By Nick Adams and Eric Nix
The Controlled Substance Act was enacted in 1970, well before modern EMS existed. The bill was signed into law by President Richard Nixon nearly two years before “Emergency!” with Johnny Gage and Roy DeSoto premiered on primetime television. Because it preceded EMS, the act is silent on the need for controlled substance administration in a prehospital environment to treat pain and sedate patients.
This antiquated law has created a Wild West-style approach to controlled substances for EMS medical directors. Rules from the Drug Enforcement Administration limit emergency administration of a controlled substance, such as fentanyl and midazolam, to a patient-specific oral order.
In 2011, the DEA advised a Kentucky EMS service that the administration of a controlled substance “must be patient and issue specific” and “dispensing of a controlled substance in response to a standing order would therefore not be valid.” According to the DEA, paramedics may not administer controlled substances under protocols or standing orders.
However, some medical directors realize the necessity of administering these medications quickly in a prehospital environment and continue to allow their administration under standing orders. Medics with standing orders administer medications when indicated.
In other cases, EMS personnel must wait 20-30 or more minutes to receive a patient-specific oral order from online medical control. No paramedic wants their patients to experience pain or suffer from repeated seizures for that long when they have medications that can immediately offer relief.
Proposed legislation, sponsored by Rep. Richard Hudson (R-NC), could finally close this overlooked gap in the Controlled Substances Act. The Protecting Patient Access to Emergency Medications Act of 2015 (H.R. 4365) will allow EMS agencies to quickly administer a life-saving medication using a standing order from their medical director.
The newly introduced bill proposes to clarify DEA rules and regulations in the following ways:
- The act allows medical directors to issue standing orders for the administration of controlled substances.
- Physician signatures will not be required for the administration of controlled substances under standing orders.
- Each EMS agency would register with the DEA independently instead of depending on the medical director’s registration.
- Each EMS agency may move controlled substances freely within the agency (station to station) without additional DEA-required paperwork.
- EMS agencies will not need to register as a distributor under DEA regulation, resulting in less expense and requirements for the agency.
- EMS agencies would only need multiple DEA numbers if they were a multi-state EMS operation.
For over 40 years, medical directors and paramedics have found themselves in a quandary regarding controlled substance administration, caught between their patients’ well-being and federal regulations. The Emergency Medications Act of 2015, which is still in committee, offers the opportunity to improve the consistency of rapid administration of controlled substances for patients. As a patient advocate, every emergency medical responder should express to their Congressional representative the need to support and pass this legislation.
About the authors
Nick Adams has been in EMS since 1992 when he joined a volunteer rescue squad in southwestern Virginia. Since then he has worked in private, fire-based, and military EMS. Nick earned his Bachelor of Science degree in emergency management and Master of Public Administration degree from Jacksonville State University. Adams is a Special Operations Lieutenant for Cobb County Fire and Emergency Services, in Georgia. He also serves on the board of directors for the Georgia Association of Emergency Medical Services and the Metro Atlanta EMS Conference.
Eric Nix, MD, is a board-certified emergency physician who serves as the medical director of Cobb County Fire and Emergency Services. He is an attending physician at WellStar Kennestone Hospital in Marietta, Georgia, one of the state’s busiest Level II trauma and comprehensive stroke centers. A former paramedic, he attended Mercer University School of Medicine and completed emergency medicine residency training at Yale-New Haven Hospital.