By Aimin Alton
StopNarcoticTampering.org
Narcotic diversion in EMS is in the headlines again with allegations being reported in both Michigan and Oklahoma in the past two weeks. I’ll forgive the casual reader that believes these are infrequent incidents, isolated to other parts of the country, far removed from their circle of influence.
The most recent claims center on the alleged diversion of morphine and Demerol from an ambulance service in Oklahoma and what investigators say is tampering of morphine and Fentanyl at a Michigan ambulance service. The frightening reality is that such incidents occur far too often. In recent times, there have been narcotic diversion cases in EMS across the country including in Blanco, Texas; Las Vegas, Nevada; Lincoln, Nebraska; Sacramento, Santa Barbara and Ventura, California; and Spokane, Washington.
In the Michigan case, a Genesee County paramedic is accused of switching out morphine and Fentanyl with saline to use himself. Those proven of tampering with narcotics, I’ll call them “addicts in hiding,” are in essence creating a counterfeit product by taking a known good medication and replacing it with what they hope is merely an inert substance (saline). The addict will then leave the container in the system, all the while not raising any red flags for missing narcotics.
Of all the types of narcotic diversion out there, tampering with or substituting saline for the narcotic is nearly the most insidious, while also inhumane, and selfish. The tampered with container is left in the system to be used by an unsuspecting paramedic on an unsuspecting patient. The only thing more insidious would be to replace the narcotic with something intentionally harmful.
So how do we protect our narcotics from being tampered with?
While researching other narcotic control and accountability systems, I’ve found that our industry standard of handling narcotics is essentially sub standard and full of holes, creating opportunities for a committed addict (good addicts are committed) to exploit. But there are a few good systems out there that do a better job than most at protecting their narcotics from being tampered with. As is often the case, the systems I’ve found that have the strongest safeguards were created in the wake of learning some very hard lessons.
Among the techniques to better safeguard your agency’s narcotics are:
Reverse Distribution
Used by Charleston County EMS, South Carolina, and most recently by a private ambulance company in Southern California that wishes to remain unmentioned. All narcotic containers are returned to headquarters. Instead of wasting any unused medication, it is returned for random analysis. Where this system is used, all parts of the narcotic container should be returned, especially the lids from vials, and the wrappers that held the Carpujets.
Benefits to this type of system are that evidence is retained, rather than discarded, and personnel know that all returned stock or fraction thereof will be analyzed. Fear of getting caught causes addicts to tamper with narcotics rather than outright steal them; fear of having returned narcotics come back as saline has prevented any further cases of diversion from being discovered in Charleston.
Stronger Containers
The method of tampering as allegedly used in Michigan would be difficult to commit at the FDNY or Clark County FD (Las Vegas) because they utilize unique systems to protect their narcotics. A commercial shrink wrap machine. In the FDNY’s system, a metal slug is placed over the lid of their narcotic vials and the whole vial is shrink wrapped. At Clark County FD, they utilize a strong, clear, non flexing, hinged, fishing lure box, closed with tamper evident tape that has a unique serial number. The box is further secured with shrink wrap. Clark County FD utilizes more safeguards than I have space for here and is overall, the tightest narcotic control and accountability system I’ve seen to date.
Tracking
From entry into the system to exit, each narcotic we carry should be individually accounted for. RFID (Radio Frequency ID Tags) is years away from being on every narcotic, unless the FDA gets their way. In the mean time, consider utilizing another form of non removable ID Tag on every container.
QI, CQI, TQM
Essentially, verify that the medication you give works. If your patient states they are not getting relief from the narcotic, ask yourselves this: why? Quite often, the first things that come to mind are:
- We thought it was because they were drug seekers
- We thought they had low tolerances for pain
- We thought that heat has caused the drug to degrade
- We thought that not all people get relief from narcotics
However, sadly it can be the case that patients aren’t getting relief from our narcotics because we weren’t actually giving them any! If we track patient relief as well as we track CPR compression:ventilation ratios, would we see signs that our narcotics may have stopped working? If so, that should be a trigger that our narcotics need to be analyzed for efficacy, environmental damage and tampering.
These are merely a few examples from a list of many improvements we can make to insure the efficacy and safety of our narcotics. Awareness of past history and jealously protecting our industry’'s integrity are key to not repeating it.
Aimin Alton has more than 12 years experience in the field of EMS. He serves as a firefighter for the Ventura County, Calif., Fire Department and is licensed by the state of California as a Mobile Intensive Care Paramedic. Aimin is a strong advocate for EMS professionals, and for the patients they serve, by raising awareness and creating solutions for narcotics diversion within the industry. Toward that goal, Aimin founded Alton & Associates and StopNarcoticTampering.org, for which he serves as the program director. Similarly, as a member of the California State Firefighters’ Association EMS Committee, Aimin formed and leads the CSFA Emergency Responder Substance Abuse Task Force. He also provides a presentation titled “Narcotic Tampering Awareness & Detection,” where he outlines the known methods of tampering with physical examples and how to spot them. You can contact Aimin at aalton@alton-associates.com.