Pharmacy, Physicians Assistants, and Podiatry. Each provides an overview of their individual activities relating to the adoption of guidelines and efforts to communicate with licensed practitioners regarding the topics outlined in the Drug Use Trends study. Thank you for the opportunity to supply information to you regarding our work on this important topic. Please feel free to contact me with any questions.

From: NTSB
To: State of Iowa
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Kansas
Date: 3/6/2018
Response: We have not received any information from you since this recommendation was issued, and it is currently classified OPEN--AWAIT RESPONSE. Please update us regarding actions you have planned or completed to satisfy Safety Recommendation I-14-1.

From: State of Kansas
To: NTSB
Date: 12/15/2014
Response: -From Debra L. Billingsley, JD, Executive Secretary, Kansas State Board of Pharmacy: As requested copy of Kansas State Board of Pharmacy newsletter. The National Transportation Safety Board (NTSB) provided the Kansas State Board of Pharmacy with medication safety recommendations for pharmacists and other health care providers. To see the pharmacist recommendations and the safety study titled “Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment,” visit the Board’s website at https://pharmacy.ks.gov, and click on the “NTSB Medication Safety Recommendations” link located under the “News” section.

From: NTSB
To: State of Kansas
Date: 12/12/2014
Response: Because Ms. Billingsley did not describe your plans to address this recommendation, it remains classified OPEN—AWAIT RESPONSE pending our receipt of those details.

From: State of Kansas
To: NTSB
Date: 11/2/2014
Response: -From Debra L. Billingsley,JD, Executive Secretary, Kansas State Board of Pharmacy: The Kansas State Board of Pharmacy is in receipt of your letter regarding the recommendations of NTSB that encouraged pharmacists to discuss with patients the effects their medical condition and medication may have on their ability to safely operate a vehicle. The Board of Pharmacy met on October 16 and 17, 2014 and discussed the request that the Board share the recommendations and safety study with our licensees. The Kansas Board has placed this information on our Pharmacy website at www.kansas.gov/pharmacy. We have also referenced this on our Facebook page and will reference the report in our December 2014 newsletter. Thank you for providing us with this information. Please let us know if we can be of further service.

From: Commonwealth of Kentucky
To: NTSB
Date: 6/4/2019
Response: -From Darla K. Sayre, Executive Staff Advisor, Kentucky Board of Pharmacy: NTSB Recommendations for Prescribing CS The National Transportation Safety Board (NTSB), an independent federal agency, is charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation, including railroad, highway, marine, and pipeline accidents. The probable cause of accidents is determined, and safety recommendations are issued that are aimed at preventing future accidents. As a result of conducting the safety study, “Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment” (SS 14/01), recommendations were made by NTSB and an inquiry was communicated to former Kentucky Governor Steve Beshear to determine how the following recommendations are met by health care providers in Kentucky. Safety Recommendation I-14-001 Include in all state guidelines regarding prescribing controlled substances for pain a recommendation that health care providers discuss with patients the effect their medical condition and medication use may have on their ability to safely operate a vehicle in any mode of transportation. Safety Recommendation I-14-002 Use existing newsletters or other routine forms of communication with licensed health care providers and pharmacists to highlight the importance of routinely discussing with patients the effect their diagnosed medical conditions or recommended drugs may have on their ability to safely operate a vehicle in any mode of transportation. Pharmacists, when dispensing controlled substances (CS), should routinely address and implement NTSB recommendations by discussing and documenting their discussions with patients on the effect their medical conditions and medication use may have on their ability to safely operate vehicles in any mode of transportation.

From: NTSB
To: Commonwealth of Kentucky
Date: 3/19/2019
Response: We note that, effective December 13, 2018, the KBML amended its regulation, 201 KAR 9:260, to specifically require that a physician prescribing or dispensing controlled substances discuss with each patient the effect the patient’s medical condition and medication use may have on his or her ability to operate a vehicle in any mode of transportation. We further note that, effective December 7, 2018, the KBN amended its regulation, 201 KAR 20:057, by adding language to section 9(17) that addresses the recommended action. These revisions satisfy Safety Recommendation I-14-1, which is classified CLOSED--ACCEPTABLE ACTION.

From: Commonwealth of Kentucky
To: NTSB
Date: 2/22/2019
Response: -From J. Michael West, General Counsel, Kentucky Board of Nursing: 201 KAR 20:057 was amended effective 12/7/2018 and the language specified at Section 9(17) is consistent with that in your email below. See current language at https://apps.legislature.ky.gov/law/kar/201/020/057.pdf. The Legislative Research Commission has recently updated their website. So, let me know if you have any problems with that link or have any other questions.

From: Commonwealth of Kentucky
To: NTSB
Date: 1/29/2019
Response: -From Michael Rodman, Executive Director, Kentucky Board of Medical Licensure: In September 2014, the National Transportation Safety Board ("NTSB") issued Recommendations I-14-1 and -2 as a result of its safety study, Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment. In June 2018, the NTSB notified the Kentucky Board of Medical Licensure ("KBML") of the need to revise the KBML's regulations relating to the prescribing of controlled substances for pain to more specifically require that physicians discuss with patients the effect of the patient's medical condition and medication use may have on his/her ability to safely operate a vehicle in any mode of transportation. I am pleased to report that the KBML has fulfilled Recommendation I-14-1 by amending its regulation, 201 KAR 9:260, to specifically require that a physician prescribing or dispensing controlled substances shall discuss with each patient the effect of the patient's medical condition and medication use may have on the patient's ability to operate a vehicle in any mode of transportation. The amended regulation went into effect on December 12, 2018 and a copy is enclosed for your information. In addition, the NTSB cited Recommendation 1-14-2 and asked for documentation that the KBML uses routine forms of communication (i.e. newsletters) to advise its licensees on the importance of routinely discussing with patients the effect the patient's medical condition and medication use may have on his/her ability to safely operate a vehicle in any mode of transportation. In response, the KBML published an article in its Summer 2018 newsletter highlighting the NTSB's Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment report and advising its licensees of the importance of routinely addressing with patients the effects of their medical conditions and medications on the ability to operate any mode of transportation. A copy of the newsletter is enclosed for your information. Thank you for bringing the NTSB recommendations to the KBML 's attention and allowing an opportunity for response. If you have any questions, please do not hesitate to contact me.

From: NTSB
To: Commonwealth of Kentucky
Date: 8/28/2018
Response: We previously noted that the Kentucky Board of Nursing (KBN) was adding language to its administrative regulation on advanced practice registered nurse (APRN) prescribing standards for controlled substances, 201 KAR 20:057, Section 9, to satisfy this recommendation. We further note that the KBML approved changes to 201 KAR 9:260 to satisfy this recommendation, and that the KBML has filed the amendment with the Kentucky Legislative Research Commission. Pending completion of the revisions by the KBN and by the KBML, Safety Recommendation I-14-1 remains classified OPEN--ACCEPTABLE RESPONSE.

From: Commonwealth of Kentucky
To: NTSB
Date: 7/20/2018
Response: -From Michael S. Rodman, Executive Director, Kentucky Board of Medical Licensure: For your review, I have attached a link to the most recent KBML newsletter. You will find a copy of the newsletter article that you recommended and was emailed to every physician in KY. In addition, the Board approved the Board to make changes in our prescribing regulation a few weeks ago and we have already working on incorporating the changes recommended by NTSB. It will take several months before the change is official; however, we will provide a final copy once it is completed. https://kbml.ky.gov/newsletter/Documents/2018-03%20Summer.pdf Again, thank you for your assistance.

From: Commonwealth of Kentucky
To: NTSB
Date: 7/20/2018
Response: -From Michael S. Rodman, Executive Director, Kentucky Board of Medical Licensure: For your review, I have attached a link to the most recent KBML newsletter. You will find a copy of the newsletter article that you recommended and was emailed to every physician in KY. In addition, the Board approved the Board to make changes in our prescribing regulation a few weeks ago and we have already working on incorporating the changes recommended by NTSB. It will take several months before the change is official; however, we will provide a final copy once it is completed. https://kbml.ky.gov/newsletter/Documents/2018-03%20Summer.pdf Again, thank you for your assistance.

