Toward a new best practice for controlled
By William Gleason, BS, EMT-P & Neal J. Richmond, MD, FACEP
Of all the things we do in EMS, there aren’t all that many opportunities to make a difference each day. Many of
our patients need little more than transport to
an ED, whether for primary care or chronic
Thus, when any of us gets the chance to
administer morphine or fentanyl to a patient
with third-degree burns, or to push midazolam
in a case of status epilepticus, or to use an induction agent like ketamine for a difficult airway,
we may just get to make a difference. We may
feel a sense of gratitude, too, for our ability to
use those controlled substances—opioids, ben-zodiazepines and anesthetic induction agents—
that we go through a lot of trouble to carry.
This trouble stems from the fact that substance abuse affects not only our patients, but
many of our colleagues as well—often tragically.
As a result, it’s our responsibility to track the
use of these drugs, both to ensure their appropriate and safe administration, and to prevent
their potential diversion.
Diversion refers to the act of diverting a controlled substance from its intended purpose,
whether at the time of administration or the
time of wasting.
Our ability to effectively manage the problem of diversion may be traced to the lack of
EMS-specific regulations in the original Controlled Substances Act of 1970. Since very
little guidance was provided regarding EMS
interpretation of the law, a kind of Wild West
approach has characterized our handling of
controlled substances for the last half-century.
Some agencies require online medical control,
while others prescribe these drugs under standing order medical protocols.
To the dismay of EMS medical directors,
system executives and their legal counsels, the
U.S Drug Enforcement Agency (DEA) has
more recently interpreted this law as stating
that “… dispensing of a controlled substance
in response to a standing order would … not
be valid.” 1
This has opened the door to potential medicolegal exposure for systems that administer
controlled substances under standing orders and
has, therefore, been one of the driving forces
behind the recent introduction of the Protecting Patient Access to Emergency Medications
Act of 2016. Recently passed by the U.S. House
of Representatives, this bill is still under review
in the Senate. Among other things, it removes
the requirement for real-time medical control
and individual prescriptions. 2
Although we may be on the verge of a collective sigh of relief in anticipation of the passage
of this new law, it may be a false hope to think
that it will truly solve the problem of diversion.
EMS systems may track controlled substances, butthe processes they use are often
rudimentary, whether relying on paper forms,
signatures and manual drug counts or some
form of technology and software. Nevertheless,
substantial time, effort and financial resources
are spent to make these foolproof, and to eliminate the possibility for error.
Policies on the handling of controlled substances typically regulate distribution, resupply and wasting of unused drugs. There are
processes for recognizing and addressing