I’ve been seeking an answer for some months now, and it appears to be: “It depends.”
One of my most successful office-based buprenorphine patients was due to renew his commercial driver’s license (CDL). He’s had his CDL for years, and has never had a serious accident. He’s been a stable patient of mine for around four years, and his last illicit opioid use was ten years ago. He started his recovery at a methadone clinic, and then transitioned to another buprenorphine doctor’s office-based practice before he transferred to me four years ago.
He’s held a commercial driver’s license (CDL) all of those years.
Since he has done so well, we’ve discussed the pros and cons of starting a slow taper off buprenorphine. Due to recurring pain issues, he would probably require intermittent opioid medication if he tapered off buprenorphine. Ultimately, we decided he would have a better quality of life and a lower risk of a relapse to uncontrolled opioid use if he remains on buprenorphine indefinitely.
Like so many of my patients, once his addiction was treated, he excelled at his job, and he’s received several promotions over the past few years. However, even though he doesn’t drive a truck every day, he’s still required to keep a CDL in order to keep his job.
When he went for his usual Department of Transportation driver’s exam this year, he was turned down for his CDL. He was told that people on narcotics can’t get a commercial driver’s license.
The Department of Transportation has undergone some changes over the past few years. Back when I was in primary care, any doctor could fill out the DOT form for a patient to get a CDL. Some doctors were rather slap-dash in their efforts, and I suppose that’s why doctors now have to quality to do these CDL exams. Starting a few years ago, doctors must take a training course and pass a test in order to register to do DOT exams. All such doctors are listed on the National Registry of Certified Medical Examiners.
When he was asked about his medications, he lied and told them he wasn’t on any medications. He was conflicted about this; he wanted to tell the truth, but was afraid that if he did so, his livelihood would be in danger. We discussed this issue at one of his visits, and I told him what I knew at the time. Patients maintained on methadone can’t get a CDL if they reveal that to the medical examiner, and I doubted buprenorphine would be viewed any differently. I also told him the DOT doesn’t test for buprenorphine. He passed all DOT exams in the past because the examiner didn’t know he was on maintenance medication. DOT doesn’t test for anything but marijuana, cocaine, opiates, amphetamines, and PCP. (Yes, you read that right. PCP.)
The DOT test will detect opiates, that is, substances derived from the opium poppy, but won’t detect synthetic opioids like methadone, buprenorphine, fentanyl, and the like.
I also told my patient that I did not feel he was impaired from the buprenorphine I prescribed, as he had a tolerance to any sedating effect it could have. I told him I’m much rather meet him on the road than a driver who took Ambien the night before. And I told him it was ultimately up to him to decide what to tell the DOT examiner.
So my patient didn’t tell the DOT examiner that he was on buprenorphine. He was afraid if he did tell the examining doctor, his employer would find out and he would be fired. He was also afraid he wouldn’t be able to get his CDL if he told the truth. As it turns out, he was correct.
As expected, my patient’s DOT drug screen was negative for all substances. However, this examiner checked the state prescription monitoring program, where he saw my patient’s prescriptions for Suboxone. So the examiner denied my patient his CDL.
I felt so badly for my patient. Here he was, as successful as a person can be in recovery, being turned down both because he is taking buprenorphine, and also because he didn’t tell the DOT examining doctor that he was taking buprenorphine.
I wanted to advocate for my patient, and in a misguided effort, wrote a letter to my state’s DOT. It was a great letter, emphatically worded, with data references, but I sent it to the wrong place. Eventually, my patient got a letter from the state DOT saying it was fine with them that he keep driving, but that suitability for a CDL wasn’t under their purview. When I called for more information, they told me I needed to contact the Federal Motor Carriers Safety Administration (FMCSA).
It took repeated calls (six) to this government agency before I was able to talk to someone, but finally I reached a person who gave me the scoop. Her name was Angela, and she told me that if my patient was on methadone, there was no way he could get a CDL. She also said that with buprenorphine, it was decided on a case-by-case basis, and that I would need to talk to the physician doing my patient’s DOT exam, and that the decision was ultimately up to this person. She also said my patient had the right to seek a second opinion about his CDL.