From: NTSB
To: Commonwealth of Kentucky
Date: 7/6/2018
Response: We previously noted that the Kentucky Board of Nursing (KBN) was adding language to its administrative regulation on advanced practice registered nurse (APRN) prescribing standards for controlled substances, 201 KAR 20:057, Section 9, to satisfy this recommendation. We note from Mr. Rodman’s e-mail that the KBML is preparing an amendment to 201 KAR 9:260 to satisfy this recommendation. After approval by the KBML, the amendment will be filed with the Kentucky Legislative Research Commission. Pending completion of the revisions by the KBN and by the KBML, Safety Recommendation I-14-1 remains classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: Commonwealth of Kentucky
Date: 6/8/2018
Response: We note that the Kentucky Board of Nursing is adding language to its administrative regulation on advanced practice registered nurse (APRN) prescribing standards for controlled substances, 201 KAR 20:057, Section 9, to satisfy this recommendation. To fully satisfy this recommendation, similar action will be needed by the Kentucky Board of Medical Licensure. Pending completion of the revisions by the Kentucky Board of Nursing and similar action by the Kentucky Board of Medical Licensure, Safety Recommendation I-14-1 is classified OPEN--ACCEPTABLE RESPONSE.

From: Commonwealth of Kentucky
To: NTSB
Date: 6/8/2018
Response: -From Michael S. Rodman, Executive Director, Kentucky Board of Medical Licensure: We have received your correspondence dated June 8, 2018, regarding Safety Recommendations 1-14-1 and 2. Please be advised the Kentucky Board of Medical Licensure will begin taking steps this month to address this issue by presenting an amendment to 201 KAR 9:260 to the full Board, on June 21, 2018, for their consideration. Once approved by the Board, we will officially file the amendment with the Kentucky Legislative Research Commission. In addition, we will place an article in our Summer 2018 Newsletter regarding this matter so that it will comply with Recommendation 1-14-2. Once these actions are completed, our office will provide you with notification and electronic copies. On behalf of the Board, thank you for bringing this matter to our attention.

From: Commonwealth of Kentucky
To: NTSB
Date: 4/26/2018
Response: -From Nathan Goldman, General Counsel, Kentucky Board of Nursing: In response to your letter to Gov. Matt Bevin dated March 6, 2018 regarding the actions taken by the Kentucky Board of Nursing concerning NTSB Safety Recommendations I-14-1 and I-14-2, please be advised that we have taken the following steps: 1. We have published information about the recommendations in our latest newsletter. http://epubs.democratprinting.com/publication/?i=489911&ver=html5#{"issue_id":489911,"page":0}. See page 13. 2. We are in the process of adding language to the Board’s administrative regulation on APRN prescribing standards for controlled substances, 201 KAR 20:057, Section 9. The language is: (17) For any prescription for a controlled substance, the prescribing APRN shall discuss with the patient the effect the patient’s medical condition and medication may have on the patient’s ability to safely operate a vehicle in any mode of transportation. We anticipate the promulgation process for the new language will take approximately 4 to 6 months to complete.

From: NTSB
To: Commonwealth of Kentucky
Date: 3/6/2018
Response: A November 16, 2015, letter from Ms. Paula Schenk, Executive Director, Kentucky Board of Nursing, reviewed sections of Kentucky’s laws and administrative regulations regarding the authority and procedures for an advanced practice registered nurse (APRN) to prescribe both controlled and noncontrolled substances. She concluded that these regulations addressed Safety Recommendation I-14-1. On January 12, 2016, we replied that, although they recommend discussing the risks and benefits of a medication with patients, the regulations that Ms. Schenk provided did not specify the need to discuss the dangers of operating a vehicle while using the medication. We wrote that, without such language being included in the regulations, we believed the risks would not be routinely addressed with patients, and we disagreed that the regulations satisfied Safety Recommendation I-14-1. We asked you to reconsider your position based on the information discussed in our letter and in our report, and we pointed out that, to satisfy our recommendation, appropriate revisions were needed for all of the commonwealth’s guidelines regarding prescribing controlled substances, including any issued by the Kentucky Board of Medical Licensure. Accordingly, Safety Recommendation I-14-1 remained classified OPEN--AWAIT RESPONSE.

From: NTSB
To: Commonwealth of Kentucky
Date: 1/12/2016
Response: We note that, in Kentucky, an Advanced Practice Registered Nurse (APRN) has the authority to prescribe both controlled and non-controlled substances, and that the Kentucky Board of Nursing’s administrative regulation, 201 KAR 20:057, sets the scope and standards of practice for APRNs. We reviewed regulation sections that Ms. Schenk provided and found that although they recommend discussion with the patient of the risks and benefits of the medication, they do not specify a need to discuss the dangers of operating a vehicle while using the medication. We believe that without the inclusion of such language in the regulations, these risks will not routinely be addressed with patients. In our study, we found that national guidelines developed by the American Pain Society and American Academy of Pain Medicine for the prescription of chronic opioid therapy specifically recommended that “Clinicians should counsel patients on chronic opioid therapy about transient or lasting cognitive impairment that may affect driving and work safety. Patients should be counseled not to drive or engage in potentially dangerous activities when impaired or if they describe or demonstrate signs of impairment.” We also found that some states have attempted to address misuse and overdose of opioids and other controlled substances by developing guidelines (such as rule number 201 KAR 20:057) regarding prescribing these substances and that, although some of these state guidelines include a specific recommendation that health care providers discuss transportation risks with patients when prescribing opioids or other controlled substances, others (such as Kentucky) do not. We issued Safety Recommendation I-14-1 because we had concluded that state guidelines for health care providers prescribing controlled substances provide an opportunity to highlight the importance of discussing risks in all transportation modes when prescribing these medications. We do not agree with Ms. Schenk that the language of the Kentucky administrative regulation satisfies Safety Recommendation I-14-1, and we ask that the commonwealth reconsider this position based on the information discussed here and in our report. We also point out that, to satisfy our recommendation, appropriate revisions will be needed for all guidelines of the commonwealth regarding prescribing controlled substances, including any issued by the Kentucky Board of Medical Licensure. Because we have not yet received a reply discussing the guidelines issued by the Kentucky Board of Medical Licensure, Safety Recommendation I-14-1 remains classified OPEN—AWAIT RESPONSE.

From: Commonwealth of Kentucky
To: NTSB
Date: 11/16/2015
Response: -From Paula S. Schenk, MPH, RN, Executive Director, Kentucky Board of Nursing: We are in receipt of your letter to Governor Steve Beshear concerning NTSB Safety Recommendations 1-14-1 and 1-14-2. You ask whether and how your recommendations are implemented. The recommendations relate to health care providers discussing with patients the effect their medical condition and medications they use may have on their ability to safely operate a vehicle in any mode of transportation. In Kentucky, an Advanced Practice Registered Nurse (APRN) has the authority to prescribe both controlled and non-controlled substances. Ky. Rev. Stat. (KRS) 314.011, 314.042. The Kentucky Board of Nursing has promulgated an administrative regulation, 201 KAR 20:057, which the sets scope and standards of practice for APRNs. The relevant provisions state: "Section 9. Prescribing Standards for Controlled Substances. (1 )(a) This section shall apply to an APRN with a CAPA-CS if prescribing a controlled substance other than a Schedule II controlled substance or a Schedule Ill controlled substance containing hydrocodone. (3) The APRN shall, prior to initially prescribing a controlled substance for a medical complaint for a patient: (a) Obtain the patient's medical history and conduct an examination of the patient and document the information in the patient's medical record. An APRN certified in psychiatric/mental health shall obtain a medical and psychiatric history, perform a mental health assessment, and document the information in the patient's medical record; (b) Query KASPER for all available data on the patient; (c) Make a written treatment plan stating the objectives of the treatment and further diagnostic examinations required; (d) Discuss with the patient, the patient's parent if the patient is an unemancipated minor child, or the patienfs legal guardian or health care surrogate: 1. The risks and benefits of the use of controlled substances, including the risk of tolerance and drug dependence; 2. That the controlled substance shall be discontinued when the condition requiring its use has resolved; and 3. Document that the discussion occurred and that the patient consented to the treatment. (4) The treatment plan shall include an exit strategy, if appropriate, including potential discontinuation of the use of controlled substances." "Section 10. Prescribing Standards for Controlled Substances from Schedule II and Schedule Ill Containing Hydrocodone. (1 )(a) This section shall apply to an APRN with a CAPA-CS if prescribing a controlled substance from Schedule II or Schedule Ill controlled substance containing hydrocodone. (3) Prior to the initial prescribing of a Schedule II controlled substance or a Schedule Ill controlled substance containing hydrocodone to a human patient, an APRN shall: (a) Obtain a medical history and conduct a physical or mental health examination of the patient, as appropriate to the patient's medical complaint, and document the information in the patient's medical record; (b) Query the electronic monitoring system established in KRS 218A.202 for all available data on the patient for the twelve (12) month period immediately preceding the patient encounter and appropriately utilize that data in the evaluation and treatment of the patient; (c) Make a written plan stating the objectives of the treatment and further diagnostic examinations required; (d) Discuss the risks and benefits of the use of controlled substances with the patient, the patient's parent if the patient is an unemancipated minor child, or the patient's legal guardian or health care surrogate, including the risk of tolerance and drug dependence; and (e) Obtain written consent for the treatment." In our opinion, the language of the administrative regulation would cover the concerns of your agency as expressed in the Safety Recommendations. In addition, we will publish your Safety Recommendations in the next issue of our newsletter.

