When policy eclipses reason … oh, and clinical medicine
I last discussed the HIMS program in July of 2020. My article, titled “Lifetime Monitoring: A Warning To Airmen,” followed the FAA’s policy change to establish lifetime monitoring for those in the HIMS program, and those yet to be in the HIMS Program. Since that time, the FAA attempted to soften that policy by and through a second policy called “The Step Down Plan.”1 Since there appears to be no clear end in sight, I think it best to revisit the FAA’s beloved program and highlight some new concerns. Whether these concerns make their way to your is up to you.
First and foremost, I want to make it crystal clear that I in no way want to invalidate the HIMS program for those airmen that truly need it. The program has been historically successful for airmen who genuinely suffer from alcoholism and have been correctly diagnosed with substance use disorder, as defined in the DSM. My goal with these articles is not to nullify the program for those individuals; rather, my goal is to make the program stronger by mitigating the pollution of airmen into the program whose admission is simply inappropriate.
In the last year and a half, I have seen little to no change with the HIMS program. I am still seeing 121 carriers using the program as an HR backboard and a litigation shield. I am still seeing episodes of regulatory substance abuse being inappropriately assigned a regulatory diagnosis of substance dependence for which entry into the HIMS program is required. I am still seeing unwavering deference given to a positive dry blood spot test, and not to the mountain of supplemental tests that invalidates the one administered by a lab tech who has no familiarity with tests and failed to follow the directions. I am still seeing the FAA come up with new iterations of what I call the ‘syntax shuffle’, where medical direction is masked as medical evaluation. Most recently, the new syntax shuffle involves the HIMS requirement of intensive outpatient. Instead of explicitly requiring intensive outpatient rehabilitation, the FAA has been utilizing the following verbiage:
“Please be advised that evidence of current alcohol dependence recovery treatment [meeting American Society of Addiction Medicine Level 2 criteria, for at least a month] is the first step of reconsideration.”2
I intend to talk about each point discussed above in a series of articles, but the casual use of American Society of Addiction Medicine (ASAM) criteria is something which should be addressed sooner rather than later. ASAM Level 2 criteria is subdivided into two (2) categories, 2.1 and 2.5. Level 2.1 criteria intensive outpatient treatment, while 2.5 requires at least partial hospitalization.
Level 2.1 is traditionally what the FAA is referring to when they ask for “evidence” of Level 2 criteria. According to the ASAM textbook, “a patient who is appropriately placed in a Level 2.1 program is assessed as meeting the diagnostic criteria for substance use and/or other addictive disorder as defined in the current Diagnostic and Statistical Manual of Mental Disorder (DSM) of the American Association or other standardized and widely accepted criteria, as well as the dimensional criteria for admission.” 3
The contrariety in the FAA’s request is as frustrating as it is nonsensical. Essentially, the FAA is requesting that an airman provide evidence of substance dependence treatment, which is a term that while recognized by the current regulations, has not been used since the DSM-3, that meets the industry criteria, which requires the use of the DSM-5. But wait, there is more!
According to the ASAM text, “direct admission to a level 2.1 program is advisable for a patient who meets specifications in Dimension 2 (if any biomedical conditions or problems exist) and in Dimension 3 (if any emotional, behavioral, or cognitive conditions or problems exist), as well as at least one of Dimensions 4, 5, or 6.”4 For reference, “biomedical” conditions, as utilized by the ASAM, are biological and physiological aspects of addictions. For example, a genetic disposition to alcohol use would be a biomedical condition. If such an example were to be true for an airman, he or she would be directly admitted into ASAM level 2.1 if the following Dimensions were met:
The airman would also have to meet the criteria in Dimension 3, below, assuming emotional, behavioral, or cognitive conditions existed as well:
The airman would also have to meet at least one of Dimensions 4,5, or 6, below: