ADDRESSING ALCOHOL ABUSE
Thanks to ALPA’s
more than 3,500 pilots are flying today after loss of their
medical certificate to a disease that once kept all affected pilots out of their cockpits.
By Esperison Martinez, Contributing Editor
Air Line Pilot, April 2004, p.17
Many airline pilots would not be able to identify the acronym HIMS, whose contribution to restoring good pilots to the cockpit by helping them overcome alcoholism has increased aviation safety. ALPA’s Human Intervention and Motivation Study program has returned more than 3,500 pilots to the cockpit since it began nearly 30 years ago.
HIMS was begun, fashioned, and developed for airline pilots by airline pilots because a thoughtful, frank, in-your-face-physician stood before the 1972 ALPA Board of Directors and opened the taboo subject of alcoholism in the cockpit. No reliable or systemwide method existed then to provide help for airline pilots who had alcohol problems.
In the early 70s, pilots diagnosed with alcohol dependence were summarily fired from their jobs, lost their FAA medical certification, and were banned from the airline piloting profession. The notion that alcoholism could be a bona fide disease was alien to most laypersons and decision-makers in the air transport industry; the prevailing attitude was "once a drunk, always a drunk," and as a result, alcohol-addicted pilots stayed in the closet. "Too often, the only way we would discover an alcoholic pilot was when withdrawal seizures struck while on duty," said an FAA official.
Dr. Richard L. Masters knew differently. He had been appointed in 1969 to the new role of Aeromedical Advisor to ALPA’s governing bodies and was charged with advising the union’s leaders about pilot health and welfare problem areas. Dr. Masters was clear that no epidemic of pilot alcoholism existed, but he wanted Board members to recognize that any pilot who drank, and many did, might be susceptible to the illness. He emphasized that then-existing attitudes of airline managements and the FAA were incompatible with early identification and treatment. For example, from 1960 to 1971, eight pilots petitioned the FAA for alcoholism exemptions; all were denied. Further, the FAA granted only 10 of 15 petitions submitted from 1971 to 1974.
Dr. Masters received unanimous approval to establish a health program to address the illness. Working with him were two pilots, Capts. R.W. Gilstrap (United) and G.S. Chase (Continental/United).
Two years later, they introduced a program that they believed would be trusted and accepted by pilots, would convince airline managements and the FAA about the need for such a program, would not tarnish the pilots image, and would be funded by an outside source.
The program followed a pilot-specific model that requires recognition of the illness by all parties, intervention, evaluation, referral to treatment, rehabilitation, and FAA reissuing the airman’s medical certificate. The National Institute for Alcohol Abuse and Alcoholism (NIAAA) worked closely with the ALPA team that developed the program, which became the Human Intervention and Motivation Study. The NIAAA initially provided 3 years’ funding for HIMS.
By 1984, active HIMS programs had been established at most of the major U.S. airlines. By then, the program had returned 1,200 pilots to the cockpit and had achieved a 90 percent recovery rate. Unfortunately, budget cutbacks forced the NIAAA to cease funding.
Having achieved the goal of establishing an accepted pilot alcohol intervention program, ALPA withdrew from its role as "administrator." The program continued under supervision of the FAA, independent medical sponsors, and airline medical officers.
At that time, pilots and the U.S. airline industry were caught in the upheavals of deregulation. Many airline management and government officials who had accepted HIMS were either gone or were leaving. Elements of the airline-industrywide HIMS program began to be incorporated into locally developed programs and were given a new name. Officials assumed that past experience would carry over and that new, upcoming drug- and alcohol-testing provisions would act as inhibitors to alcoholism in the cockpit. Attentiveness and interest in a wide-scale HIMS program began to slacken.
Blistering news media coverage of pilots violating alcohol-use regulations in the early 1990s demonstrated that hybrid recovery programs were not working nearly as well as had HIMS. Consequently, in 1992, the FAA funded a resurrection of HIMS. By that time, deregulation had caused a major makeover of the air carriers. The domination of major airlines was waning while the number of smaller carriers grew. This change in the makeup of pilots and airline managements brought about the recreation of HIMS.
"Those who had originally started HIMS thought that it would be one program for the entire U.S. airline industry and that it would function the same at all airlines," said Dr. Don Hudson, who joined the ALPA Aeromedical Office in 1987 and became Aeromedical Advisor after Dr. Masters retired in January 1992. "Over the years, however, each airline has used the original HIMS program as an approximate blueprint, not following it exactly. Each airline has separate corporate and ALPA cultures that influence what the program at that airline looks like."