From: NTSB
To: Commonwealth of Kentucky
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Louisiana
Date: 3/6/2018
Response: We have not received any information from you regarding this recommendation since it was issued 3½ years ago. Please update us on any actions you have planned or completed to satisfy the recommendation, which is currently classified OPEN--AWAIT RESPONSE.

From: NTSB
To: State of Louisiana
Date: 1/12/2016
Response: Mr. Broussard’s e-mail did not address this recommendation. Pending the state of Louisiana’s replying to us that it will act as recommended, Safety Recommendation I-14-1 remains classified OPEN—AWAIT RESPONSE.

From: NTSB
To: State of Louisiana
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: State of Louisiana
To: NTSB
Date: 11/12/2015
Response: -From Malcom J. Broussard, Executive Director, Louisiana Board of Pharmacy: Pursuant to the NTSB recommendations, the Louisiana Board of Pharmacy included an article on the topic in the April 2015 edition of its quarterly newsletter, a copy of which is attached.

From: NTSB
To: State of Maine
Date: 3/6/2018
Response: A January 21, 2016, letter, signed by Major Christopher Grotton, Support Services Division, Maine State Police, described the policy of the Maine State Police’s aviation unit regarding the use of over-the-counter drugs, prescribed drugs, alcohol, and uncontrolled substances that may affect a pilot’s capabilities. Although these policies are related to the issues discussed in our report, our intent in issuing these recommendations was to ensure actions by health care providers and pharmacists treating the general public (including members of the state police force) who may operate a vehicle in any mode of transportation. On March 11, 2016, we replied that the actions we recommended were most appropriately the responsibilities of state organizations that license and regulate health care providers, such as the Boards of Medical Licensure, Osteopathic Medicine Licensure, Nursing, and Pharmacy. We asked that these boards review our recommendations and develop a plan for satisfying them. Pending that action, Safety Recommendations I-14-1 and -2 remained classified OPEN--AWAIT RESPONSE.

From: NTSB
To: State of Maine
Date: 3/11/2016
Response: We are concerned that you may not understand our intent in issuing these recommendations. Major Grotton’s letter described the policy of the aviation unit of the Maine State Police regarding the use of over-the-counter drugs, prescribed drugs, alcohol use, and uncontrolled substances that may affect a pilot’s capabilities. Although these policies are related to the issues discussed in our report, our intent is to ensure actions by health care providers and pharmacists treating the general public (including members of the state police force), who may operate a vehicle in any mode of transportation. We believe these actions are most appropriately the responsibilities of state organizations that license and regulate these health care providers, such as the Boards of Medical Licensure, Osteopathic Medicine Licensure, Nursing, and Pharmacy. We ask that these Boards review our recommendations and develop a plan for satisfying them. We point out that, when we issued Safety Recommendation I-14-2, we included a sample article that could be placed in the newsletters and on the websites of these Boards to satisfy the recommendation. Another copy of that article is attached; in addition, we can provide an electronic copy of the article if doing so would be helpful. The article may be freely edited and revised to comply with any length or style guidelines of the newsletter of each Board. Pending appropriate actions by these Boards, Safety Recommendations I-14-1 and -2 remain classified OPEN--AWAIT RESPONSE.

From: State of Maine
To: NTSB
Date: 1/21/2016
Response: -From Major Christopher Grotton, Support Services Division, Maine State Police: The Department’s policy regarding the use of over the counter (OTC) drugs, prescribed drugs, alcohol use; and uncontrolled substances that may affect the pilot’s capabilities are outlined in our General Orders and in the Air Wing Standard Operating Procedures (SOP). It is the requirement and responsibility of each Pilot to report to the commanding officer in charge of the Air Wing and to the respective flight surgeons, any substance consumed or injested whether prescribed or OTC if the substance fits within the guidelines of reportable medications. Please see below our SOP regarding the use of Intoxicants and Drugs: (Excerpt from General Order E-34) E. Use of Intoxicants and Drugs: 1. Use of Intoxicants: A. The use of intoxicants by a pilot or flight crew member while on duty or within eight hours prior to duty is prohibited. The pilot or flight crew member may not be intoxicated or suffering from the effects of an intoxicant when reporting for duty. B. Except in an emergency, a pilot shall not allow a person who is under the influence of intoxicating beverages to be transported in Bureau aircraft. C. Consumption of alcoholic beverages in Bureau aircraft is prohibited. 2. Use of Drugs: A. A pilot or flight crew member whose ability to fly is affected by a drug shall not operate or crew a Bureau aircraft. 1. Certain drugs in common use have a marked effect on the nervous system detrimentally affecting the pilot or crew’s ability to fly. 2. The pilot or crew member shall ask their doctor if any prescribed drug, or any nonprescription medicines they are taking will affect their ability to operate or crew a Bureau aircraft. B. In the event the pilot or crew member is affected or potentially affected by any drug, the pilot or crew member shall voluntarily stop flying. 1. In the event the use of the drug is long term, the pilot or crew member shall notify the commanding officer in charge of the Traffic Division. 2. Pilot or crew members will be directed to see a flight surgeon to determine the officer’s status. 3. The pilot or crew member will not return to flight status until approved by a flight surgeon and the commanding officer in charge of the Traffic Division. Regarding NTSB’s recommendations I-14-1 and -2, we have directed our Chief Pilot to obtain periodicals from flight surgeons concerning the consumption of OTC, or prescribed medications, and to include them in the topics of discussion for Air Wing training.

From: NTSB
To: State of Maine
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Maryland
Date: 9/19/2018
Response: On June 5, 2018, we said that there did not appear to be any prescribing guidelines for advanced practice registered nurses in Maryland, but there were prescribing guidelines issued by the Maryland Board of Physicians. We said that, to satisfy Safety Recommendation I-14-1, these guidelines should be revised by adding the recommended discussion between the prescriber and the patient. For example, adding “Discuss with the patient that, while using the medication, he or she will not be able to safely operate a vehicle in any mode of transportation” to Section 2, “When Prescribing,” would satisfy the recommendation. Secretary Neall’s letter did not discuss any plans to make the recommended revisions to the prescribing guidelines, nor to take any other action to satisfy Safety Recommendation I-14-1, which remains classified OPEN--UNACCEPTABLE RESPONSE.

From: State of Maryland
To: NTSB
Date: 7/3/2018
Response: -From Robert R. Neall, Secretary, Maryland Department of Health: Thank you for your June 05, 2018 letter concerning the NTSB's Safety Recommendations I-14-1 and I-14-2. Per your request, Maryland 's Boards of Physicians, Nursing, and Pharmacy have al l agreed to publicize the information provided by your office. Specifically, 1. the Board of Physicians included the infom1ation in an e-newsletter sent to all their licensees on June 29, 2018, 2. the Board of Nursing placed the info1mation on their website July 03, 2018, and 3. the Board of Pharmacy will publicize the info1mation in their Fall, 2018 newsletter. We are pleased to have resolved this issue. Thank you for your inquiry.

