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Safety Recommendation Details

Safety Recommendation I-14-002
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: 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.
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 (Closed - Acceptable Action)
Commonwealth of Puerto Rico (Open - Await Response)
Commonwealth of Virginia (Closed - Acceptable Action)
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 - Acceptable 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 - Acceptable Response)
State of Louisiana (Open - Acceptable Response)
State of Maine (Open - Await Response)
State of Maryland (Open - Acceptable Response)
State of Michigan (Open - Unacceptable Response)
State of Minnesota (Closed - Acceptable Action)
State of Mississippi (Open - Acceptable 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 - Acceptable 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 (Open - Acceptable Response)
State of Oregon (Closed - Acceptable Action)
State of Rhode Island (Closed - Acceptable Action)
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 (Closed - Acceptable Action)
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 (Closed - Acceptable Action)
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 April 18, 2016, we received an e-mail from Mr. Joe Baker, Executive Director, Florida Board of Nursing, that included a link to the Florida Board of Nursing’s spring 2016 quarterly newsletter, which contained an article based on the sample that we provided when we issued Safety Recommendation I-14-2. That action satisfied the recommendation for the Board of Nursing. Ms. Dudley’s March 30, 2016, e mail said that the Boards of Pharmacy, Medicine, and Osteopathic Medicine planned to take similar action. On July 21, 2016, we asked for copies of any articles published by the other boards in their newsletters. Pending publication of similar articles by the other boards, Safety Recommendation I-14-2 was classified OPEN--ACCEPTABLE RESPONSE. We have not heard from you regarding this recommendation since the 2016 e-mails from Ms. Dudley and Mr. Baker. Please send us copies of any articles published by boards other than the Board of Pharmacy. If the other boards have not yet published the recommended information, please tell us when they plan to do so. We are happy to send you another copy of the sample article if needed, and we point out that publishing the sample article will satisfy Safety Recommendation I-14-2.

From: NTSB
To: State of Florida
Date: 7/21/2016
Response: Mr. Baker’s April 18, 2016, e-mail included a link to the Florida Board of Nursing’s spring 2016 quarterly newsletter, which contained an article based on the sample that we provided. That action satisfies the recommendation for the Board of Nursing. Ms. Dudley’s e mail indicated that the Boards of Pharmacy, Medicine, and Osteopathic Medicine plan to take similar action. Please send us copies of any articles published by the other boards in their newsletters. Pending publication of similar articles by the other boards, Safety Recommendation I-14-2 is 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: Ms. Dudley’s e-mail did not address actions taken to address Safety Recommendation I 14-2. We recently e mailed Ms. Dudley another copy of the sample article that we had included in our letter issuing this recommendation. Publication of this article in newsletters and other routine forms of communications by the Florida Boards of Medicine, Osteopathic Medicine, Nursing, and Pharmacy will satisfy this recommendation. The sample article may be freely edited to comply with the appropriate length and style guidelines of each newsletter. Please send us copies of any articles published in these newsletters, or links to the articles on websites. Pending our receipt of a substantive reply regarding plans to distribute this article by all of these Boards, Safety Recommendation I-14-2 remains classified OPEN—AWAIT 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 in March 2016, the HMB and the HBN issued memoranda to all physicians, physician assistants, and advanced practice registered nurses in Hawaii with information about our study and recommendations, including a copy of the sample article that we provided when we issued the recommendation. We further note that the Hawaii Board of Dental Examiners issued a similar memorandum in April 2016. Issuing these memoranda satisfies Safety Recommendation I 14-2 which is classified CLOSED--ACCEPTABLE ACTION.

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: Ms. Awakuni Colon also wrote that the Hawaii Medical Board and Hawaii Boards of Pharmacy, Nursing, and Dental Examiners would be placing both of these recommendations on their individual board webpages under “Important Announcements” for their licensees and the public, and that a copy of the recommendations would be shared with the Hawaii Department of Public Safety, Narcotics Enforcement Division—the agency that registers practitioners who prescribe controlled substances and narcotics in Hawaii. In our March 11, 2016, reply, we pointed out that when we issued Safety Recommendation I-14-2, we included a sample article summarizing the important findings from our study that could be published to satisfy Safety Recommendation I-14-2. We emphasized that publishing the provided article would be more effective than simply disseminating the recommendations by themselves, without the context that the article provided. On January 4, 2016, we e-mailed another copy of this sample article to the Department of Commerce and Consumer Affairs, again pointing out that each of the boards could publish the sample article to satisfy Safety Recommendation I-14-2, and we asked that you inform us when this information was distributed and provide us a copy of what was published or the relevant website links. Pending distribution of the sample article on the websites of the Hawaii Medical Board and Hawaii’s Boards of Pharmacy, Nursing, and Dental Examiners, Safety Recommendation I-14-2 was classified OPEN--ACCEPTABLE RESPONSE. As with Safety Recommendation I-14-1, we have not received any further information from you since Ms. Awakuni Colon’s letter. If our sample article has been distributed by the boards, please send us a copy or a link to the appropriate websites. If it has not yet been distributed, please tell us when the boards plan to do so.

