By Ben Hoffman, MD, MPH
Chief Medical Officer, WorkSTEPS
This article is part of an ongoing WorkSTEPS occupational health series exploring emerging risks, regulatory shifts, and prevention strategies impacting today’s workforce.
Key Insights
- Untreated obstructive sleep apnea (OSA) reduces alertness, reaction time, and situational awareness, increasing safety risk.
- OSA often overlaps with other health conditions, compounding fatigue and crash risk.
- Breakdowns occur in execution, including screening, referrals, follow-through, and adherence.
- Managing OSA requires clear ownership and structured processes to effectively reduce risk.
If a defect in a truck quietly tripled crash risk, every fleet in the country would scramble to pull those vehicles off the road. Yet, we tolerate something similar in our drivers every day: untreated obstructive sleep apnea (OSA), a common condition where breathing repeatedly stops or is reduced during sleep due to airway blockage.
Truck driving can be dangerous work, particularly for commercial drivers operating long hours. It relies on long and irregular hours and depends on a workforce that often has limited access to primary and preventive care. Against that backdrop, OSA is not only a medical diagnosis; it’s a systems risk at the intersection of driver health, fatigue, safety, and liability.
The Driver Health Reality Behind the Wheel
When we look at commercial drivers, we consistently see a cluster of conditions that elevate crash risk: obesity, hypertension, diabetes, untreated OSA, complex comorbidities, polypharmacy, and significant mental health burdens. Driver health is not a side issue as it directly shapes alertness, reaction time, and resilience on every shift.
OSA sits at the center of this cluster. It is characterized by repeated collapse of the upper airway during sleep, leading to fragmented sleep, excessive daytime sleepiness, impaired concentration, slower reaction time, and reduced situational awareness.
Various studies suggest that a substantial proportion of professional drivers have mild to severe OSA with risk increasing alongside higher body mass index (BMI) and cardiometabolic conditions. At the same time, many drivers lack consistent primary care and have limited opportunities for evaluation outside of certification exams, leaving a large population at risk but undiagnosed or undertreated.
Why This Remains an Under-Managed Risk
While the risks of sleep apnea are increasingly recognized, that understanding has not been translated into consistent, effective management across the industry.
If the medical case is clear, why hasn’t OSA been treated like other major safety hazards? Several factors contribute:
- Regulatory ambiguity: There is no specific, enforceable federal OSA regulation for commercial drivers, leaving examiners to rely on professional judgment.
- Industry structure: Most carriers are small operators or independents without the infrastructure for consistent screening and follow-up.
- Driver concerns: Fear of job loss, reduced income, or stigma can discourage symptom reporting and evaluation.
- Execution breakdowns: Referral delays, poor equipment support, and lack of ownership lead to gaps in follow-through.
What an Effective OSA Strategy Looks Like
OSA is both diagnosable and treatable. For employers and safety leaders, the challenge is less about identifying risk and more about building systems that consistently manage it.
An effective strategy has several key elements.
- Risk-based screening should be routine. At each certification exam, drivers should be assessed using clinical history, physical findings such as BMI and neck circumference, and validated questionnaires. The goal is not diagnosis in the moment, but consistent identification of those needing further evaluation.
- Referral pathways must be efficient. When risk is identified, access to diagnostic testing, whether in-lab or home-based, should be clear and timely. Long, unstructured referrals increase drop-off.
- Certification decisions should be informed by objective data. A diagnosis of OSA does not automatically disqualify a driver. Many can be safely certified if they are on effective treatment and demonstrate adherence. PAP devices, which treat sleep apnea by delivering pressurized air to keep the airway open during sleep, also provide objective usage and outcome data to support initial certification and renewals.
- Programs require centralized oversight. Someone must be accountable for identifying at-risk drivers, tracking referrals and results, monitoring adherence, and ensuring consistent documentation.
- Communication must focus on performance and safety. When drivers understand that treatment can improve alertness, mood, and overall health, and support their ability to work, they are far more likely to engage.
What This Means for Transportation Leaders
Without a clear federal standard, managing OSA in transportation has become a test of leadership.
Companies that treat it as a strategic safety issue are more likely to see fewer preventable crashes, better driver health outcomes, and stronger defensibility when incidents occur. Left unaddressed, these risks are often attributed to “driver error,” when they are in fact both predictable and preventable.
Conclusion
For transportation executives, safety leaders, and medical examiners, the key questions are straightforward:
- Do we know our true OSA risk profile across the driver population we rely on?
- Can we demonstrate a defensible process for identifying, evaluating, and managing that risk?
- Are we using structured screening, modern diagnostics, and objective adherence data to protect both drivers and the public?
We understand this risk better than we manage it. The opportunity now is to close that gap.
Dr. Ben Hoffman is a highly seasoned physician executive with an extensive background in occupational and environmental health, clinical medicine, and transportation safety. He has been employed by government agencies, non-profits, and multinational corporations including GE, Waste Management, Anheuser-Busch, and DuPont. Dr. Hoffman trained at Yale, Brown, and Mt. Sinai School of Medicine and is board certified in internal medicine, preventive medicine, and environmental/occupational health.
He has published widely and holds a Professorship (Adjunct) at the University of Texas School of Public Health. He has held professorships at Tufts University Friedman School of Nutrition, Dartmouth School of Medicine, Boston University, and the University of New Hampshire. He is active on numerous committees and boards, including Global Health at the National Academy of Sciences/Institute of Medicine, IPIECA, the International Association of Oil & Gas Producers (OGP), and is a former chair of the U.S. DOT/FMCSA Medical Review Board.
