Seemingly, there is a new headline every month that tells a surprisingly similar tale about a paramedic caught with his hand in the cookie jar. In this case, the cookie jar is the cache of morphine or other drugs with tremendous abuse potential that are carried on advance-life-support vehicles. Use and abuse of narcotics in EMS is not a new problem; however, the extent and frequency have become more dramatic. Consequently, the Drug Enforcement Agency no longer is showing much leniency or tolerating any excuses for problems. In fact, fines are now being levied against fire departments and medical directors.
Morphine and some other form of analgesic or pain control are a must on EMS units. We would be doing a disservice to patients if this therapy was not available. It is important then that programs, policies and processes are put in place to ensure the security of controlled substances and that patients are getting the medication they need.
Any controlled-substance policy starts with good hiring practices. Technology is no substitute for such practices. Pre-employment screening for opiates and other gateway drugs is imperative. Once an employee is off probation and in a unionized environment, such a problem will be costly in terms of time, money, and management effort to remediate the situation or remove the employee from the organization. A no-tolerance policy during the probation period and prompt follow-up on any questionable test is imperative. And any process that includes testing for controlled substances must conform to proper certification and standards for such testing.
One reason that theft or abuse of pain medications on EMS units is becoming more prevalent is the growing abuse of opiates by high-school students. The Home Safety Council has listed the abuse of prescription medication as one of the leading causes of death in teens today. The easy access to a parent's medication and the abundance of opiate pills and heroin on the street make it easy for kids to get access to narcotics. As that problem proliferates among high-school students, it then becomes prevalent in the hiring pools.
When a pilfering occurs, the storage container commonly is filled with saline or water to replace the stolen drug. In many cases, the tampering is so well-concealed that it is rarely noticed. In some cases, however, paramedics simply abused what was left in the containers after administering the medication to patients. One such case involved a paramedic taking a Q-tip and swabbing the remainder of the medication from the containers.
Suspicious containers require special testing and they need to be treated like evidence with a chain of custody. One suggestion would be to use the arson instigators to process and investigate the incident.
A patient's medication is another common source of narcotics for abusers. Rarely is there accountability for patient medications. A report from a family member about missing medication should be a red-flag event for EMS field supervisors. Because medications often are taken to the hospital, there are multiple opportunities for them to be lost as the patient is moved through the healthcare system. Here, technology offers a solution. Some electronic patient-care reporting systems can scan the UBC code on the medication bottle into the medical report. This process allows for accurate documentation and eliminates the need to have the medication accompany the patient.
Processes must be established to reduce the chances that unauthorized narcotics use will occur. First, look at how your narcotics are stored and distributed. Drug enforcement agency rules typically require some kind of two-lock system or security barrier. Equally important is the daily sign-in and sign-out of the medication that is on the vehicles. While this traditionally has been a paper chase to obtain the signatures, it is important that regimented daily checks of the narcotics are ingrained in the culture of the organization. Tampering needs to be identified early. Early identification reduces the number of people who will need to be included in any subsequent investigation.
A variety of control mechanisms to secure the controlled substances are available. The simplest technologies are tamper-proof tape or shrink-wrap. Containers or individual medications can be sealed with tape that discolors or displays a warning that materializes when an attempt is made to remove it. Various safes, controlled-entry cabinets and vehicle lock boxes also are available, ranging from old-fashioned key entries to digital/electronic key entries to biometric scanners that open based on the users' fingerprints. Some of the biometric safes can transmit through the mobile data terminals in the vehicles so that an EMS manager can be alerted whenever the safe or lock box is accessed. Most biometric safes can be monitored remotely. Some computer programs that control access to biometric safes can be linked to many commercial scheduling software products to limit access to the vehicle safe only when the person is scheduled on-duty.
Magnetic card keys also are common; however, they can be lost or borrowed. Consequently, verifying the person who opened the safe or lock box could be difficult in a disputed tampering case. Small push-pin combination locks or cash-style lock boxes are not suitable for EMS units. Ambulance designers and manufacturers can offer stronger secured storage. Knox's Medivault can be mounted flush inside a vehicle. This device can be keyed to the Knox system or a pin code can be issued to each individual. The log-in for opening and closing can be downloaded or sent wirelessly to a monitoring computer or even to a PDA.
But the front-end security is only part of the solution. Once the medication is administered, the leftovers or remaining medication can be a problem. Procedures for handling unused controlled substances need to be refined to ensure accountability. The quality-improvement officer or division within an organization is another good asset for ensuring that you have solid control over your narcotics storage and administration. Consistent monitoring of the personnel authorized to administer narcotics may reveal trends that trigger closer scrutiny. For example, a paramedic who is administering three to five times more morphine than the other paramedics should raise a red flag.
It is management's responsibility, along with the medical director, to randomly audit the narcotics or controlled-substances logs. Fire and EMS chiefs should review their department's narcotic checks-and-balances system. Several layers are required to deter misuse of medications. Engineering, policy and supervision all are needed to effectively secure controlled substances, in order to protect the organization and the patient. If you don't have a problem today, it is just a matter of time before you do. Get started.
Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is the fire science program coordinator at the Community College of Southern Nevada and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in fire management and a master's degree in public administration.
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