From: NTSB
To: State of Hawaii
Date: 3/11/2016
Response: We note that Hawaii’s Board of Pharmacy, Board of Nursing, Board of Dental Examiners, and the Hawaii Medical Board will be placing both these recommendations on their individual board webpages under “Important Announcements” for their licensees and the public to view. We further note that a copy of our recommendations will be shared with the Hawaii Department of Public Safety, Narcotics Enforcement Division, which is the agency that registers practitioners who prescribe controlled substances and narcotics in Hawaii. When we issued this recommendation, we included a sample article that we believe summarizes the important findings from our study, and whose publication would more effectively satisfy Safety Recommendation I-14-2 than simply publicizing the recommendations by themselves, without the context that the article provides. On January 4, 2016, we e-mailed another copy of this sample article to the Department of Commerce and Consumer Affairs. Please use this article, and feel free to edit it as appropriate to match any length or style guidelines for your websites or publications. Publication of this sample article by each of the Boards will satisfy Safety Recommendation I-14-2. Please inform us when you distribute this information, and provide us a copy of what is published, or a link to where it appears on these websites. Pending distribution of the sample article on the websites of Hawaii’s Board of Pharmacy, Board of Nursing, Board of Dental Examiners, and the Hawaii Medical Board, Safety Recommendation I-14-2 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: We note that the Idaho Board of Nursing plans to include an “Update from the Board of Nursing” in the August 2018 issue of RN Idaho, as discussed above. This update will direct nurses who wish to learn more to visit our main website (www.ntsb.gov). Further, the sample article that we included when we issued the recommendation will be placed on the websites of the Idaho Board of Nursing and ANA Idaho. In our June 12, 2018, and June 22, 2018, e-mails to Ms. Evans, we pointed out that directing nurses to the main NTSB website was not the best course of action because information regarding this issue is not posted there directly, nor is it easily found by someone unfamiliar with navigating the site. As an alternative, we sent Ms. Evans a link to our safety study, Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment (a link was also included in our sample article). The actions the Idaho Board of Nursing plans to take will satisfy Safety Recommendation I 14 2 once they are completed, provided they include an appropriate link for nurses wishing to obtain more information. Please tell us when these activities are complete and send us a copy of the RN Idaho with the update (or a link to the relevant edition). Pending that action, Safety Recommendation I-14-2 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 in 2015, the Idaho Board of Pharmacy satisfied its portion of Safety Recommendation I-14-2 by publishing our sample article. The Idaho Board of Medicine briefly mentioned our study in its newsletter shortly after we issued our safety study in 2014, and recently published our sample article in its Winter 2018 newsletter, satisfying the Board of Medicine’s portion of Safety Recommendation I-14-2. The Idaho Board of Nursing, which has not yet responded to this recommendation, also needs to publish the sample article or similar information to complete the recommended action. Once the recommended information is published in the Board of Nursing’s newsletter, please send us a copy. Pending that publication, Safety Recommendation I 14 2 remains 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: Ms. Kerr wrote that Idaho’s Board of Medicine planned to highlight this recommendation in the next issue of its quarterly newsletter. On November 3, 2014, we asked that you send us a copy of the relevant article from the Board of Medicine’s newsletter after it was published. We also said that to satisfy this recommendation, the Idaho Boards of Nursing and Pharmacy needed to take similar action. When we issued Safety Recommendation I-14-2, we included a sample article that could be easily distributed via these boards’ newsletters or websites, and we pointed out that doing so would satisfy the recommendation. Pending completion of these actions, Safety Recommendation I-14-2 was classified OPEN--ACCEPTABLE RESPONSE. We have not received any further information regarding this recommendation in the 3 years since Ms. Kerr’s e-mail. Please send us any newsletters that include the sample article or links to websites where it has been posted. If any of the boards have not yet taken the recommended action, please tell us when they plan to do so.

From: NTSB
To: State of Idaho
Date: 11/3/2014
Response: We are encouraged that Idaho’s Board of Medicine plans to highlight this recommendation in the next issue of its quarterly newsletter. To fully respond to this recommendation, the Idaho Board of Nursing and the Idaho Board of Pharmacy will also need to take similar action. Please send us a copy of the relevant article from the Board of Medicine’s newsletter after it has been published. Pending completion of these actions, Safety Recommendation I-14-2 is classified OPEN—ACCEPTABLE RESPONSE.

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 the IDFPR circulates a quarterly pharmacy newsletter to its licensees and industry organizations, and that you plan to address this recommendation in that newsletter in May 2018. We further note that the IDFPR also plans to start publishing a newsletter for medical professionals and will address this recommendation there, as well. When we issued Safety Recommendation I-14-2, we included a sample article that could be easily included in a newsletter to satisfy the recommendation. We included this sample article in our April 11, 2018, e-mail to Ms. Masiello, as well. Please tell us whether your new newsletter will be distributed to all medical professionals in Illinois with prescribing authority, including physicians, physician assistants, and advanced practice registered nurses. Also, please send us copies of the newsletters that address this recommendation once they are published. Pending our review of the published articles, Safety Recommendation I-14-2 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: IDFPR currently circulates a quarterly pharmacy newsletter to its licensees and industry organizations. We plan to address this topic in the upcoming newsletter scheduled for circulation in May 2018. IDFPR also plans to start circulating a medical newsletter, and will examine addressing the NTSB's recommendation in this newsletter, as well. We thank you for the opportunity to discuss how IDFPR is addressing the recommendations made by the NTSB. If you have any questions, do not hesitate to contact us.

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: 5/18/2016
Response: The articles published in Iowa Boad of Pharmacy’s (IBOP) quarterly newsletter regarding patient counseling about their prescription drugs satisfy this recommendation for the IBOP. We also read with interest the information in Mr. Clabaugh’s letter regarding IBOP activities that aid in periodically inspecting pharmacies and pharmacist practices to verify compliance with patient counseling requirements. Among these is a “shopper survey,” in which an inspector, posing as a patient, presents a prescription for dispensing, while also purchasing another product such as an over-the-counter (OTC) preparation that could create an adverse reaction or might be contraindicated for use in combination with the prescription drug. Our study found diphenhydramine, a common medication used in many OTC products, to be the most common impairing medication among the pilot fatalities that we have investigated. We urge the IBOP to educate pharmacists about the impairments that make vehicle operation unsafe when using products containing diphenhydramine and to advise of this concern when selling these products. The press release developed by the Board of Medicine to satisfy Safety Recommendation I-14-1 also satisfies this recommendation. The reminder sent by the Iowa Board of Professional Licensure when issuing new licenses, and when renewing existing licenses, also satisfies this recommendation. We note that an article about our study was published in the February, March, April, 2015, issue of the Iowa Board of Nursing’s newsletter, and was republished in the February, March, April, 2016, issue of the newsletter. The recent issue includes an editor’s note stressing the importance of informing patients of the potential risks that drugs and medical conditions can cause while operating a vehicle in any mode of transportation. Finally, we note that on February 19, 2016, the Iowa Board of Dentistry sent an article to members in its online database about our study and the recommendation to counsel patients about operating a vehicle when using impairing medications. With these recent actions, the state of Iowa has completed the recommended action, and Safety Recommendation I-14-2 is classified CLOSED—ACCEPTABLE ACTION.

