Last week in Missouri, two nurses, a paramedic, and a pharmacist were indicted on charges of stealing pain medications and other drugs. They allegedly took them from hospitals and a pharmacy, but you don’t have to look much harder to find tales of similar meds taken from ambulances and EMS caches, often by those charged with securing and administering them.
That can put their EMS organizations in dicey positions. The Protecting Patient Access to Emergency Medications Act (PPAEMA) staved off a brewing EMS/DEA conflict in 2017, but at the expense of making agencies, not just their medical directors, liable for controlled-substance violations. Handling them improperly can result in violation notices, fines, and loss of licenses.
Maintaining compliance with controlled-substance regulations was the subject of an EMS World Expo presentation Thursday by Capt. Jessica Banks and medical social worker Lauren Young of Florida’s Palm Beach County Fire Rescue.
The relevant law, PPAEMA, was an EMS-specific update to the 1970 Controlled Substances Act, which didn’t account for EMS because EMS barely existed yet. This led states to step in with their own legislation over the years, and PPAEMA was intended to standardize and clarify the prehospital use of various drugs.
Its main components allow controlled substances to be given under standing orders, which the DEA had threatened to prohibit; allow EMS agencies to register with the DEA to administer the drugs, rather than just their medical directors; and allow a single registration to cover multiple sites within a state.
To make sure PBCFR kept in the clear, Banks investigated what the various components of federal law specify. Right off she found a misconception: that controlled substances must be stored behind two differently keyed locks. That’s not what the pertinent law (21 CFR §1301.75) says—it only specifies storage in cabinets that are “securely locked” and “substantially constructed.” PPAEMA permits storage in EMS vehicles but doesn’t negate the obligation for physical security and deterrence of unauthorized access.
In cases of theft or loss, an EMS agency must notify the DEA within one business day. It has two months to investigate what happened, internally or with the involvement of law enforcement, and if the theft/loss is confirmed, it must complete DEA Form 106. This covers “significant” losses, Banks said, and not minor discrepancies, but if leadership is unsure or detects a pattern of small losses, it should file the form anyway.
Expired drugs must be securely stored until disposal, and disposal must render them “nonretrievable”—i.e., permanently altered. This can be through incineration or use of a chemical digestion agent. All 50 states also allow the use of reverse distributors; in Palm Beach’s case, the department transfers them to law enforcement. Two employees must be present for all loading/unloading.
Young noted a number of recent cases of EMS providers stealing or diverting meds and cited the National Survey on Drug Use and Health’s finding that up to 10% of firefighters may abuse prescription drugs (a rate likely underreported). EMS is also at risk: The Substance Abuse and Mental Health Services Administration has found that 36% of providers suffer depression, 72% of EMTs are sleep-deprived, and 20% of EMTs suffer post-traumatic stress disorder. More likely have lesser levels of traumatic stress, making them vulnerable to self-medication and abuse.
They certainly have access: in ambulances, emergency departments, patients’ homes, and through drugs wasted, expired, or slated for disposal. Agencies must monitor this closely; Banks receives a daily report of providers’ use and monitors for patterns. Any handling of controlled substances outside of protocols is a huge warning sign, noted Young.
For EMS providers struggling with drug problems, the range of strategies can include peer support, employee assistance programs/counseling, medication assisted treatment, and AA/NA. Be compassionate, nonjudgmental, and there for your EMS family, Young urged—addiction is a medical condition, not a personal failing.
Finally, all controlled-substance records, files, and forms should be retained for two years, and those for Schedule II substances like fentanyl and morphine should be kept separate from others. Best practices include electronic tracking, rather than paper; reconciling ePCRs with narcotics logs; and vigilance to patterns, trends, and suspicious behaviors.