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and most common pharmacological effects encountered as related to flight safety.
Central nervous system depressants
Any depression of the central nervous system would render a pilot unfit for duty. The value of an alert mind
and clear thought processes needs no discussion or defence. It can be stated definitely that sedatives,
hypnotics, narcotics, etc. prohibit flying until sufficient time has lapsed after the last dose to allow
metabolism of the pharmacon in question to reach an acceptable level. The same principle applies to the air
traffic controller whose role in flight safety is also of high importance. Individual variation can be quite
wide with respect to the metabolism of depressants, so any rule of conduct must be very conservative. It is
for this reason that in general a 24-hour period is suggested prior to resumption of flight duties after
administration of a central nervous system depressant. It is certainly true that short-term hypnotics exist that
can be used and still allow the pilot to return to duty only 8 hours after ingestion of the sedative, e.g.
zolpidem (Ambien®) in a dose of 10 mg. Under well-supervised operational conditions, it may be safer for
a pilot to occasionally use a short-acting hypnotic between transmeridian long-haul flight segments to
assure adequate sleep during rest periods, than to operate without adequate sleep.
It would be undesirable for flight crews to use such medication without medical supervision from
physicians having a full understanding of aircraft operations. Self-medication should be discouraged.
Particular attention should be paid to the risk of self-medication when operations include stop-overs at
destinations where sedatives are more readily available than at home base.
The main therapeutic central nervous system depressants are:
• antihistamines
• flurazepam, nitrazepam, diazepam, methaqualone
• glutethimides (Doriden®, Noludar®, Quaalude®)
• ureides, carbamates, (Placidyl®, Valmid®)
• bromides
• barbiturates
• meperidines (Demerol®, Lomotil®, Pethidine®)
ICAO Preliminary Unedited Version — November 2009 III-14-4
• methadone group (dextropropoxyphen, Darvon®)
• codeine and its derivatives
• morphine and its derivatives
• opiates (paregoric1, opium).
Note that the above list contains medicines used for a wide variety of therapeutic purposes (e.g.
anti-spasmodics, anti-allergics, analgesics, etc.) but all have the common effect of central nervous system
depression, and hence disqualify a licence holder whose performance is affected by them.
Pharmaca affecting the autonomic nervous system
Since the autonomic (involuntary or vegetative) nervous system affects virtually all body systems with the
exception of the skeletal (voluntary) musculature, “autonomic pharmaca” would be expected to have a
variety of complex effects. Stimulation of the sympathetic (thoraco-lumbar, sympatho-adrenal, or
adrenergic) portion of the autonomic system can induce tachycardia, increased cardiac output, mydriasis,
lessened fatigue, raised blood sugar levels, rise in body temperature, peripheral vasoconstrictions, and a
general response to overcome stress.
Parasympathetic (cholinergic or craniosacral) discharge tends to produce bradycardia, lower blood pressure
and cardiac output, miosis, increased gastrointestinal activity, peripheral vasodilation, and contraction of
the bladder and rectum. Predominance of one of these two autonomic systems can be achieved by either
direct stimulation of the system in question or inhibition of the other. Sympathetic discharge is essential in
times of stress or emergency.
Sympathomimetic pharmaca, which in a sense would seem to be useful in producing a state of alertness and
efficiency and help to overcome fatigue, are not advised for civil aviation operations because of their
potential for causing agitation, nervousness, tremor, tachycardia, irritability, and impaired judgement.
Examples of the more commonly used sympathomimetic pharmaca are ephedrine, adrenaline, amphetamine,
and isoproterenol.
Parasympathetic depressants do not usually produce the dramatic sympathetic discharge following
administration of a sympathomimetic drug but rather tend to induce mydriasis, dry mouth, and urinary
bladder hesitancy. A pre-existent glaucoma could also be severely aggravated. While such effects are
usually not severe, especially in certain modern preparations, their usage by active licence holders should
be controlled. Some examples of pharmaca of this type are belladonna (which contains the anticholinergics
hyoscyamine and atropine) and atropine itself.
Parasympathetic stimulants or parasympathomimetic pharmaca tend to produce painful contractions in the
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Manual of Civil Aviation Medicine 2(103)
