Medications and flying

As a student of flight, you are about to learn--if you didn't already--that pilots are required to follow the procedures laid out in the federal aviation regulations in order to obtain and keep a medical certificate. Conditions can develop between flight physicals that temporarily disqualify you from exercising the privileges of your medical certificate--so can the fact that you're taking certain medications, even if only on a short-term basis. But it can be difficult to ascertain just which medications are acceptable while flying, and which are prohibited.

As an aviation medical examiner (AME), I am often consulted by pilots who ask if they can fly while taking a specific medication. Here is the advice I provide: Between aviation medical examinations, you are your own AME, and you must decide if you are safe to fly.

Federal Aviation Regulation (FAR) 61.53 prohibits a person from acting as pilot in command or as a required pilot flight crew member while that person (1) "knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate necessary for the pilot operation" or (2) "is taking medication or receiving other treatment for a medical condition that results in the person being unable to meet the requirements for the medical certificate necessary for the pilot operation."

FAR 91.17(a)(3) states that no person may act or attempt to act as a pilot crewmember of a civil aircraft while using any drug that affects the person's faculties in any way contrary to safety.

While the medical regulations in FAR Part 67 do not list specific medications, the judgment does not have to be your own. You are not constrained from seeking advice, and you should obtain authoritative information. You can call your AME, call the AOPA Medical Certification Department at 800/USA-AOPA, or access the detailed information available at AOPA Online.

If you are taking a medication--any medication--it must be listed on the FAA Form 8500 you complete and attest as true in your AME's office. Now, let's be reasonable. If you take a rare dose of over-the-counter aspirin, Tylenol (acetaminophen), Advil, a laxative, or the like, and are not taking the medication when you see your AME, an omission is not unreasonable. However, if you are taking any prescription medication, or using any over-the-counter medication routinely, it must be reported.

Your AME will likely advise of aeromedical issues concerning the drugs you are taking at the time of your application. However, the calls that I usually receive concern medication that a pilot or student pilot has just begun to take or will begin, on prescription of their physician. They already have a current medical certificate in hand, and of course could not have listed the drug when they presented the form to their AME on their last medical renewal.

We cannot expect every physician to be aware of the potential conflicts between flying and the medications that they prescribe. That is why aviation medicine is a specialty, and why AMEs receive extensive and recurrent training by the FAA to gain and retain the designation to issue medical certificates. I have seen doctors advise pilots not to fly with innocuous medications--I suspect they are uncomfortable with anyone flying. Others are unaware of the physiological effects of taking medications aloft, and they assume if there are no complications on the ground there will be none in the air.

As a rule, medication effects on the ground will be magnified aloft. This is caused by a combination of hypoxia, decreased atmospheric pressure, vibration, disequilibrium, stress, and other factors. The flight environment is in many ways hostile, and it exaggerates human pathology.

However, there is a much more basic question when considering medications aloft. Why are you taking the medication? In many cases it is the illness, and not the medication, that is the limiting factor. For example, you awaken one morning with a heavy head and blocked ears. You stand and feel a little unbalanced and dizzy. You decide to take an over-the-counter medication, say aspirin. Can you safely fly while continuing to take this medication?

It should be obvious that you should not fly because of the medical condition. While medication itself might contribute to temporary grounding (beware of sinus and decongestant medicines as they have sedative effects), the headache, disequilibrium, and ear congestion are what must keep you out of the air. Taking a headache, imbalance, and an ear blockage aloft is a prescription for disaster--and has been the documented cause of significant aircraft accidents.

If you are self-medicating with continuous or frequent over-the-counter medication, the chronic condition warranting that drug must be carefully considered.

There are general rules concerning prescription medications. Rule one is the same as that which applies to over-the-counter medications. Is the condition being treated a disqualifying condition? Please refer to the article below for conditions that by regulation are disqualifying. If you have any of those conditions, whatever medication you are taking--no matter how effectively it is ameliorating the condition, and even if the medication is approved--you cannot fly.

