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an aircraft or with the safe performance of duties.
Note.— Use of herbal medication and alternative treatment modalities requires particular attention to possible
side-effects.
In addition, Annex 2 – Rules of the air - has the following Standard:
2.5 Problematic use of psychoactive substances
No person whose function is critical to the safety of aviation (safety-sensitive personnel) shall undertake that
function while under the influence of any psychoactive substance, by reason of which human performance is
impaired.
No such person shall engage in any kind of problematic use of substances.
ICAO Preliminary Unedited Version — November 2009 III-14-2
The term “problematic use” is defined in Annex 1 as follows:
The use of one or more psychoactive substances by aviation personnel in a way that:
a) constitutes a direct hazard to the user or endangers the lives, health or welfare of others; and/or
b) causes or worsens an occupational, social, mental or physical problem or disorder.
It should be pointed out that treatment, often self-administered, with traditional remedies, the use of herbal
medicines, and various other kinds of alternative therapy are commonplace in most of the world. In some
cultures, traditional medicine is the first choice of treatment for many medical conditions. The medical
examiner should be aware of this, as the pilot may not volunteer such information, considering herbal
medicines and other “over-the-counter” preparations safe and harmless in spite of the fact that they may
have significant side-effects in the context of aviation.
On occasion, medicines are utilized not for illness but as a preventive measure, e.g. anti-malarial agents,
hepatitis vaccines, anti-diarrhoeals, antibiotics, etc. The possible flight safety impact of preventive
medication is a consideration particularly encountered in tropical operations.
Not only must the medical examiner consider the expected pharmacological effects of a given pharmacon
but also the possibility of unwanted side-effects and idiosyncrasy. All considerations of medication as
applied to a flight crew member must be in compliance with the provisions of Annex 1.
This chapter concerns the flight safety aspects of the major classes of therapeutic medicines. Its purpose is
to aid in the implementation of the provisions of Annex 1 in a manner to achieve international uniformity in
the safest disposition of pilots undergoing pharmacotherapy. Certainly, a knowledge of the operational
aspects and working conditions pertaining to the pilot is essential in making decisions concerning
medication. Reference is made to Part II, Chapter 1, of this manual (Physiological factors of relevance to
flight safety).
PRINCIPLES OF PHARMACOTHERAPY
AND FLIGHT SAFETY
In considering whether a licence holder should continue to exercise licence privileges whilst on pharmacotherapy,
certain questions should be asked:
a) Is the disease process for which pharmacotherapy is necessary in itself normally disqualifying?
b) What are the usual and expected pharmacological actions of the pharmacon in question, are they
likely to endanger flight safety and, if so, what is the duration of these effects?
c) What are the possible side-effects and their duration, where “side-effects” refers to undesired
responses to medication.
If the answer to the first question is in the affirmative according to the provisions of Annex 1, then the
question of whether pharmacotherapy is accompanied by an acceptably low risk requires careful
consideration by the medical examiner. Discussion with a Medical Assessor will often be required. If the
disorder to be treated does not per se preclude aviation operations, then questions b) and c) become
paramount.
ICAO Preliminary Unedited Version — November 2009 III-14-3
There are many therapeutic medicines in use today and the pharmaco-physiology of pharmaca is a complex
science; recent years have seen a number of unusual adverse effects described. It is reasonable to approach
the problem of medication in the pilot by considering the problem from the aspect of undesirable (i.e. unsafe)
responses to medication. Examples of undesirable attributes include:
a) central nervous system effects (e.g., sedation, euphoria, cognitive impairment)
b) autonomic nervous system effects (e.g., bradycardia, miosis, agitation)
c) effects on special senses (e.g., vestibular toxicity, retinopathy)
d) organ toxicity, either of direct impact on aviation (e.g., pulmonary toxicity) or requiring excessive
monitoring.
The first two examples are relatively common and are discussed in more detail below.
UNDESIRABLE PHARMACOLOGICAL ACTIONS
The varieties of possible pharmacological actions are great in number, but it is possible to define the major
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Manual of Civil Aviation Medicine 2(102)