When HIMS restarted in 1992 as HIMS II, a new training approach began with new FAA funding. The new program provided for a 42-month training and education schedule consisting of seminars and training materials for all air carriers, with an emphasis on newly established airlines and regional carriers.
Capt. Richard Stone (Delta, Ret.), who had served ALPA as its Executive Chairman for Aeromedical Resources, was named to serve as program manager for HIMS II.
The program’s new training and education included a mass mailing about alcohol and alcoholism as a family disease to 57,000 pilots at 46 airlines, a video depicting how to make HIMS elements effective, and an outline of a model program for air carriers to use in dealing with alcoholism. Mini 1-day seminars were added to the 3-day "national" seminar that HIMS conducted. The lessons learned while the program was dormant (1984–1992) and ALPA’s ongoing lobbying for federal funding for HIMS has kept the program active ever since.
Dr. Hudson says, "The fact we are now dealing with a younger pilot base means that HIMS itself has to continue to focus more on its education role. Many people coming into the U.S. airline industry now have never heard of HIMS. It is the kind of program that you really have to sell every two years at your airline, because of the changeover in personnel."
That clearly was the case in 1998, at the start of the third renewal of the program. The annual seminar held then, thought planners, would serve as a "refresher" for the attendees. But much to their surprise, almost 80 percent of those attending were new to the subject and to the HIMS program.
The same numerical balance held for the most recent HIMS seminar, held in Denver, Colo., on Sept. 23, 2003; but this time, the HIMS planners had expected it and were well prepared.
Dr. Audie Davis, HIMS program manager, opened the seminar. Now in his second contract term with HIMS, he formerly headed, for 30 years, the FAA division that decides what pilots are fit to fly. Working together with Dr. Masters in developing what would become HIMS, Dr. Davis became the most effective force within the FAA for overcoming the FAA’s belief that recovered alcoholic pilots should never return to the cockpit.
What was once a seminar intended only for pilots and designed to make the attendees fully ready to carry out the HIMS program at their airline has over the years been honed to a crisp, detailed 2½-day education program "to train peer pilot committee members, airline managers, and physicians in dealing with substance abuse within the pilot profession," Dr. Davis told the assembled crowd of 138 in welcoming them to the 2003 seminar. He emphasized, "This seminar is only the first step in qualifying you to work in this field. Experience in assisting with identification, intervention and continuing care must come from other trained and experienced members in the system."
By the time the data-laden program was over, attendees would clearly understand the role they would play in the triad of cooperation among airline management, union, and the FAA that allows the HIMS methods to succeed. This audience was familiar with the concepts "alcoholism is not self-induced" and "alcoholism is a disease." Here, they would learn the "why" of those facts.
Dr. Davis told the group, "As in any other professional occupation, about 7 to 10 percent of airline pilots will develop the disease during their piloting career. Each year, the number of pilots in a HIMS program ranges from 110 to 130, although for one 3-year period, it fell to 105, 97, and 87. In 2002, the FAA granted 80 special issuance [airman medical certificates], and as of mid-September 2003, 61 had special issuances."
Dr. Hudson said that the relapse rate remains low for rehabilitated pilots. "From the beginning, our 24-month rate has been 10 to 15 percent, meaning 85 to 90 percent will have remained sober at the two-year mark. After the two-year mark, we see about a 10 percent relapse rate over the remainder of a pilot’s career."
He added that the recovery rate is well above the rate of most programs in existence, except for some of the professional programs, such as the one for physicians, which is based on HIMS and is also at the 90 percent mark. "HIMS elements," he said "are the blueprint for successful recovery programs for professionals, nationwide."
Lynn Hankes, MD, FASAM, director of the Washington [state] Physicians Health Program and a HIMS Advisory Board member, has been with the program for more than 15 years and is among the 100 pioneer U.S. physicians who passed the first certification exam in addiction medicine.
At the core of the HIMS educational effort is understanding that chemical dependency is truly a disease—this is critical to working with those afflicted with it. Dr. Hankes reviewed the classes of drugs and noted that, contrary to popular opinion, the mortality rate of about 300 per day for alcohol-related deaths is higher than the 10 per day from illegal drugs.
Addiction, noted Dr. Hankes, is characterized by three core elements—loss of control, compulsive use, and continued use despite adverse consequences. Faced with alcohol or another drug, addicted individuals cannot predict three things: whether they will use; if they do use, how much they will use; and what behavior will follow.
Dr. Hankes explained, "You must understand ‘denial,’ or waste the next three days: Denial is a distorted relationship between the individual and the chemical. Denial is not lying. Lying is a conscious attempt to distort the truth. Denial is a subconscious defense mechanism. It is a little trick the mind plays on itself to protect it from hearing overwhelming bad news."