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: On December 15, 2014, Ms. Debra L. Billingsley, then Executive Secretary, Kansas State Board of Pharmacy, sent us the December 2014 issue of her board’s newsletter, which included an article about our study and recommendations. On December 14, 2015, Ms. Mary Bluebaugh, then Executive Administrator, Kansas State Board of Nursing, sent us the April/May/June 2015 edition of her board’s newsletter, which contained an article with the recommended information. On January 27, 2016, we replied that these publications satisfied Safety Recommendation I-14-2 for the Kansas Board of Nursing and the Kansas State Board of Pharmacy. The only remaining action needed to satisfy the recommendation was for the Kansas Board of Healing Arts to publish a similar article in its newsletter. Pending completion of that action, Safety Recommendation I-14-2 was classified OPEN--ACCEPTABLE RESPONSE. Please tell us whether the Kansas Board of Healing Arts has published such an article in its newsletter and, if so, send us a copy of the article or a link to the website where it can be found. If the article has not yet been published, please tell us when the board plans to do so.

From: NTSB
To: State of Kansas
Date: 1/27/2016
Response: We note that the April, May, June 2015 edition of the Kansas Board of Nursing’s newsletter contains an article with the recommended information. That publication satisfies the recommendation for the Kansas Board of Nursing; we previously indicated that the article about our study and recommendations published in the December 2014 issue of the Kansas State Board of Pharmacy’s newsletter satisfied the recommendation for that board. The only action still needed is publication of a similar article in the newsletter of the Kansas Board of Healing Arts. Pending completion of that action, Safety Recommendation I-14-2 remains classified OPEN—ACCEPTABLE RESPONSE.

From: State of Kansas
To: NTSB
Date: 12/14/2015
Response: -Mary Bluebaugh, MSN, RN, Executive Administrator, Kansas State Board of Nursing: I am forwarding you an e-mail that was sent to NTSB on December 16, 2014. Also I am including the link to the newspaper that the information was published. http://www.ksbn.org/nursingnewsletter/2015/2qtr2015.pdf. On the front page of the newsletter half way down the page is n-state (in a big box) and it shows the National Transportation Safety Board Recommendations is on page 8. If you scroll to page 8 you will see the article that was reproduced. Please let me know if you have any other questions.

From: NTSB
To: State of Kansas
Date: 2/10/2015
Response: Ms. Billingsley provided a copy of the December 2014 issue of the Kansas State Board of Pharmacy’s newsletter, which included an article about our study and recommendations. The Kansas State Board of Pharmacy has now satisfied its part of your state’s response to this recommendation, but the Kansas Board of Healing Arts and the Kansas Board of Nursing also need to take similar action. Pending completion of these actions, Safety Recommendation I-14-2 remains classified OPEN—ACCEPTABLE RESPONSE.

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: We are encouraged that the Kansas Board of Pharmacy has placed the information we requested on both its website and its Facebook page. We note that the Board also planned to include a reference to our study and the text of the recommendations in its December 2014 newsletter. For the state to satisfy this recommendation, the Kansas Board of Healing Arts and the Kansas Board of Nursing also will need to take similar action. Please send us a copy of the relevant article from Board of Pharmacy’s December 2014 newsletter, as well as copies of articles or other relevant communications from the other two boards. Pending completion of the recommended actions and our review of all the related articles and postings, Safety Recommendation I-14-2 is classified OPEN—ACCEPTABLE RESPONSE.

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: NTSB
To: Commonwealth of Kentucky
Date: 7/15/2019
Response: As we previously wrote, the Kentucky Board of Nursing satisfied this recommendation by publishing an article in the spring 2018 edition of its newsletter, the KBN Connection, about our study and actions that advance-practice registered nurses in Kentucky should take when prescribing pain medications. Similarly, the Kentucky Board of Medical Licensure satisfied this recommendation by publishing an article in the summer 2018 edition of its newsletter. Ms. Sayre sent us a copy of the June 2019 edition of the KBP’s newsletter, which included an article about our study and recommended actions for pharmacists in Kentucky. The KBP’s publication of this article completes the action recommended; accordingly, Safety Recommendation I-14-2 is classified CLOSED--ACCEPTABLE ACTION.

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: As we previously wrote, the KBN satisfied Safety Recommendation I 14 2 by publishing an article in the spring 2018 edition of its newsletter, the KBN Connection, about our study and actions that advance-practice registered nurses in Kentucky should take when prescribing pain medications. Similarly, the KBML satisfied this recommendation by publishing our sample article in the summer 2018 edition of its newsletter. The only remaining action needed to fully satisfy this recommendation was for the KBP to publish the sample article, or similar information, in its newsletter. We note that the KBP will publish a version of our sample article, modified to better tailor it for pharmacy practice, in the June 2019 edition of its newsletter. Please send us a copy of that newsletter after it is published. Pending our review of the published newsletter, Safety Recommendation I-14-2 remains classified OPEN--ACCEPTABLE RESPONSE.

From: Commonwealth of Kentucky
To: NTSB
Date: 2/26/2019
Response: Larry Hadley, Executive Director, Kentucky Board of Pharmacy - The Kentucky Board of Pharmacy has an article ready to go. The article is a modification of the article provided by NTSB, but tailored for pharmacy practice. This article will be published in the June 2019 edition of the NABP (National Association of Boards of Pharmacy)/Kentucky Board of Pharmacy newsletter. This is a quarterly publication sponsored and by funded by NABP. The format is two pages of national pharmacy news provided by NABP and two pages of Kentucky pharmacy news provided by the Board of Pharmacy. The newsletter goes to every pharmacist, about 10,000, licensed in Kentucky. I hope our approach to the dissemination of your valuable information is satisfactory. If not, please let me know.

