EMS DOCS’ PERSPEC TIVES ON STREET MEDICINE
Managing controlled substance use on the upstream side
By Neal J. Richmond, MD, FACEP
Diversion policies may be thought of as the downstream side of a system’s approach to controlled substance
management. The upstream side, including
human resources and occupational health processes for recognizing and testing individuals at risk, may be worth some attention, too.
Discovering and reporting drug diversions may
result in career-ending consequences for our
friends and colleagues. However, closing our
eyes to this problem may result in even more
devastating consequences, including loss of life.
It may also lead to potential injury and
death of partners, patients, and bystanders,
when emergency response vehicles are operated under the influence of legally prescribed
or illegally diverted medications.
DIVERSION AT ITS SOURCE
Our jobs are stressful and, at times, painfully repetitive, boring and even backbreaking. Many of us get into this work at a young
age, often in the absence of a lot of other life
experience. Suddenly, we find ourselves face
to face with unspeakable tragedy and trauma.
We’re exposed to the suffering of our patients,
and we experience our own physical and emotional pain as well.
Although many of us enter into this profession with a desire to help others, we bring
to the job an entire spectrum of personalities
and coping mechanisms.
We also have relationships, families and
financial responsibilities. These things are
challenging enough to navigate on their own,
let alone when they are impacted by—and have
an impact on—our work.
Although it can be helpful to analyze the
uncomfortable emotional and psychological
states we often find ourselves in, ultimately, we
have to find ways to adapt or alter our response
to stress—if we want to be able to reasonably
function at work and at home.
COPING & ITS LIMITATIONS
In some cases, we may seek professional counseling and treatment, as well as the support of
friends, colleagues and loved ones. However,
all too often we titrate anxiety, depression and
post-traumatic stress by self-medicating with
tobacco, alcohol or caffeine. Some may slip
into non-recreational use of pot, as well as the
use of opiates, benzodiazepines, or anesthetic
agents like propofol and ketamine.
To make matters more complicated, these
substances typically induce tolerance and
addiction. Thus, one needs more and more
to achieve the same degree of baseline function or happiness, if not outright euphoria —
something that’s especially dangerous in the
face of low tolerance to side effects like respiratory depression.
Trying to get off these substances is also
difficult, whether it’s due to psychological
dependence or true physiologic symptoms
Our work is a kind of double-edged sword,
in that it may not only amplify our tendencies
for substance abuse but, perhaps more insidiously, it also provides an environment where
accessing these substances may be tempting—
if not altogether unavoidable.
Although we can’t predict how different individuals will react to the combined stress of
their lives and jobs, simply trying to manage
the potential for substance use and diversion
on the downstream side, is insufficient.
Further upstream, human resources and
occupational health services may be able to
provide a degree of prevention, in addition to
improving our work environments and providing a variety of support services.
For example, hiring policies can address
whether personnel who require chronic opi-
ates or benzodiazepines for “normal” daily
function should be driving response vehicles
and treating patients in the first place—let
alone whether they should have ongoing access
Individuals who are “cleared” by personal
physicians or occupational health providers to
return to work following illnesses or injuries
that require treatment with controlled medications, might be required to submit to drug
testing for a period of time. This may not
entirely mitigate the likelihood of diversion,
but it might provide a more realistic transition period between prior prescription use and
potential future abuse.
System occupational health processes
should also be carefully reviewed and not
taken for granted. Drug testing doesn’t mean
that certain opioids or other substances are
Personnel may test positive for drugs and
then be reported as “negative”—if they can
provide prescriptions for their use. Even
though the use of these drugs may be legal,
the risk of personnel taking them while driving response vehicles or making critical patient
decisions may go undetected.
PUTTING IT ALL TOGETHER
Typically, policies for diversion operate on the
downstream side of controlled substance management, when it’s already too late. If we could
couple them with meaningful policies on the
upstream side, they may just make a difference.
The subject of drug diversion will be discussed in the November issue, as will one system’s approach (MedStar Mobile Healthcare,
Texas) to tracking and monitoring controlled
substance use. JEMS
Neal J. Richmond, MD, FACEP, is board certified in emergency medicine and is the med-
ical director for the MedStar Mobile Healthcare
System in Fort Worth, Texas.
Learn more from Neal Richmond at the
EMS Today Conference, Feb. 21–23, in
Charlotte, N.C. EMS Today.com