OK, I thought. Now we’re getting somewhere. Before my patient spent time and money talking to a doctor for a second opinion, I thought I should try talking to the first doctor who had turned him down. This doctor was on staff at the same teaching hospital where I did my residency in Internal Medicine about a billion years ago, so I hoped he would be educated and open to the facts I wanted to present.
After all, I thought, science was on my side. Studies have not shown differences of reaction times and driving abilities between patients maintained on buprenorphine and normal controls. There is no evidence that I’m aware of that shows maintained patients shouldn’t be behind the wheel. That fact, plus my patient’s successful recovery should convince this doctor.
It did not.
I’ll spare my readers painful details, but this doctor was not open to what I had to say. I felt like this doctor was so hung up on the fact that my patient had lied that he couldn’t hear anything else I was saying. Yes, I told him, my patient did lie, but he did so out of fear that his boss would find out about his substance use disorder, and that he would lose his job. He has a wife and kids to support, and I think many people would lie in similar circumstances.
After I had harped on that for some time, this doctor said that people prescribed narcotics can’t get a CDL, that was that, case closed.
When doctors say things like that, I get confused. I hate the term “narcotic,” because it means different things to different people. To some, it means opioids. To others, it means illicit drugs. If we look at the root of the word, “narco,” which means sleep, a narcotic is a substance that puts people to sleep.
So what does the FMCSA mean when they use the word “narcotic?”
For the purposes of my conversation with this doctor, it meant my patient would not be getting his CDL.
I went to the website of the FMCSA to see exactly the wording of their statement. Here it is:
“If a driver uses a drug identified in 21 CFR 1308.11 (391.42(b)(12)) or any other substance such as amphetamine, a narcotic, or any other habit forming drug, The driver is medically unqualified. There is an exception: the prescribing doctor can write that the driver is safe to be a commercial driver while taking the medication. In this case, the Medical Examiner may, but does not have to certify the driver.”
I thought 21 CFR 1308 would give me more exact information, but when I found it on the internet, it does not. It’s just the law that categorizes potentially addicting drugs into Schedules 1-5.
Does this mean that any person filling a controlled substance can’t get a commercial driver’s license? Really? Will there be any people left to drive trucks if everyone prescribed a controlled substance is excluded from driving?
Or will this unfairly apply only to patients on medication-assisted treatment? I don’t know.
Anyway, my patient took a copy of the letter I had written for him to another DOT examining physician, for a second opinion. This doctor granted him a time-limited CDL, and my patient is OK for now.
For now. He’s still worried about his job security in the future, and so am I. Several of my patients are on buprenorphine, and I worry if they will also be denied. I’m happy to advocate for them – assuming they are doing well – but it feels a bit unfair to me.
I have patients on methadone and buprenorphine through our opioid treatment program (OTP). They can get CDLs without problem, because their data is more protected than my office-based patients. OTP data is not posted on the prescription monitoring program in my state because privacy laws prevent this. There has been talk recently about changing this law. But for now, a patient attending the OTP, on the same medication as my office-based patient who was initially denied his CDL, can be granted a CDL because OTP records are held to a higher standard of confidentiality.
The Veterans Administration, where large quantities of controlled substances are prescribed, does not (yet) report to the state prescription monitoring program, so those patients’ medications also would not be revealed to a DOT medical examiner.
It’s a weird world.
If my patient is turned down in the future for his CDL, would he qualify for disability? It seems like that should be the case, and that’s another question I have.
But my patient wants to work. He doesn’t want to go on disability.
I understand that driving commercially is a safety-sensitive job, and people doing those kinds of jobs aren’t granted the same confidentiality about drug use and addiction as people doing other jobs. It’s the same in other safety-sensitive jobs, like medical professionals, pilots, and the like. I drive frequently, and I do want all drivers to be safe.
But I would like for decisions about who can drive and who cannot to be made on the basis of science and fairness, not on persona bias or happenstance.