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 said that the article in the Spring 2018 edition of the KBN’s newsletter, KBN Connection, about our study and actions that APRNs in Kentucky should take when prescribing pain medications satisfied Safety Recommendation I-14-2 for the KBN. We note that the Summer 2018 edition of the KBML newsletter contains the sample article that we included when we issued this recommendation, satisfying the recommendation for the KBML. The only remaining action needed to fully satisfy this recommendation is for the Kentucky Board of Pharmacy to publish the sample article, or similar information, in its newsletter. Pending that, Safety Recommendation I-14-2 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

From: NTSB
To: Commonwealth of Kentucky
Date: 7/6/2018
Response: We previously said that the article in the Spring 2018 edition of the KBN’s newsletter, KBN Connection, about our study and actions that APRNs in Kentucky should take when prescribing pain medications satisfied Safety Recommendation I-14-2 for the KBN. We note that, to satisfy this recommendation, the KBML will also place an article in its Summer 2018 newsletter. We recently sent copies of our sample article to the KBML and the Kentucky Board of Pharmacy, which they can publish in their newsletters to satisfy this recommendation. Pending publication of their newsletters containing the recommended information, Safety Recommendation I-14-2 remains classified OPEN--ACCEPTABLE RESPONSE.

From: NTSB
To: Commonwealth of Kentucky
Date: 6/8/2018
Response: We note that the Spring 2018 edition of the Kentucky Board of Nursing’s newsletter, KBN Connection, contained an article by Ms. Pamela C. Hagan about our study and actions that APRNs in Kentucky should take when prescribing pain medications. This article satisfies Safety Recommendation I-14-2 for the Kentucky Board of Nursing. To fully satisfy this recommendation, the Kentucky Boards of Medical Licensure and Pharmacy need to take similar action. Please send us their newsletters containing the information when they are published. Until then, Safety Recommendation I-14-2 remains 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: Ms. Schenk also wrote that the Kentucky Board of Nursing planned to publish the information discussed in this recommendation in the next issue of its newsletter. In our reply, we said that to satisfy this recommendation, the Kentucky Boards of Medical Licensure and Pharmacy needed to take similar action, and we asked that each board provide us with a copy of its respective newsletter containing the information. Pending publication of the recommended information in the newsletters of all three boards, Safety Recommendation I-14-2 was classified OPEN--ACCEPTABLE RESPONSE. We have not received any further information from you regarding these recommendations since we sent our January 2016 reply. Please send us copies of any newsletter articles that have been published or, if they have not yet been published, tell us when the boards plan to do so.

From: NTSB
To: Commonwealth of Kentucky
Date: 1/12/2016
Response: We note that the Kentucky Board of Nursing plans to publish the information discussed in this recommendation in the next issue of its newsletter. For the Board of Nursing’s convenience, we have provided it a sample article it may use. To satisfy this recommendation, the Kentucky Board of Medical Licensure and the Kentucky Board of Pharmacy will need to take similar action. Please provide us with a copy of their respective newsletters containing the information, once the articles have been published. In the meantime, pending publication of the recommended information in the newsletters of all three boards, Safety Recommendation I-14-2 is classified OPEN—ACCEPTABLE 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: On November 12, 2015, we received an e-mail from Mr. Malcolm J. Broussard, Executive Director, Louisiana Board of Pharmacy, with a copy of the board’s April 2015 newsletter, which contained the sample article that we provided when we issued this recommendation. On January 12, 2016, we replied that the Louisiana Board of Pharmacy had completed its work, but similar action was needed by the Louisiana Boards of Medical Examiners and Nursing. Pending those boards taking similar action, Safety Recommendation I 14-2 was classified OPEN-ACCEPTABLE RESPONSE. We have not received any further information regarding this recommendation in the 2 years since then. Please send us copies of any newsletter articles published by the Board of Medical Examiners or the Board of Nursing to satisfy this recommendation. If the articles have not yet been published, please tell us when the boards plan to do so.

From: NTSB
To: State of Louisiana
Date: 1/12/2016
Response: We note that the April 2015 newsletter of the Louisiana Board of Pharmacy starts with a copy of the sample article that we included in our letter issuing this recommendation. The Louisiana Board of Pharmacy has completed its work, but similar action is needed by the Louisiana Board of Medical Examiners and the Louisiana Board of Nursing. Pending those Boards’ taking similar action, Safety Recommendation I-14-2 is classified OPEN—ACCEPTABLE 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: We note that the Board of Physicians included the recommended information in an e newsletter sent to all its licensees on June 29, 2018; the Board of Nursing posted the information on its website on July 3, 2018; and the Board of Pharmacy plans to publicize the information in its Fall 2018 newsletter. The Board of Physicians’ e-newsletter and the notice on the Board of Nursing’s website provide the text of our recommendation and a link to our report. This action satisfies the recommendation for the Board of Physicians and the Board of Nursing, though we believe the information would be more effective if the boards had published the sample article we provided. Please send us the Board of Pharmacy’s Fall 2018 newsletter once it is published. Pending our review of that information, Safety Recommendation I-14-2 is classified OPEN--ACCEPTABLE 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: When we issued this recommendation, we included a sample article that could be easily placed into the newsletter or on the website of the boards licensing medical professionals in Maryland to satisfy the recommendation. To obtain another copy of the sample article, please contact Mr. Jeffrey Marcus, Safety Recommendation Specialist, at marcusj@ntsb.gov. In previous correspondence, we asked that you send us any newsletters or the locations of any websites that contain the recommended information. Based on the information in Mr. Neall’s letter, it appears that this information has not been distributed by any of the boards in Maryland. As discussed above, we normally expect action to satisfy our recommendations to be completed within 3 to 5 years, but there does not appear to have been anything completed or planned to address this recommendation. Pending publication of the sample article, or similar information, in the newsletters of the Maryland Boards of Physicians, Nursing, and Pharmacy, or on their websites, and our review of these publications, Safety Recommendation I-14-2 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: Dr. Sharfstein wrote that the Maryland Board of Physicians (MBOP) had used its newsletter and global e-mails to communicate with prescribers of controlled dangerous substances (CDSs), and it planned to include our recommendation in its spring newsletter. Our study found that the single most commonly identified potentially impairing drug was an antihistamine. On April 6, 2015, we replied that including our recommendations in the spring 2015 issue of the MBOP’s newsletter partially addressed Safety Recommendation I-14-2; however, because we issued the recommendation to include all prescribed medications, to fully address the recommendation, the MBOP needed to urge that all physicians with prescribing authority in Maryland routinely discuss with their patients the effect that their diagnosed medical conditions and correct use of prescribed drugs (not only CDSs) may have on their ability to safely operate a vehicle in any mode of transportation. In addition to the MBOP, we also said that the Maryland Boards of Nursing and Pharmacy should communicate similar guidance to all their prescribing members. Pending completion of the recommended action by all the relevant boards, Safety Recommendation I-14-2 was classified OPEN--ACCEPTABLE RESPONSE. We have not received any further information from you regarding this recommendation since Dr. Sharfstein’s letter. Please send us a copy of the notice the MBOP included in its spring 2015 newsletter, as well as any other notices addressing this recommendation that have been distributed by the MBOP or the Maryland Boards of Nursing or Pharmacy.