He said, "The drinking continues because the chemically dependent person can’t see the cause and effect connection between the drinking and the problems. The bottom line for the attendees to carry away is that alcoholics and addicts do not drink or drug the way they do because they want to; they drink or drug the way they do because they have to!
"As in many other diseases," Dr. Hankes pointed out, "the root cause is not known. The defect appears to be a combination of a brain chemical imbalance and certain psychological traits or lack thereof. Alcoholism is permanent and prone to relapse. It stands alone, independent of other conditions. It is often progressive through early, middle, and late stages. It follows this same predictable pattern in all afflicted individuals; Lastly, it is contagious in that the stress of living with an alcoholic person produces a condition similar to post-traumatic stress syndrome in anyone emotionally bonded to the alcoholic."
Dr. Hudson addressed the relationship between airline culture and alcohol. While virtually every society may encourage "appropriate use" of alcohol as stress relief, airline industry rules about when it can be used are very specific. All pilots are aware of the consumption parameters; but Dr. Hudson says the rigidity of the rules often leads to binge drinking, consuming a lot of drinks very quickly, among pilots who abuse alcohol.
The caution that attendees need to convey to their pilot group, he indicated, is that binge drinking may make it possible for a pilot to stay within company drinking rules, but owing to the body’s metabolism rate for alcohol, that pilot can be at risk of breaking the FAA legal limits prohibiting flying while having a blood alcohol concentration of between .02 and .039 milligrams percent. He cited as an example four high profile incidents of 2002, in which the pilots involved all tested more than .06 BAC (blood alcohol concentration) after consuming 8 to 14 drinks the evening before, all within the pre-duty time limits.
Dr. Hudson explained that an empty stomach causes the blood stream to absorb the alcohol more quickly than one with food in it. Once the alcohol is absorbed, the blood stream sends it to the brain and it metabolizes primarily in the liver and secondarily in the kidneys. In 90 percent of people, the body metabolizes alcohol at the approximate rate of .015 milligram percent, or about .3 fluid ounces, per hour. So, although a person may stop drinking within the confines of the preduty drinking rules, if that person consumes more alcohol than his or her body can metabolize in the hours before the duty begins, the alcohol test result can still be above the legal alcohol concentration limit.
Two long-term HIMS-connected pilots, Capts. Chris Storbeck (Delta) and Chris Behl (America West), provided hands-on practical information about working HIMS-related committees in the pilot groups.
Capt. Storbeck, Delta Pilots Assistance Committee Chairman, stressed that committee members should trust their intuition when involved in identifying cases of substance abuse. Most initial information about a pilot who may be having problems, he said, usually comes from fellow flightdeck and cabin crewmembers. Other sources include on-duty drug tests, security screening reports, and hotel incident reports. Sometimes, a family member concerned about a pilot’s behavior will call. On rare occasions, pilots seek HIMS help on their own. Capt. Storbeck further described the need for providing a supportive atmosphere, the information to be obtained, the workings of a confidential investigation, and the methods of various interventions used at Delta.
Capt. Behl, speaking from experiences within a smaller carrier, covered similar subjects. In addition to stressing the need for "long-term commitment by committee members" to give meaning to the "rehabilitate, don’t terminate" goal of America West’s program, he discussed the "bubble theory." He noted that pilots function in a corporate bubble (CB), or the working environment, and a private bubble (PB), or the living environment. In the CB, if a pilot begins to falter, a means exists to gain that information, but in the PB, getting any information is extremely difficult, Capt. Behl said. Another factor in the bubble theory is that, in the CB, an affected pilot can appear "Sky King" clean, but his or her family may have an entirely opposite view. "We are here to learn what help to offer and how to have that offer accepted," he said and went on to describe the working of his group’s program.
Not a policing action
Crewmembers unfamiliar with HIMS may look upon it and associated programs as a policing action, but that is way off the mark, says Dr. Hudson. "We are concerned with the medical aspects of the addiction and how to help the pilot recover," he said. Still, he understands the reluctance to report something when one can more easily rationalize: "It’s none of my business; it’s personal behavior. It’s not my place to be the alcohol police."
However, getting a pilot into treatment sooner rather than later may be the most helpful thing a peer can do to help his or her fellow pilot. Crewmembers debating whether to report can look upon the 3,500 pilots already returned to the cockpit for assurance that the program is intended to help, not jeopardize, a career. Moreover, getting a pilot help before that pilot has violated any regulation or company policy can be the most effective way to help preserve that individual’s career.
Nancy Hay, a longtime counselor and an expert in the family dynamics of addictions, described the trauma that a family experiences, how individual members are affected, and the unspoken code of conduct (don’t talk, trust, or feel) in an alcoholic family system. She cautioned HIMS workers to "take care of yourself." Committee members, she said, can all too often become so caught up in their committee work that their own family life begins to suffer, as well as often creating stress for themselves.
Dr. Jon Jordan, FAA Federal Air Surgeon, spoke about the operational aspects of medical certification and issues facing HIMS committee representatives. He commented on how well the peer alcohol identification system has worked over past years, but noted an upswing in violation cases. "Education," he said, "is a necessary tool, but it doesn’t always work." Nonetheless, he encouraged the continued revitalization of HIMS.
During his Q-&-A session, pilots in the audience asked about a "new" FAA policy of emergency revocation of the pilot’s medical and airman certificate, in which a pilot is charged with violating the alcohol regulations (including failing a DOT/FAA-required alcohol test). Dr. Jordan responded that, while people may see it as a draconian approach and as a change in policy, the FAA’s Flight Standards Service has always had the authority to revoke a pilot’s medical certificate and airman’s certificate for violations. He cited the "past year’s surge" of violations when talking about the current practice of automatically imposing "emergency" revocation proceedings.
Dr. Nicholas Lomangino, acting manager of the FAA’s Office of Aerospace Medicine, later clarified the status of a pilot entering the HIMS program. He said that a pilot who enters a rehabilitation program, such as HIMS, without having violated the alcohol prohibitions in the federal aviation regulations is required to surrender only his or her medical certificate. In such cases, a pilot who has not violated pertinent FAA regulations is, therefore, able to retain his or her airman certificate.
Speaker after speaker supplied practical, hands-on type information to the attendees, who would return to their airlines and become engaged in sharing what they learned with their pilot groups to encourage peer reporting, when necessary, and in working with identified pilots to rid them of the addiction directing their lives and help restore them to their profession.
The attendees learned methods of intervention, first through lectures, then using role-playing techniques. Later, Capt. William Noyes (Hawaiian) commented on an intervention role-playing session in which an unintentional "accusatory" tone was heard, noting, "If we have a tendency to sound accusatory rather than conciliatory, it may be because pilots tend to address a problem directly and normally…but that is not the intent. Anybody who may become involved in an intervention is doing it with the best intentions and warmth of the heart; it is not an easy thing to do, and we are doing it out of genuine concern and compassion."
Suzanne Kalfus, an ALPA attorney, spoke about how to manage the legal parameters and landmines that HIMS volunteers can encounter while providing information, receiving reports, staging interventions, monitoring peers, helping pilots return to work, and providing feedback to the MEC.
The seminar also covered the assessment and treatment aspects of psychological evaluations, how cases are prepared for the FAA medical certification process, what Alcoholics Anonymous (AA) is and what it is not, and a detailed discussion on the rules of drug and alcohol testing.
Dr. Collin Howgill of the U.K. Civil Aviation Authority (CAA), who was one of a dozen physicians attending the seminar, serves as the CAA’s senior medical officer responsible for the certification of pilots with drug and alcohol problems. He was also a first-time attendee but has been associated with certification issues for some time. He doesn’t believe any program similar to HIMS exists among airlines in the U.K.
"I think HIMS is fascinating," he said. "Having read the literature provided to us who attended, I have been thinking that it may be a very good idea to set up something similar in the U.K. The beauty of the HIMS system is that you are actually being proactive in trying to stop people before they are found drunk in the cockpit, before they run into problems. That’s got to be a good thing."
Throughout the seminar, Dr. Davis’s opening caution remained a constant: "This seminar is only the first step in qualifying you to work in this field. Experience in assisting with identification, intervention, and continuing care must come from other trained and experienced members in the system."
The assumptions that underlay the HIMS program as it was developed remain at the core of program today:
• Alcoholism is a primary treatable disease.
• The FAA and the American Medical Association will define alcoholism.
• Occupational alcoholism programs will have a higher success rate than nonwork-related programs.
• The intensity of job motivation characteristic of airline pilots will yield a greater recovery rate.
• Abstinence is essential to successful rehabilitation.
• Alcoholism readily fits the disease-prevention model.
• Education can be a factor in changing behavior.
• Airline pilot professionalism and the ALPA Code of Ethics promote periodic review of performance.
• Knowledgeable and trained individuals are required to staff the program.
• An open, honest approach toward recovery is basic to quality sobriety and is consistent with pertinent FARs.
• An alcoholic pilot deserves individual professional attention.
• Unsuccessful repeated efforts at treatment for alcoholism warrant cessation of flying on medical grounds.
• Education of the pilot group members is crucial to the success of the program.