From: State of Maryland
To: NTSB
Date: 6/8/2018
Response: -From Kimberly C. Lang, PhD, Director, Health Occupations Board and Commissions: Thank you for your recent letter to Governor Hogan concerning NTSB's safety recommendations (attached). As Director for Maryland's Health Occupations Boards and Commissions, I am working with the Boards concerning your requests. So that there is a clear understanding of what is being requested, would you kindly send to me, on behalf of these Boards: -examples of the implementation you have found satisfactory in other states for both I-14-1 and I-14-2, -a list of those states who have implemented your recommendations, and -a copy or website link to the articles referenced in I-14-2. Thank you for your consideration.

From: NTSB
To: State of Maryland
Date: 6/5/2018
Response: This recommendation asks that prescribers discuss the safety risks associated with operating a vehicle in any mode of transportation with patients using a controlled substance to treat pain. This recommendation does not address any actions by pharmacists because pharmacists do not have prescribing authority for controlled substances. We reviewed information on the website of the Maryland Department of Health and, although we did not find any prescribing guidelines for advanced practice registered nurses in Maryland, we did locate the prescribing guidelines issued by the Maryland Board of Physicians (https://www.mbp.state.md.us/resource_information/res_con/resource_consumer_od_board_guidance.aspx). To satisfy Safety Recommendation I-14-1, these guidelines should be revised by adding the recommended discussion between the prescriber and the patient. For example, adding “Discuss with the patient that, while using the medication, he or she will not be able to safely operate a vehicle in any mode of transportation” to Section 2, “When Prescribing,” would satisfy Safety Recommendation I-14-1. We normally expect action to satisfy our recommendations to be completed 3 to 5 years after a recommendation is issued. This recommendation is now over 3½ years old and it does not appear that any action has been completed or is planned to address it. Pending revisions to the Maryland Board of Physician’s prescribing guidelines to include the recommended discussion between the prescriber and the patient, Safety Recommendation I-14-1 is classified OPEN--UNACCEPTABLE RESPONSE.

From: State of Maryland
To: NTSB
Date: 4/4/2018
Response: -From Robert R. Neall, Secretary, Maryland Department of Health: Thank you for your inquiry regarding the NTSB's safety recommendations 1-14-1and1-14-2. Maryland takes seriously its commitment to ensure the health and safety of all of our citizens. Maryland's Health Occupations Boards and Commissions do not establish standards of care. While some Boards, such as the Board of Pharmacy and the Board of Podiatry, have chosen to disseminate NTSB's recommendations through websites, informational bulletins, and newsletters, this is a voluntary action. While not mandated, those who prescribe medication or recommend over-the-counter drugs typically discuss the impact it may have on a patient. The duties of a pharmacist include providing counseling to their patients when dispensing. Frequently, literature concerning side effects and warning labels accompany a drug. Should the NTSB wish to contact individual practitioners regarding its recommendations, we would be pleased to work with you and your staff to secure mailing lists for the five entities impacted: Board of Physicians, Board of Nursing, Board of Dental Examiners, Board of Podiatric Medical Examiners, and Board of Pharmacy. Again, thank you for your correspondence.

From: NTSB
To: State of Maryland
Date: 3/12/2018
Response: On December 23, 2014, we received a letter from former Secretary Joshua M. Sharfstein, Maryland Department of Health and Mental Hygiene, discussing actions that Maryland was taking to prevent alcohol and drug overdoses as well as other problems related to prescription drug misuse and diversion. On April 6, 2015, we replied that, although we appreciate that these are very important issues, they are not related to this recommendation, which focuses on the need for all health care providers to discuss with their patients the effects that their medical conditions and legitimately prescribed and correctly used medications may have on their ability to safely operate a vehicle in any mode of transportation. We asked that you describe your plans to address Safety Recommendation I 14 1 and told you that the recommendation would remain classified OPEN--AWAIT RESPONSE pending that information. We have not received any further information from you regarding this recommendation since Dr. Sharfstein’s letter. Please tell us what actions you have taken or plan to take to satisfy it.

From: NTSB
To: State of Maryland
Date: 4/6/2015
Response: Dr. Sharfstein’s letter discussed activities that Maryland is pursuing to address alcohol and drug overdose prevention, as well as other problems related to prescription drug misuse and diversion. Although we appreciate that these are very important issues, they are not related to the issue that is the subject of this recommendation: the need for all health care providers to discuss with their patients the effect that a patient’s medical condition and legitimately prescribed and correctly used medications may have on the patient’s ability to safely operate a vehicle in any mode of transportation. Accordingly, we ask that you describe your plans to address our recommendation. Pending our receipt of your detailed reply, Safety Recommendation I-14-1 remains classified OPEN—AWAIT RESPONSE.

From: State of Maryland
To: NTSB
Date: 12/23/2014
Response: -From Joshua M. Sharfstein, M.D., Secretary, Maryland Department of Health and Mental Hygiene: Thank you for your letter to Governor Martin O'Malley providing information regarding the National Transportation Safety Board safety study, Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairmentand urging Maryland to take action on two safety recommendations issued in your letter. The received your letter and asked me to respond on his behalf. I apologize for the delay in responding to your concerns. The Governor has been increasingly concerned with the rising number of deaths caused by alcohol and drug overdoses in recent years. In response to this concern, the Governor established the Governor's Overdose Prevention Council (Council) by Executive Order (.01.01.2014.12) on June 27, 2014. The Council is charged with advising and assisting the Governor in establishing a coordinated, statewide effort to reduce the number of fatal and nonfatal unintentional overdoses in the State. The Secretary of the Department of Health and Mental Hygiene (DHMH) chairs the council and oversees the implementation of this Executive Order and the work of the Council. Please find attached a copy of this Executive Order for your review. Maryland's overdose prevention efforts are rooted in the Maryland Opioid Prevention Plan; a statewide strategy for reducing overdose deaths related to pharmaceutical opioids and heroin. In addition the Maryland Prescription Drug Monitoring Program (PDMP) was fully launched in December, 2013. The PDMP aims to reduce prescription drug misuse and diversion by creating a secure database of all Schedule II-V controlled dangerous substances (CDS) prescribed and dispensed in Maryland. Other related efforts have been an Overdose Response Program, Data Initiatives, Good Samaritan Law, Local Overdose Fatality Review Teams and a CDS Emergency Preparedness Plan. Information regarding Maryland's Opioid Prevention Plan and each of the other referenced activities can be found on DHMH's Alcohol and Drug Abuse Administration's website: http://adaa.dhmh.maryland.gov/OVERDOSE PREVENTION/SitePages/Homew.aspx. In addition to the above referenced statewide efforts, the Maryland Board of Physicians (Board) has used global e-mails and its newsletter to communicate with practitioners on CDS prescribing. There is an article in the 2012 newsletter re: appropriate CDS prescribing. This newsletter can be accessed by the link http://www.mbp.state.md.us/forms/winter2012a.p.pdf. The Board is also planning to include this recommendation with reference to it coming from the NTSB in their Spring Newsletter. I hope this information is responsive to your request. Thank you again for your letter. The Governor appreciates hearing from you and, on his behalf, I thank you for your interest in Maryland's efforts in this most important endeavor.

From: NTSB
To: Commonwealth of Massachusetts
Date: 3/7/2018
Response: Our only response from you regarding these recommendations is a December 30, 2014, letter, signed by Ms. Eileen Sullivan, then Acting Commissioner, Massachusetts Department of Public Health, detailing regulations and guidelines about the patient education and prescription practices of the Massachusetts boards of Registration in Medicine (BORIM), Dentistry, Nursing, Pharmacy, and Physician Assistants. On March 6, 2015, we replied that our review did not reveal any information or regulations that specifically address the effects a patient’s medical condition or medication may have on his or her ability to safely operate a vehicle in any mode of transportation. Ms. Sullivan also wrote that the BORIM widely distributed a prescribing guideline among physicians and other health care professionals that contained the following caution: It is the responsibility of the physician to prescribe drugs with proper regard for their action and potential dangers. Physicians should carefully describe to patients the purpose and use of the drug, as well as any significant side effects that the patient may experience, and basic information on how to take the medication correctly. At that time, the BORIM was considering revising its prescribing policy to recommend that health care providers discuss the effects that patients’ medical conditions and medications may have on their ability to operate a vehicle in any mode of transportation. In our March 6, 2015, reply, we wrote that, pending such a revision that would apply to all health care providers in Massachusetts, Safety Recommendation I 14 1 was classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: Commonwealth of Massachusetts
Date: 3/6/2015
Response: Ms. Sullivan’s letter provides a detailed description of the relevant regulations and guidelines that address patient education and prescription practices of the Massachusetts’ Boards of Registration in Medicine, Dentistry, Nursing, Pharmacy, and Physician Assistants. However, our review of this information did not reveal any information or regulations that specifically address the effects a patient’s medical condition or medication may have on his or her ability to safely operate a vehicle in any mode of transportation. We note, however, that the Massachusetts Board of Registration in Medicine is considering revising its prescribing policy to include a recommendation that health care providers discuss this issue with their patients. Pending such a revision that would apply to all health care providers in Massachusetts, Safety Recommendation I 14 1 is classified OPEN—ACCEPTABLE RESPONSE.