From: NTSB
To: State of Maryland
Date: 4/6/2015
Response: In our study, we found that the single most commonly identified potentially impairing drug was an antihistamine. Dr. Sharfstein’s letter stated that the Maryland Board of Physicians (MBOP) has used its newsletter and global e-mails to communicate with prescribers of controlled dangerous substances (CDS), and it planned to include our recommendation in its spring newsletter. This plan partially addresses Safety Recommendation I-14-2; however, because we issued the recommendation to include all prescribed medications, we point out that, to fully address the recommendation, the MBOP needs to communicate with all physicians with prescribing authority in Maryland urging that they routinely discuss with each of their patients the effect that patient’s diagnosed medical condition and correct usage of the prescribed drugs (not only CDS) may have on his or her ability to safely operate a vehicle in any mode of transportation. In addition to the MBOP, we also believe that the Maryland Boards of Nursing and Pharmacy should communicate similar guidance to all their prescribing members. Pending completion of the recommended action by all the relevant boards, Safety Recommendation I-14-2 is classified OPEN—ACCEPTABLE 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: Ms. Sullivan also wrote that a joint alert had been posted to each board’s website or sent electronically to board distribution lists to remind licensees with prescriptive and dispensing authority that they are obligated to discuss the effects of medical conditions and medications with patients. The BORIM communicated with physicians through its newsletters, website, occasional e-mail “blasts,” and in grand rounds and other presentations to physicians and to the public. In our March 2015 reply, we expressed concern that this information distribution did not satisfy Safety Recommendation I-14-2 because it would result in generalized discussions regarding the effects of medical conditions and medications without emphasizing how a patient’s ability to safely operate a vehicle in any mode of transportation (not just driving) might be impacted. To satisfy this recommendation, all the boards needed to include specific information about the effects medications and medical conditions may have on safe vehicle operation. Accordingly, we asked that you provide us copies of the information that was distributed. Pending distribution of the recommended information by all of the boards, Safety Recommendation I 14-2 was classified OPEN--ACCEPTABLE RESPONSE. In the 3 years since our reply, we have not received any further information from you regarding this recommendation. Please send us copies of the joint alert, any other related information that has been published or distrubuted, and a description of any other actions that you have planned or completed to satisfy this recommendation.

From: NTSB
To: Commonwealth of Massachusetts
Date: 3/6/2015
Response: We note that the Massachusetts’ Boards of Registration in Dentistry, Nursing, Pharmacy, and Physician Assistants have either posted to their websites or sent electronically to their distribution lists a Joint Alert to remind licensees with prescriptive and dispensing authorities of their obligation to discuss with each patient the potential effects of medical conditions and medications prescribed. However, we are concerned that this distribution of information does not satisfy Safety Recommendation I-14-2, because it will result in generalized discussions of the effects of medical conditions and medications that may not emphasize how a patient’s ability to safely operate a vehicle in any mode of transportation (not just driving) may be affected. To satisfy this recommendation, all of the Boards will need to include specific information about the impact of medications and medical conditions on the safe operation of a vehicle (driving as well as operating in other modes of transportation). Accordingly, we ask that you provide us with copies of the information they have distributed. We also point out that, to assist the commonwealth of Massachusetts in satisfying the recommendation, we included with our initial letter a sample article that may easily be posted on a website or otherwise distributed. Pending the distribution of the recommended information by all of the Boards, Safety Recommendation I 14-2 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: The only information that we have from you regarding this recommendation is a December 23, 2014, letter from Ms. Lynn Langley, then Executive Director, Mississippi Board of Nursing. Ms. Langley wrote that information regarding the risks associated with drug use and transportation had been incorporated in all of the Mississippi Board of Nursing’s educational programs, and that this information would be included as a standing item in its quarterly magazine. On March 6, 2015, we replied that, for the state to fully satisfy this recommendation, the Mississippi boards of Medical Licensure and Pharmacy needed to take similar action. Pending completion of the recommended actions, Safety Recommendation I 14-2 was classified OPEN--ACCEPTABLE RESPONSE. We have not received any further information from you regarding this recommendation in the 3 years since Ms. Langley’s letter. Please let us know if the Mississppi Boards of Medical Licensure and Pharmacy have taken actions to satisfy this recommendation. If they have not yet distributed the recommended information, please tell us when they plan to do so.

From: NTSB
To: State of Mississippi
Date: 3/6/2015
Response: We are encouraged that Mississippi’s Board of Nursing has included information regarding the risks associated with drug use and transportation in all of its educational programs throughout the state, and will include the information as a standing item in its quarterly magazine, sent to all 58,000 nurses in Mississippi. For the state to fully satisfy this recommendation, the Mississippi Boards of Medical Licensure and of Pharmacy will need to take similar action. Pending completion of the recommended actions, Safety Recommendation I-14-2 is classified OPEN—ACCEPTABLE RESPONSE.