Assuming the medical disorder is not disqualifying by regulation, you should consider some safeguards. Rule two is not to fly until you have been on a new medication for some time. A rule of thumb is three weeks without side effects on the ground before resuming flying. Be particularly cautious if the medication makes you sleepy, or has an effect on your mental status. We are poor judges of our own mental status, but if your spouse tells you, "I don't like you when you are taking that medication," this is a big red flag. Please, do not fly!

Rule three: The FAA is very unlikely to approve flying while you are taking any psychotropic medications. These include tranquilizers, antidepressants, anxiolytics, stimulants, antipsychotics, and anticonvulsives. While the AOPA Board of Medical Advisors strongly supports allowing pilots with depression well-controlled by SSRIs (selective serotonin reuptake inhibitors) to be granted special issuances, this has not yet been approved by the FAA. The FAA has allowed a few pilots to continue to fly while taking Ritalin for attention deficit disorder.

Most pain medications are inconsistent with flying, and this includes narcotics like Demerol, OxyContin (oxycodone), and Vicodin (hydro-codone); and nonnarcotic analgesics like Darvon (propoxyphene) and Ultram (tramadol).

The bottom line: A medication that can affect mood, concentration, cognition, or wakefulness has little place in the cockpit.

The medication that should ground you may not, even for an otherwise nondisqualifying disorder. For example, an antiseizure medication like Neurontin may be prescribed for an "off label" indication like persistent numbness in an extremity. Well, you do not have seizure disorder, which would be disqualifying, but the medication is nonetheless disqualifying, because of its potential effects on your mental health.

As another example, many people have mental changes while taking a corticosteroid. So, if a short course of prednisone has been prescribed for poison ivy, it would be best to stay on the ground. Benadryl, a common antihistamine given for benign allergies, has sedative properties and is not approved. Be aware that medications for motion sickness like Antivert (meclizine) and Transderm (scopolamine) are not approved (see "Avoiding Airsickness," September 2006 AOPA Flight Training).

There is little point in providing a long list of medications in this article in the hope it will include the specific medication of interest to you. However, the indications for prescription, the likelihood of FAA approval or disapproval, and the steps necessary if you are taking drug are available in the members-only section of AOPA Online. AOPA Online's medical database is searchable for a particular medication by trade name or generic name, by drug type, and by indications. The site is regularly updated. This is important as new drugs are constantly reaching the market. Even after a drug is available, our knowledge of side effects changes over the years, and so does the way the FAA views a particular drug.

AOPA Online's medication database may simply indicate that the absence of side effects alone is sufficient justification to resume flying. In other cases there may be a specific waiting period, a required evaluation, a mandated consultation, a maximum approved dosage, or the requirement for regular status reports to the FAA.

The list also has another important function. For many illnesses a physician has the choice of prescribing any of several medications. For example, in treating hypertension there are probably 50 different drugs available. However, there are several that may effectively lower blood pressure, but will not be approved by the FAA. You can access the list under "hypertension," and discuss with your physician your preference to be on an approved medication if it is possible.

Unless your physician has a particular interest in aviation medical certification, he or she will not be aware of which medications will be allowed or disallowed by the FAA.

Also be aware that there are idiosyncratic reactions to drugs. These are side effects that may not be mentioned in the medical literature, as they may occur to you alone. They may be disqualifying, even if the drug is acceptable to the FAA.

Always assume a medication is not compatible with flying. Before you fly, confirm the drug is safe, likely to be FAA-allowed, and that you have no side effects on the ground. And if you develop side effects in the air--regardless of a drug's effectiveness and lack of side effects on the ground--you cannot continue to fly.

Dr. Ian Blair Fries is a CFI, senior aviation medical examiner, and ATP, and holds a Lear 35 type rating. He serves on the AOPA Air Safety Foundation Board of Visitors and is cochairman of the AOPA Board of Medical Advisors.