From: Commonwealth of Massachusetts
To: NTSB
Date: 12/30/2014
Response: -From Eileen Sullivan, Acting Commissioner, Massachusetts Department of Public Health: I am writing on behalf of Governor Deval Patrick in response to your recent letter, dated September 23, 2014, requesting information on Massachusetts' policies to reduce the use of prescription medication while operating a transportation vehicle, as described in recommendations I-14-1 and I-14-2. The Commonwealth of Massachusetts, through its boards of licensure for health professionals, has enacted regulations and issued guidance to address prescribing and patient education practices by licensed prescribers. Under the Department of Public Health, the Board of Registration in Dentistry, the Board of Registration in Nursing, the Board of Registration in Pharmacy, and the Board of Registration of Physician Assistants have existing regulations and guidelines in place requiring licensees to discuss with patients the effects of medical conditions and dug products prescribed and dispensed: i. Board of Registration in Dentistry- 234 CMR 5.06(1) requires registered dentists to prescribe controlled substances in conformity with M.G.L. c. 94C, its regulations and all applicable state and federal statutes and regulations pertaining to controlled substances. o 234 CMR 5.06( 4) requires licensed dentists, prior to prescribing a hydrocodone-only extended release medication that is not in an abuse deterrent form, to thoroughly assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and to discuss the risks and benefits of the medication with the patient. o Advisory on the Management of Pain (adopted March 11, 2009 and amended July 20, 2011) advises that Board-licensed dentists are responsible for developing and implementing evidence-based pain management plans that include comprehensive and on-going pain assessments, appropriate pharmacological and non-pharmacological modalities, and the substantiation of adequate symptom control. Additionally, it advises that dentists maintain effective pain management competencies, as required at M.G.L. c. 94C, §18( e), that include counseling patients about the side effects of their medications. ii. The Board of Registration in Nursing- 244 CMR 4.06 requires those engaged in APRN practice (Nurse Anesthetist, Nurse Midwife, Nurse Practitioner and Psychiatric Clinical Nurse Specialist) to perform health education and counseling for patients. a 244 CMR 4.07(3) requires the APRN, prior to prescribing a hydrocodoneonly extended release medication that is not in an abuse deterrent form, to thoroughly assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and to discuss the risks and benefits of the medication with the patient. a Advisory Ruling 09-01: Management of Pain provides guidance to Massachusetts nurses with prescriptive authority and specifies that all nurses are responsible and accountable for engaging in the practice of nursing in accordance with accepted standards of care which include, among others, the provision of patient, family/significant other and/or caregiver education; and that APRN s with prescriptive authority will acquire and maintain competencies, as required at MGL c. 94C, § 18( e), that include counseling patients about the side effects of their medications. iii. The Board of Registration in Pharmacy- M.G.L. 94C, § 21A and 247 CMR 9.07 Maintaining Patient Records, Conducting a Prospective Drug Utilization Review and Patient Counseling requires a pharmacist to maintain patient records and conduct a prospective drug utilization review (DUR) before each new prescription is dispensed. A DUR may alert a pharmacist to medical conditions or prescriptions that may result in consultation with the patient or prescriber. a 247 CMR 9.07 (3) further requires that a pharmacist or designee offer the services of a pharmacist to discuss, with all patients presenting new prescriptions, issues that in the pharmacist's professional judgment are deemed to be significant for the health and safety of the patient, including the patient's ability to safely operate vehicles and machinery. a 247 CMR 9.04(8)(e) requires a pharmacist to counsel patients regarding the use of hydrocodone-only extended release medication that is not in an abuse deterrent form. a 2009-01, Policy on the Management of Pain was implemented to ensure patient access to appropriate and effective pain management. This policy outlines best practices when dispensing controlled substances for pain management. IV. The Board of Registration of Physician Assistants- 263 CMR 5.07 Prescription Practices of a Physician Assistant requires a Physician Assistants to follow the guidelines of the Board of Registration in Medicine for the use of Controlled substances for the treatment of pain. o 2009-01 Policy on Management of Pain outlines pain management practices including counseling of patients about side effects of controlled substances. o 263 CMR 5.07 (12) Prescribing Hydrocodone-Only Extended-Release Medication. Prior to prescribing a hydrocodone-only extended release medication that is not in an abuse deterrent form, a licensee must assess the patient, including an evaluation of the patient's risk factors, substance abuse history, presenting condition(s), current medication(s) and a check of the online Prescription Monitoring Program and discuss the risks and benefits of the medication with the patient A Joint Alert for the Board of Registration in Dentistry, the Board of Registration in Nursing, the Board of Registration in Pharmacy and the Board of Registration of Physician Assistants has been posted to each Board's website and/or sent electronically to Board distribution lists to remind licensees with prescriptive and dispensing authorities of their obligation to discuss the effects of medical conditions and medications prescribed with patients. Under the Executive Office of Health and Human Services, the Board of Registration in Medicine (BORIM) has a prescribing guideline which is widely distributed among physicians and other health care professionals. BORIM's Prescribing Practices Policy and Guidelines (Adopted 8/111989, Amended 11117/2010) contains this caution: "It is the responsibility of the physician to prescribe drugs with proper regard for their action and potential dangers. Physicians should carefully describe to patients the purpose and use of the drug, as well as any significant side effects that the patient may experience, and basic information on how to take the medication correctly." BORIM has also adopted the Federation of State Medical Board's pain policy, the "Model Policy for the Use of Controlled Substances for the Treatment of Pain (2004)." This policy discusses informed consent, and the need to inform the patient about drug. In addition to these policies, the QPSD has put out a Report on Hydromorphone (Dilaudid) that cautions health care professionals on the use of that particular opioid. This report alerts prescribers to the medication's side effects and to the dangers of using Dilaudid at the same time as other analgesics. At that time, BORIM can include a recommendation to the Prescribing Policy that health care providers discuss with patients about the effect that their medical condition and medication may have on their ability to operate a vehicle, in any mode of transportation. BORIM also communicates with physicians through the use of Board newsletters, the Board's website, through occasional email "blasts" to all physicians and by participating in grand rounds and other presentations to physicians and to the public. Through this, the Board can include information about the impact of driving through these outreach methods, and often share alerts and other material from our partners in state and federal government through these options, particularly email blasts. I appreciate the opportunity to share Massachusetts' ongoing work to address prescription drug misuse and abuse, and the National Transportation Safety Board's work to reduce the use of such substances while operating vehicles to ensure public safety. If I can provide any additional information in response to this request, please do not hesitate to contact me.

From: NTSB
To: State of Michigan
Date: 3/7/2018
Response: We previously received a November 17, 2014, letter from Mr. Mike Zimmer, then Acting Director, Michigan Department of Licensing and Regulatory Affairs, and a November 20, 2014, e-mail from Dr. Richard Burney, then Chair, Michigan Board of Medicine (BOM), regarding these recommendations. On December 12, 2014, we replied that we were encouraged that, according to Mr. Zimmer, these recommendations would be considered by Michigan’s Advisory Committee on Pain and Symptom Management and the Controlled Substances Advisory Committee, as well as the Michigan boards of Medicine, Pharmacy, and Osteopathic Medicine. However, we were concerned with—and disagreed with—Dr. Burney’s statement that these recommendations had been discussed briefly at a BOM meeting and had received no support whatsoever. Dr. Burney’s e-mail cited four reasons the BOM had found no merit in our recommendations, which we discussed in our reply. We disagreed with each reason and reiterated that the state of Michigan should take the recommended actions. We asked that you reconsider the BOM’s decision to take no action and, pending completion of the recommended actions, Safety Recommendations I-14-1 and -2 were classified OPEN--UNACCEPTABLE RESPONSE. We have not received any further information from you regarding these recommendations in the 3 years since our last letter. Please update us on any actions that you have planned or completed to satisfy these recommendations.