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: Dr. Gustafson also wrote that the Montana Board of Nursing’s newsletter relates primarily to nurse licensing requirements and does not include issues of good medical and clinical practice, such as those discussed in this recommendation. Therefore, she concluded the newsletter is not an appropriate publication for the action we recommended. In our January 12, 2016, reply, we said that for you to satisfy this recommendation, the Montana Boards of Medical Examiners and Pharmacy needed to distribute the recommended information in their newsletters or other routine communications. Pending that action, Safety Recommendation I-14-2 remained classified OPEN--AWAIT RESONSE. We have not received any further information from you regarding this recommendation in the 2 years since our letter. Please update us about any actions you have planned or completed to satisfy the recommendation.

From: NTSB
To: State of Montana
Date: 1/12/2016
Response: Dr. Gustafson indicated that the Montana Board of Nursing’s newsletter relates primarily to nurse licensing requirements. As a result, it appears that the newsletter does not discuss issues of good medical and clinical practice, and therefore is not appropriate for the action specified in this recommendation. For the state to satisfy this recommendation, the Montana Board of Medical Examiners and the Board of Pharmacy will need to distribute the recommended information in their newsletters or other routine communications. Pending confirmation that the boards will pursue that action, Safety Recommendation I-14-2 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: 3/15/2018
Response: We previously said that the December 2014 issue of the Nevada State Board of Medical Examiners newsletter, published shortly after we issued this recommendation, contained a thorough article describing our study and the actions that should be taken by medical prescribers as a result. In addition, the Nevada Board of Pharmacy’s April 2016 newsletter included an article about our study. These publications satisfied this recommendation for the Nevada State Board of Medical Examiners and for the Nevada Board of Pharmacy. In an October 13, 2014, e-mail, Ms. Barbara Longo, then Executive Director, Nevada Board of Osteopathic Medicine, said that her board was adding the language in our recommendation to its website and planned to include the language in its newsletter. On January 27, 2016, we said that the only remaining action needed to satisfy this recommendation was for the Nevada Board of Nursing to publish an article similar to those published by the other boards. Pending that action, Safety Recommendation I 14-2 remained classified OPEN--ACCEPTABLE RESPONSE. Please send us a copy of the article from the Nevada Board of Osteopathic Medicine’s newsletter, as well as any articles about our study that have been published by the Nevada Board of Nursing. If such articles have not yet been published, please tell us when the boards plan to do so.

From: State of Nevada
To: NTSB
Date: 4/14/2016
Response: -From Larry L. Pinson, Pharm.D. Executive Secretary, Nevada State Board of Pharmacy: The article has indeed been published and sent to all of the pharmacists in the state of Nevada. You may access it through our website (BOP.NV.GOV) under “resources” then “newsletter” if you care to see the final draft.

From: NTSB
To: State of Nevada
Date: 1/27/2016
Response: We note that the December 2014 issue of the newsletter of the Nevada State Board of Medical Examiners, published shortly after we issued this recommendation, contained a thourough article describing our study and the actions that should be taken by medical prescribers as a result. That publication satisfies this recommendation for the Nevada State Board of Medical Examiners. We also note that the Nevada Board of Pharmacy plans in the near future to place an item in its quarterly newsletter and post a related notice on its website. We have previously noted that the Nevada Board of Osteopathic Medicine was adding the language in our recommendation to its website, and also planned to include the language in its newsletter. Please send us a copy of the relevant articles from the Board of Osteopathic Medicine’s newsletter and from the Board of Pharmacy’s newsletter once they become available. For the state to satisfy this recommendation,the Nevada Board of Nursing also will need to take similar action. Pending our receipt of articles published in the newsletters of the Nevada Board of Osteopathic Medicine and the Nevada Board of Pharmacy, and the Nevada Board of Nursing’s taking similar action, Safety Recommendation I 14-2 remains classified OPEN—ACCEPTABLE 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: We are encouraged that Nevada’s Board of Osteopathic Medicine is adding the language in our recommendation to its website, and also plans to include the language in its next newsletter. For the state to satisfy this recommendation, the Nevada Board of Medical Examiners, the Nevada Board of Nursing, and the Nevada Board of Pharmacy also will need to take similar action. Please send us a copy of the relevant article from the Board of Osteopathic Medicine’s newsletter once it has been published. Pending completion of the recommended actions and our review of the additional related articles and postings, Safety Recommendation I 14-2 is classified OPEN—ACCEPTABLE RESPONSE.

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: When we issued this recommendation, we provided a sample article that the boards could easily drop into a newsletter or other published communication. In 2016, the North Dakota Board of Nursing published the article in edition 54 of the Dakota Nursing Connection, which we have previously said satisfed the recommendation for that board. We note that the June 2016 edition of the North Dakota Board of Pharmacy’s newsletter contains the sample article, satisfying the recommendation for the Board of Pharmacy. Finally, we note that the North Dakota Board of Medicine recently prominently placed a link to the sample article on its website, as well as a link to the “Tri Regulator Statement on Opioid Prescribing/Dispensing.” The Board of Medicine also sent e-mails to all licensed physicians, residents, and physician assistants that included a link to the statement. These actions satisfy Safety Recommendation I-14-2, 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: When we issued this recommendation, we provided a sample article that the boards could easily drop into a newsletter or other published communication. In 2016, the NDBON published the article in edition 54 of the Dakota Nursing Connection, satisfying the recommendation for that board. We recently provided another copy of the sample article to Ms. McDonald. For the recommended action to be complete, the NDBOP must publish the sample article, and the NDBOM must publish it or an article describing the guidelines it develops to satisfy Safety Recommendation I-14-1 once they have been approved. Please send us those articles to review once they have been published. Until then, Safety Recommendation I 14 2 remains classified OPEN--ACCEPTABLE RESPONSE.