From: NTSB
To: State of Michigan
Date: 12/12/2014
Response: We are encouraged by Mr. Zimmer’s letter, which stated that these recommendations would be considered by Michigan’s Advisory Committee on Pain and Symptom Management and the Controlled Substances Advisory Committee, as well as the Michigan Boards of Medicine, Pharmacy and Osteopathic Medicine. However, we are concerned by Dr. Burney’s e mail stating that these recommendations had been discussed briefly at a recent meeting of the BOM and had received no support whatsoever. Dr. Burney stated four reasons why the BOM had found no merit in our recommendations. These are our responses to the BOM’s statements: 1. The BOM believes that, because our recommendations do not address diphenhydramine, a commonly used over-the-counter medication obtainable without a prescription, they will not be effective. Although diphenhydramine was the most common impairing drug found in our study, we also found that the toxicological evidence retrieved from an increasing proportion of fatally injured accident pilots demonstrated that these pilots had used controlled substances. Our report discussed a 1997 study by the American Academy of Pain Medicine and the American Pain Society documenting that the use of opioid pain relievers had contributed to a significant increase in the use of controlled substances over the preceding 20 years, and that opioids are the largest contributor to the increased misuse of, and fatal accidental overdoses from, prescribed controlled substances. Although we did not issue Safety Recommendations I-14-1 and -2 to deal specifically with issues related to diphenhydramine and other over-the-counter medications, we issued recommendations to the Federal Aviation Administration to address such medications. 2. The BOM stated that, because physicians are already required to inform patients about side effects of prescriptions, as are pharmacists, and this information is also provided to patients when they pick up their prescriptions, these recommendations are unnecessary and will have no effect. As we stated in our study, states differ in their guidelines for health care providers. Although some states’ guidelines recommend that such providers discuss transportation risks with patients when prescribing opioids or other controlled substances, others do not. Even existing state guidelines that address driving may not address risks to operators in other modes of transportation. Safety Recommendation I-14-1 was issued to address these disparities. We recognize that current Michigan regulations may already require that patients be advised of transportation risks when they are prescribed opioids and other controlled substances; however, we are not aware of Michigan regulations to that effect. If you can provide us the specific, current document that addresses notification of all operators about transportation risks (as opposed to a general caution about operating machinery), we would be able to close Safety Recommendation I-14-1 in an acceptable status for your state. 3. Dr. Burney’s e-mail stated that there is no mechanism for taking the actions we recommend. If the state in fact has no mechanism for informing prescribers about a public safety concern associated with prescribing medications, such a lack could constitute a basis for us to close these recommendations. However, we question that Michigan does not have guidelines regarding prescribing controlled substances for pain, especially as Dr. Burney states that prescribers are already required to inform patients about the potential side effects of prescriptions. If such a requirement is currently in effect, in order to satisfy Safety Recommendation I 14 1, the state need only modify its requirement to include discussion of the effect on a patient’s ability to safely operate a vehicle in any mode of transportation. We are aware that the Federation of State Medical Boards’ Model Policy on the Use of Controlled Substances in the Treatment of Pain already complies with Safety Recommendation I-14-1. After receiving Dr. Burney’s e mail, we examined the “Health Professionals” section of the Michigan LARA website and noted several links (Health Alerts, Miscellaneous Publications, and Healthlink Newsletters) which might be appropriate venues for you to publish the sample article that we included in our letter issuing Safety Recommendation I-14-2. 4. The BOM stated that the proper target audience for these recommendations is pilots, as they are the ones who control when and where they take medications. Our report discussed that we have investigated accidents and made similar recommendations across all modes of transportation. Although no toxicology study similar to our report on pilots is currently available for operators in other modes of transportation, the results of our study were consistent with data for the general US population, which shows that sales of opioids and other controlled substances have increased substantially over the past 15 years. As increases in opioid use have been documented in pilots, specifically, and in the population in general, it is highly likely that a similar trend exists for operators across the other transportation modes. Consequently, we ask that you reconsider the BOM’s decision to take no action in response to our recommendations. Pending completion of the recommended actions, Safety Recommendations I-14-1 and -2 are classified OPEN—UNACCEPTABLE RESPONSE.

From: State of Michigan
To: NTSB
Date: 11/20/2014
Response: -From Richard E. Burney, MD, Professor Emeritus of Surgery, University of Michigan: I am writing in response to the request for comments regarding proposed regulations I-14-1 and –2, which would ask health care providers to discuss the effects of prescription drugs with their patients and to highlight the importance of this in newsletters and other forms of communications with health care providers. There are a number of flaws in the thinking behind these proposed recommendations. They may look good on the surface and are, I suppose, harmless, but at the same time they are useless and unnecessary. First, the drug most abused, according to the report, is diphenhydramine, which is available over the counter. It can be and is obtained without a prescription. Second, physicians are already required to inform patients about side effects of prescriptions, as are pharmacists, and the information is also found in information that is provided at the time prescriptions are picked up. Another regulation encouraging this is unnecessary and will have no effect. Third, at least in Michigan, there is no mechanism for doing either of the things that are proposed even if they had merit. Fourth, the proper target audience for this information is pilots – they are the ones that are in control of when and where they take medications. If you want to get a message to them, the best way to do this is by going directly to them, not indirectly through new state guidelines and newsletters to hundreds of thousands of physicians the vast majority of whom will never see a pilot in their practice. This recommendation was discussed briefly at the last meeting of the Michigan Board of Medicine, which I chair, and received no support whatsoever.

From: State of Michigan
To: NTSB
Date: 11/17/2014
Response: -From Mike Zimmer, Acting Director, State of Michigan, Department of Licensing and Regulatory Affairs: Thank you for your Safety Recommendation 1-14-1 and 1-14-2 to Michigan's Governor Rick Snyder regarding communications to health care providers and pharmacists encouraging them to provide to their patients safety information related to medications and medical conditions. Please be advised that these recommendations will be communicated to Michigan's Advisory Committee on Pain and Symptom Management and also to the Controlled Substances Advisory Committee with the potential of inclusion in upcoming discussions, newsletters, and/or presentations. Additionally the information will be provided to the Boards of Medicine, Pharmacy and Osteopathic Medicine to review.

From: NTSB
To: State of Minnesota
Date: 5/12/2016
Response: We note that the Minnesota Boards of Medical Practice, Nursing, and Pharmacy adopted the Joint Statement on the Impact of Health Conditions and Medication Use on the Operation of Vehicles, which contains the recommended discussion; consequently, Safety Recommendation I 14 1 is classified “Closed—Acceptable Action.” We also note that, in February 2016, following adoption of the Joint Statement, each of the Boards issued a media press release and posted the statement on its website. This action satisfies Safety Recommendation I-14-2, which is classified CLOSED—ACCEPTABLE ACTION.

From: State of Minnesota
To: NTSB
Date: 4/1/2016
Response: -From Tara Holt, State Substance Abuse Strategy Coordinator, Minnesota Department of Human Services: I am writing on behalf of Governor Mark Dayton. Thank you for the opportunity to inform your office of Minnesota’s response to the recommendations you issued to the state of Minnesota on September 23, 2014. The letter has been written in conjunction with the Boards of Medical Practice, Nursing, Pharmacy, and Department of Labor and Industry to ensure a comprehensive response to the National Transportation Safety Board’s September 23, 2014 I-14-1 and I-14-2 recommendations. The Boards of Medical Practice, Nursing and Pharmacy have adopted a Joint Statement on the Impact of Health Conditions and Medication Use on the Operation of Vehicles (Joint Statement) in response to the National Transportation Safety Board’s I-14-1 recommendation. In February 2016, following adoption of the Joint Statement by each Board, the Boards of Medical Practice, Nursing and Pharmacy issued a media press release and posted the Joint Statement on each Board’s website. The Joint Statement is meant to offer guidance to pharmacists and licensed healthcare providers who are authorized to prescribe medications. To effectively assist patients with medical conditions or medications that may impair an individual’s ability to operate a vehicle, health professionals should, within their scopes of practice: • Provide education to patients regarding medical conditions and medications, including prescription, over-the-counter, and dose increases, that may impact their ability to operate vehicles safely. • Educate patients regarding drug interactions bearing in mind the combination of medications, health conditions, and/or alcohol, and the potential for additive effects or resultant increases in central nervous system depressant effects, and the impact these interactions may have on an individual’s ability to operate a vehicle. • Exercise increased clinical vigilance when patients are instructed to consume concurrent medications that cause central nervous system depression and carefully consider the risks associated with such combinations. • Engage the patient, family members, and caregivers as active participants in medications or health conditions that may impair the patient’s ability to operate a vehicle. • Provide consultation on all new prescriptions and refills and with patients. Pharmacists are required to provide such consultation pursuant to MN Rule 6800.0910. • Ensure that drugs that are administered systemically as controlled substances under Minnesota Statutes, chapter 152, and parts 6800.4200 to 6800.4250, and other drugs deemed appropriate in the professional judgment of a pharmacist, are labeled according to the requirements of part 6800.3400 and in addition contain the following: "Caution: Taking this drug alone or with alcohol may impair your ability to drive." Additionally, ensure controlled substances are also labeled: "Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed" pursuant to MN Rules 6800.4150. • Comply with all state and federal laws and regulations regarding prescribing, dispensing, and administering drugs including but not limited to MS 147, 147A, 148.235, 151 and 152. Additionally, on November 12, 2015, the Board of Pharmacy electronically communicated with all licensed pharmacies and pharmacists a reminder that Minnesota Statutes and Rules contain the following requirements: • When the use of any drug containing a controlled substance, as defined in chapter 152, or any other drug determined by the board, either alone or in conjunction with alcoholic beverages, may impair the ability of the user to operate a motor vehicle, the board shall require by rule that notice be prominently set forth on the label or container. Rules promulgated by the board shall specify exemptions from this requirement when there is evidence that the user will not operate a motor vehicle while using the drug • Drugs administered systemically as controlled substances under Minnesota Statutes, chapter 152, and parts 6800.4200 to 6800.4250, and other drugs deemed appropriate in the professional judgment of the pharmacist and dispensed to or for an adult patient, other than an inpatient of a hospital or nursing home, shall be labeled according to the requirements of part 6800.3400 and in addition shall contain the following: "Caution: Taking this drug alone or with alcohol may impair your ability to drive." Controlled substances shall also be labeled: "Caution: Federal law prohibits the transfer of this drug to any person other than the patient for whom it was prescribed." Pharmacists are required to provide counseling on all new prescriptions. Counseling is also required for refills when, in the professional judgment of the pharmacist, it is deemed necessary. Counseling for drugs that impair Central Nervous System function should include information about the possibility that the drug can impair the ability to drive or operate any other type of machinery. When a pharmacist is helping a patient to select an Over the Counter (OTC) drug, pharmacists would be well-advised to let patients know if the drug can impair the patient’s ability to drive or operate machinery. The Department of Labor and Industry has updated its Model Patient/Provider Contract for Long-term Treatment with Opioid Medication to comply with the National Transportation Safety Board’s recommendations. The updates, effective February 1, 2016, specifically require patients to acknowledge that their health care providers have discussed with them that medications may affect their ability to safely operate a vehicle. The opioid rules take necessary steps to ensure public safety by requiring prescribing health care providers to discuss with patients the risks associated with long-term treatment with opioid analgesic medications, the specific medications to be used, and possible side effects. The State of Minnesota is committed to ensuring the traveling public is provided the highest level of safety and to develop strategies and identify solutions to address your recommendations. We believe the action steps we have taken are indicative of our commitment to compliance with the National Transportation Safety Board’s recommendations and ensure the safety of the public. If you have concerns or require additional clarification, feel free to reach out to me.

From: NTSB
To: State of Minnesota
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Mississippi
Date: 3/12/2018
Response: We have not received any information from you regarding steps you have taken to satisfy this recommendation. Please update us on any actions you have planned or completed. Pending your response, Safety Recommendation I-14-1 remains classified OPEN--AWAIT RESPONSE.

From: NTSB
To: State of Mississippi
Date: 3/6/2015
Response: Because Ms. Langley’s letter did not describe your plans to address this recommendation, it remains classified OPEN—AWAIT RESPONSE pending our receipt of those details.

From: State of Mississippi
To: NTSB
Date: 12/23/2014
Response: -From Lynn Langley, DNP, FNP-BC, ANP-BC, CPHQ, Executive Director, Mississippi Board of Nursing: The information you provided has been very informative and can certainly impact the citizens in Mississippi. We have included the information regarding the risks associated with drug use and transportation in all of our educational programs throughout the state. Also, the information will be posted as a standing item in our magazine which is published quarterly and sent to all 58,000 nurses.

From: NTSB
To: State of Missouri
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Missouri
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Montana
Date: 3/12/2018
Response: Our only response from you regarding this recommendation was a November 13, 2015, e-mail from Dr. Cynthia Z. Gustafson, then Executive Director, Montana Board of Nursing. Dr. Gustafson wrote that advanced practice registered nurses (APRNs) who have medication prescribing authority are charged with safe patient care and also with using best practices; however, no rule specifically requires an APRN to discuss with patients how to safely operate a vehicle while using a controlled substance. On January 12, 2016, we replied that we issued Safety Recommendation I-14-1 because our study showed that state guidelines for health care providers afford an opportunity to highlight the importance of discussing risks in all transportation modes when prescribing these medications. To satisfy this recommendation, all of the Montana boards that regulate professions with prescribing authority, including the Montana Board of Medical Examiners, needed to include in their guidelines the recommended discussion between prescribers and patients. Pending the Montana Board of Nursing and the Montana Board of Medical Examiners revising their guidelines as recommended, Safety Recommendation I-14-1 remained classified OPEN--AWAIT RESPONSE. We have not received any further information from you regarding this recommendation in the 2½ years since Dr. Gustafson’s e-mail. Please update us on any actions you have taken or plan to take.

From: NTSB
To: State of Montana
Date: 1/12/2016
Response: We note that the Montana Board of Nursing licenses advanced practice registered nurses (APRN) who have medication prescribing authority. Subchapter 24.159.14 of the Montana code contains the regulations and standards related to APRN practices, and rule number 24.159.1464, “Prescribing Practices,” contains the standards for prescribing. Dr. Gustafson pointed out in her e-mail that, although APRNs are charged with safe patient care and also with using best practices, no rule specifically charges an APRN to discuss with patients the safe operation of vehicles while the patient is using a controlled substance. In our study, we found that national guidelines developed by the American Pain Society and American Academy of Pain Medicine for the prescription of chronic opioid therapy specifically stated, “Clinicians should counsel patients on chronic opioid therapy about transient or lasting cognitive impairment that may affect driving and work safety. Patients should be counseled not to drive or engage in potentially dangerous activities when impaired or if they describe or demonstrate signs of impairment.” We also found that some states have attempted to address misuse and overdose of opioids and other controlled substances by developing guidelines (such as rule number 24.159.1464) regarding prescribing these substances and that, although some of these state guidelines include a specific recommendation that health care providers discuss transportation risks with patients when prescribing opioids or other controlled substances, others (such as Montana) do not. We issued Safety Recommendation I-14-1 because we had concluded that state guidelines for health care providers regarding prescribing controlled substances provide an opportunity to highlight the importance of discussing risks in all transportation modes when prescribing these medications. To satisfy this recommendation, all of the Montana Boards that regulate professions with prescribing authority will need to include in their guidelines the recommended discussion between prescribers and patients. This includes the Montana Board of Medical Examiners. Pending confirmation that both the Montana Board of Nursing and the Montana Board of Medical Examiners will act to revise their guidelines as recommended, Safety Recommendation I-14-1 remains classified OPEN—AWAIT RESPONSE.