From: State of North Dakota
To: NTSB
Date: 4/3/2018
Response: Lynette McDonald, Deputy Executive Secretary, ND Board of Medicine: The North Dakota Board of Medicine has been taking steps to address the opioid crisis in North Dakota, including the following: The Board in conjunction with the University of North Dakota School of Medicine has provided a link to free opioid CME Modules on its website. The Board implemented and published on its website in 2013 opioid prescribing guidelines. The Board adopted rules requiring prescribers to utilize the POMP. Additionally, the Board provided an exception within its telemedicine rule for prescribing specific types of opioids used for MAT (Medication Assisted Treatment) purposes, which are used to help treat opiate addiction. The Board's Executive Secretary is a member of the Tri-Regulator Group, which is currently drafting a joint statement for approval of each Board regarding opioid prescribing. The Board remains dedicated to its role in protecting the public and will continue to advocate for other key actions regarding opiates.

From: NTSB
To: State of North Dakota
Date: 3/12/2018
Response: When we issued this recommendation, we provided a sample article that the boards could easily drop into a newsletter or other published communication. The North Dakota Board of Nursing published the article in edition 54 of the Dakota Nursing Connection, satisfying the recommendation for that group. On June 8, 2016, pending similar action by the North Dakota Boards of Medical Examiners and Pharmacy, Safety Recommendation I 14 2 was classified OPEN--ACCEPTABLE RESPONSE. If the remaining boards have published similar articles, please send us copies. If such articles have not yet been published, please tell us when the boards plan to do so.

From: NTSB
To: State of North Dakota
Date: 6/8/2016
Response: We note that, in edition 54 of the Dakota Nursing Connection, the North Dakota Board of Nursing published a copy of the sample article that we previously provided. This action satisfies the recommendation for the North Dakota Board of Nursing. Pending similar action by the North Dakota Boards of Medical Examiners and of Pharmacy, Safety Recommendation I-14-2 remains classified OPEN—ACCEPTABLE RESPONSE.

From: State of North Dakota
To: NTSB
Date: 5/4/2016
Response: -Stacey Pfenning, DNP, APRN, FNP, Executive Director, North Dakota Board of Nursing: The North Dakota Board of Nursing published the article “Evidence that pilots are increasingly using OTC prescription and illicit drugs” along with the notification to licensees regarding the NTSB goals and recommendations. Below is a link to the electronic publication. This publication is distributed to about 18,000 ND licensees and additional entities such as libraries and healthcare facilities. http://epubs.democratprinting.com/publication/?i=299438#{"issue_id":299438,"page":0} pp. 14-15.

From: NTSB
To: State of North Dakota
Date: 3/29/2016
Response: We note that, as recommended, the North Dakota Board of Medical Examiners plans to include the information about our study and its findings in a mass communication to all of its licensees. When we issued this recommendation, we included a sample article that could be included in any newsletters or other routine communications. A copy of that article is attached to this letter, and an electronic copy of it may be obtained by contacting Mr. Jeffrey Marcus at marcusj@ntsb.gov. The article may be freely edited to match any style or length guidelines of your publications. Distribution of this article to the licensees will satisfy the recommendation. The information Ms. Ternes provided regarding activities of the North Dakota Board of Nursing and the North Dakota Board of Pharmacy did not include any information related to this recommendation. The information from the Board of Nursing relates to activities related to preventing the abuse of pain medications. This is a serious issue that is worthy of careful and effective treatment; however, it is unrelated to the recommended action of informing the Board’s licensees of the need to routinely discuss 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, when the patient is using the medication appropriately and as directed. If the North Dakota Board of Nursing has a newsletter that it distributes to its licensees, or any other routine forms of communication, we are recommending that our sample article, or similar information, be included. Such action would satisfy this recommendation for that Board. With regard to action by the North Dakota Board of Pharmacy, Ms. Ternes included a copy of Section 43-15-31.2 of the North Dakota Century Code that requires a consultation on each prescription dispensed by a pharmacist. We reviewed Section 43-15-31.2, and point out that it does not contain any information about impairments to operating a vehicle associated with the use of a medication, nor does it contain any information related to the Board of Pharmacy issuing a newsletter or otherwise having routine communications with its licensees. Similar to the Board of Medical Examiners, and the Board of Nursing, to satisfy this recommendation, the Board of Pharmacy needs to include our sample article, or an article containing similar information, in a newsletter or other routine communication that it has with its licensees. In recognition of the plans by the Board of Medical Examiners to distribute information from our study, Safety Recommendation I-14-2 is classified OPEN--ACCEPTABLE RESPONSE pending publication of our sample article, or similar information, by the Boards of Medical Examiners, Nursing, and Pharmacy. We ask that, when these articles are published, you either send us a copy of the published articles, or provide us a link to their locations on each Board’s website.

From: State of North Dakota
To: NTSB
Date: 2/17/2016
Response: -From Tami Ternes, Policy Advisor, Health and Human Services, Office of Governor Dalrymple, State of North Dakota: ND Board of Nursing -“Role of the Nurse in Pain Management” https://www.ndbon.org/RegulationsPractice/PracticeStatements/Role-PainMgmt.asp The ND Board of Nursing have participation of licensing Boards with prescribers on the multidisciplinary, state-wide “Reducing Pharm Narcotics in our Communities” coalition. In 2013- 2015 included presentations and several initiatives related to narcotics. Pamela Posey would have the dates and content of relevant initiatives. ND Board of Medicine – The ND Board of Medicine will include the NTSB’s message in a mass communication to all licensees. ND Board of Pharmacy - ND Century Code 43-15-31.2 requires a consultation on each prescription dispensed by the pharmacist. The ND Board of Pharmacy expectations are that a proper consultation should include narratives on the side effects and its potential impact on a patient’s condition in regards to operating vehicles. The ND Board of Pharmacy intend to continue to stress the importance of a proper consultation which addresses these issues. http://www.legis.nd.gov/cencode/t43c15.pdf?20151221155505 (pg. 14)

From: NTSB
To: State of North Dakota
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 Ohio
Date: 8/10/2018
Response: We previously said that the November 2015 issue of the Ohio Board of Pharmacy’s quarterly newsletter, which included a description of our study and recommendations, satisfied this recommendation for the Ohio Board of Pharmacy. We also said that the Winter 2016 edition of Momentum, the Ohio Board of Nursing’s newsletter, which included an article about our study and recommendations, satisfied Safety Recommendation I-14-2 for the Ohio Board of Nursing. We note that the State Medical Board of Ohio recently posted the sample article that we included when we issued this recommendation on its website. The State Medical Board also included information in its June 2018 electronic newsletter about the resolution that it adopted, as discussed above. These actions satisfy Safety Recommendation I-14-2, which is classified CLOSED--ACCEPTABLE ACTION.

From: State of Ohio
To: NTSB
Date: 7/10/2018
Response: -From Kimberly C. Anderson, Esq., Chief Legal Counsel, State Medical Board of Ohio: The State Medical Board of Ohio adopted the attached Resolution regarding safety Recommendations I-14-1 and I-14-2 on June 13, 2018. The Board posted the attached article to its website, included information regarding the Resolution in its electronic newsletter for June 2018 and included a link to the article in a tweet. We believe with this action, the Board has satisfied both safety Recommendations I-14-1 and I-14-2. If you have additional questions, please contact me. Thank you.

From: NTSB
To: State of Ohio
Date: 5/15/2018
Response: We previously said that the November 2015 issue of the Ohio Board of Pharmacy’s quarterly newsletter, which included a description of our study and recommendations, satisfied this recommendation for the Ohio Board of Pharmacy. That newsletter also included the Board of Pharmacy’s recommendation that practitioners talk with patients before dispensing prescriptions that may impact their ability to safely operate a vehicle. Ms. Houchen’s letter included a copy of the Winter 2016 edition of Momentum, the Ohio Board of Nursing’s newsletter, which included an article about our study and recommendations, satisfying Safety Recommendation I-14-2 for the Ohio Board of Nursing. The only remaining action needed to complete this recommendation is for the State Medical Board to publish the sample article that we included with the recommendation (or similar information) in its newsletter. Pending such action, Safety Recommendation I 14 2 remains classified OPEN--ACCEPTABLE RESPONSE.

From: State of Ohio
To: NTSB
Date: 3/1/2018
Response: -From Betsy J. Houchen, RN, JD, Executive Director, Ohio Board of Nursing: This letter is in response to your February 27, 2018 correspondence to Governor John Kasich, in which you referenced the Ohio Board of Nursing (Board) December 8, 2015 letter addressed to Mr. Christopher A. Hart, Chairman, National Transportation Safety Board. The Board featured in its Winter 2016 publication, Momentum, the NTSB Safety Recommendations I-14-1 and I-14-2 (attached), along with the attached articles: 1) APRN Formulary – Revised Format; e-Prescribing Controlled Substance 2) Ohio’s New Opioid Prescribing Guidelines for Acute Pain 3) Ohio Guideline for the Management of Acute Paint Outside of Emergency Department The Board also published in the Fall 2017 issue of Momentum, an article titled, “New Limits of Prescription Opioid Analgesics for Acute Pain” (attached). All this information is available on the Board website, under the link titled, “Prescribing Authority”. As previously shared with NTSB, the Board will continue to highlight and promote the importance of nurses advising patients about all drug interactions or side effects that may adversely impact safety.

From: NTSB
To: State of Ohio
Date: 2/27/2018
Response: Our most recent information from you regarding this recommendation are a November 24, 2015, letter from Mr. Steven W. Schierholt, Executive Director, State of Ohio Board of Pharmacy, and a December 8, 2015, letter from Ms. Betsy J. Houchen, Executive Director, Ohio Board of Nursing. Mr. Schierholt sent a copy of the November 2015 issue of the Ohio Board of Pharmacy’s quarterly newsletter, which included a description of our study and recommendations, and a recommendation from the Board of Pharmacy to talk with patients before dispensing prescriptions that may impact their ability to safely operate a vehicle. On January 12, 2016, we said that this publication satisfied the recommendation for the Board of Pharmacy. Ms. Houchen wrote that the Ohio Board of Nursing planned to publish the information in the winter 2016 issue of its newsletter, Momentum, and that the information had also been posted on its website under a link titled “Prescriptive Authority Resources.” On January 12, 2016, we replied that publishing the information in Momentum would satisfy the recommendation for the Board of Nursing, but similar action was also needed by the State Medical Board of Ohio. We asked that you provide us a copy of the publications including the requested information once the articles had been published. We also asked that when the remaining organizations published the information, they consider using the sample article we sent when we issued the recommendation because it contained additional useful information. Pending such action, Safety Recommendation I 14 2 was classified OPEN--ACCEPTABLE RESPONSE. We have not received any further information from you regarding this recommendation since our January 2016 letter. Please send us a copy of the article that appeared in the winter 2016 issue of Momentum, and copies of any other articles published by the Ohio Board of Nursing or the State Medical Board of Ohio to satisfy this recommendation.

From: NTSB
To: State of Ohio
Date: 1/12/2016
Response: We note that the November 2015 issue of the Ohio Board of Pharmacy’s quarterly newsletter included a description of our study and recommendations, as well as a recommendation from the Board of Pharmacy to talk with patients before dispensing prescriptions that may impact their ability to safely operate a vehicle. This publication satisfies the recommendation for the Board of Pharmacy. We further note that the Ohio Board of Nursing plans to publish the information in the winter 2016 issue of its newsletter, Momentum, and that the information has also been posted on its website under a link titled “Prescriptive Authority Resources.” Publication of the information in Momentum will satisfy the recommendation for the Board of Nursing, but similar action is also needed by the State Medical Board of Ohio. We request that, when these remaining organizations publish the information, they consider using the sample article we sent last year when we issued the recommendation because it contains additional useful information. Pending completion of such action, Safety Recommendation I-14-2 is classified OPEN—ACCEPTABLE RESPONSE.

From: State of Ohio
To: NTSB
Date: 12/8/2015
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