From: State of Montana
To: NTSB
Date: 11/13/2015
Response: -From Cynthia Z. Gustafson, RN, PhD, Executive Director, Montana Board of Nursing: Thank you for your letter of Nov 12, 2015 regarding your recommendation to prescribers related to controlled substances. The MT Board of Nursing, does license APRNs (Advanced Practice Registered Nurses) as prescribers. They are subject to following the rules related APRN practice per our administrative rules- Subchapter 24.159.14 at this link: http://www.mtrules.org/gateway/Subchapterhome.asp?scn=24%2E159%2E14 Per 24.159.1464 Prescribing Practices – you can see the standards for prescribing. We do not have a rule specifically charging APRNs to discuss with patients safety related to operating vehicles while on controlled substances. APRNs are charged with safe patient care and also with using best practices of which you have suggested in your letter. Our newsletter efforts primarily relate to specifics about a nurse’s license requirements and so we have not had an article in our quarterly newsletter related to this issue. I think this might be more relevant to send to the APRN professional organizations as a recommendation for best practice. I hope this has provided you with needed information. Please feel free to contact me with questions.

From: NTSB
To: State of Montana
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Nebraska
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of Nebraska
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of Nevada
Date: 3/12/2018
Response: We have not received any information from you regarding this recommendation in the 3½ years since we issued it. Please tell us what actions you have planned or completed to satisfy the recommendation. Safety Recommendation I-14-1 is currently classified OPEN--AWAIT RESPONSE.

From: NTSB
To: State of Nevada
Date: 1/27/2016
Response: We ask that you inform us of the activities that the state of Nevada has started or plans to take to address this recommendation. Pending completion of activities that satisfy it, Safety Recommendation I-14-1 remains classified OPEN—AWAIT RESPONSE.

From: State of Nevada
To: NTSB
Date: 12/16/2015
Response: -From Libi Andrews, Research Analyst, Nevada State Board of Medicine: In November of 2014, I spoke to Peter Knudson, NTSB Office of Public Affairs, regarding the publishing of: "NTSB Study: Drug Use in Aviation Shows Upward Trend in Use of Potentially Impairing Medications" in the Nevada State Board of Medical Examiners (Board) December 2014 newsletter to satisfy I-14-2 as mentioned in the email below. Recent Board newsletters can be found on our website here: http://medboard.nv.gov/Resources/Newsletters/Newsletters/ You can find a copy of the article in the December 2014 issue on page 5: http://medboard.nv.gov/uploadedFiles/medboardnvgov/content/Resources/Newsletters/2014-12_Newsletter_Volume53.pdf Please feel free to forward any updated articles! I would be happy to publish new information and studies in an upcoming Board newsletter.

From: NTSB
To: State of Nevada
Date: 11/20/2014
Response: Because Ms. Longo did not describe your plans to address this recommendation, it remains classified OPEN—AWAIT RESPONSE pending our receipt of those details.

From: State of Nevada
To: NTSB
Date: 10/13/2014
Response: -From Barbara Longo, CMBI, Executive Director, Nevada State Board of Osteopathic Medicine: We are in the process of adding this proposed language to our website. We will also include it in our next newsletter. The National Safety Transportation Board would like to remind you to routinely discuss with your patients the effect their diagnosed medical conditions or recommended drugs may have on their ability to safely operate a vehicle in any mode of transportation. Is there anything else you need from me on behalf of the Osteopathic Medicine Board?

From: NTSB
To: State of New Hampshire
Date: 5/11/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of New Hampshire
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: State of New Jersey
To: NTSB
Date: 5/31/2018
Response: -From Kevin R. Jespersen, Acting Director, New Jersey Office of the Attorney General, Division of Consumer Affairs: Thank you for your letter of May I 0, 2018, addressed to Governor Phil Murphy, which has been referred to me. The appropriate personnel within the New Jersey Division of Consumer Affairs have reviewed Safety Recommendations 1-14-1 and-2, the text of which was included in your letter. Please be advised that the Division will take appropriate action to address those recommendations within five years of the first notice dated September 23, 2014. We will apprise you of these efforts as they are implemented. We sincerely regret any inconvenience that the lack of a prior response from us may have caused you. We appreciate the efforts of the National Transportation Safety Board to ensure the safety of New Jersey citizens and will fully cooperate with those efforts. If you have any questions, please do not hesitate to contact me.

From: NTSB
To: State of New Jersey
Date: 5/10/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of New Jersey
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of New Mexico
Date: 5/10/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of New Mexico
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of “Open—Await Response.” Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of New York
Date: 5/10/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of New York
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of North Carolina
Date: 5/10/2018
Response: We have not heard from you regarding these recommendations since they were issued, despite our November 12, 2015, request for an update. We normally expect actions to address our recommendations to be completed within 3 to 5 years; however, it has now been more than 3 years since these recommendations were issued and we have yet to receive a response from your state. Accordingly, Safety Recommendations I 14-1 and 2 are classified CLOSED--UNACCEPTABLE ACTION/ NO RESPONSE RECEIVED.

From: NTSB
To: State of North Carolina
Date: 11/12/2015
Response: We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others, and we normally expect actions to address our recommendations to be completed within 3 to 5 years. As we issued this recommendation more than a year ago and we have yet to hear from you regarding it, we would appreciate receiving a response within 90 days indicating actions you have taken or plan to take to implement it. In the meantime, the recommendation will retain its current classification of OPEN—AWAIT RESPONSE. Please reply at correspondence@ntsb.gov. If your response, including attachments, exceeds 10 megabytes, please e-mail us at the same address for instructions. Please do not submit both an electronic and a hard copy of the same response.

From: NTSB
To: State of North Dakota
Date: 9/12/2018
Response: We note that the North Dakota Boards of Medicine, Nursing, and Pharmacy issued “Tri Regulator Statement on Opioid Prescribing/Dispensing.” Among the items in this statement is the recommended discussion, satisfying Safety Recommendation I-14-1, which is classified CLOSED--ACCEPTABLE ACTION.

From: State of North Dakota
To: NTSB
Date: 7/25/2018
Response: -From Lynette McDonald, Deputy Executive Secretary, North Dakota Board of Medicine: Our Board approved the NTSB statement at their 7-20-18 board meeting. We have published the statement on our website under Current Topics at www.ndbom.org We also sent a blast email to all licensed physicians, residents, and PAs that included a link to the statement. If anything additional is needed, please notify us.

From: NTSB
To: State of North Dakota
Date: 5/14/2018
Response: We reviewed the prescribing guidelines and other available information on the NDBOM website, but we were unable to find any guidance that contained the recommended discussion. We contacted Ms. McDonald, who indicated that the NDBOM would develop and issue a statement with the recommended discussion and asked for further information about the discussion we are recommending. In response, we sent her information showing specific guidelines developed by other states that had satisfied Safety Recommendation I-14-1. We note that, after this discussion, she developed a statement that will be considered for approval at the July 2018 meeting of the NDBOM. In a May 4, 2016, e-mail, Dr. Stacey Pfenning, Executive Director, North Dakota Board of Nursing (NDBON), described activities by the NDBON to address this recommendation. Dr. Pfenning sent us a copy of edition 54 of the Dakota Nursing Connection, which contained a description of the NDBON’s activities that addressed this recommendation. Among these activities was the 2012 revision of the practice statement, “Role of the Nurse in Pain Management,” and the NDBON’s collaboration with the licensing boards in other states to complete the Prescription Drug Monitoring Program. On June 8, 2016, we said that these activities were likely to produce the guidelines recommended in Safety Recommendation I-14-1; however, we were concerned that the article did not mention the need for these guidelines to include a discussion with patients about the effect their medical conditions and medication use may have on their ability to safely operate a vehicle in any mode of transportation, even when taking the medication as prescribed. We have not received any further information from the NDBON about the development of these guidelines. Because pharmacists do not have prescribing authority, no action by the North Dakota Board of Pharmacy (NDBOP) is needed to satisfy this recommendation. Please send us copies of the statement approved by the NDBOM and any guidelines revised by the NDBON to satisfy this recommendation. Pending guidelines that include this information by both the NDBON and the NDBOM, Safety Recommendation I-14-1 remains classified OPEN--ACCEPTABLE RESPONSE.

From: State of North Dakota
To: NTSB
Date: