Beyond ‘take it before your shift’: Rethinking stimulant prescribing for EMS

By Melissa W. Costello, MD, MS-HCD, FACEP, FAEMS

For EMTs, paramedics, flight nurses and other emergency responders with adult attention-deficit disorder (ADD), attention-deficit/hyperactivity disorder (ADHD), narcolepsy, shift-work sleep disorder, idiopathic hypersomnia or other sleep disorders, stimulant prescribing using the traditional school/office work hours model can fall short of these clinicians’ real needs.

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The goal of treatment is not to medicate away fatigue, but to more closely match medication peaks and lows to the true workload of clinicians who work 12-24 hours and beyond. Optimal medication management contributes to the safety of the clinicians, their partners, their patients and the community.

Why EMS doesn’t fit traditional stimulant prescribing models

The prevalence of ADD, ADHD and other sleep disorders in the adult population varies between 2.5-7.8% [1]. However, studies have shown that the prevalence of these diagnoses among EMS clinicians is likely profoundly higher — approaching 60% in recent publications [2]. Many of these clinicians are prescribed long-acting stimulant-based medications (often since early childhood) that are optimized for 8-12 hours of peak performance during traditional school/work hours. Unfortunately, EMS systems do not operate on this schedule. While fatigue is often viewed as an “occupational hazard” or a “badge of honor” for clinicians, the literature clearly demonstrates that fatigue in EMS contributes to significant increases in the rates of medical errors, injuries and safety-compromising behaviors [3].

Prescribers who treat ADD, ADHD, and sleep disorders are accustomed to building medication regimens around a traditional school/work schedule. This prescribing pattern is often inadequate for addressing the needs of prehospital personnel who work longer shifts. A paramedic or a flight nurse may need high levels of alertness and attention to detail at multiple periods over a 24-hour shift. A clinician may need to wake from sleep at 3 a.m. and be fully prepared to calculate drug doses, assess flight safety, manage complex infusions and crosscheck blood products. Single-dose long-acting medication regimens that taper in effectiveness in the afternoon may increase risk for errors due to inattentiveness in the waning hours of a long shift.

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Treat the diagnosis, not the symptoms

The first question for a clinician should not be “How many extra pills do I need for a 24-hour shift?”

The first question should be “What diagnosis is being treated, and what functional impairment is this medication regimen designed to address?”

ADD, ADHD, narcolepsy, shift-work sleep disorder, circadian-sleep disorder, idiopathic hypersomnia and obstructive sleep apnea (OSA) are different diagnoses and while the medications used in treatment are similar, a global fatigue-mitigation approach needs to be tailored to the individual.

Clinic visits with prescribers should include a discussion of:

• Work and home schedule obligations
• Medication timing
• Symptom patterns
• Side effects
• Typical call volumes and timing
• Fatigue-mitigation strategies (e.g., caffeine, exercise, naps, etc.)
• Comorbid conditions (e.g., diabetes, hypertension, OSA, etc.)
• Post-shift commute risks
• Alcohol use
• Sleep medication use

An informed patient should not just assess whether a medication is “working,” but be able to provide details on:

• Dose timing
• Onset, peak effect and duration/tapering of effectiveness
• Any rebound effects
• The impacts of missed doses
• Sleep disruptions when off shift

Adverse medication effects including anxiety, palpitations, appetite suppression, irritability or overconfidence should be closely queried.

There are multiple apps and devices on the market that provide objective data regarding sleep quality and other health information. This data can significantly improve conversations with your prescriber. While the usual “refill visit” is booked in a 10-15 minute clinic slot, it is important for EMS clinicians to request (and for prescribers to allow) a longer visit at least annually to review sleep/work/lifestyle information in detail.

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Basic medication planning

It is useful to have a framework in mind when determining the best approach for clinicians that work long shifts trying to match medication timing to operational demands. The best regimen will maximize attentiveness during high-intensity periods without compromising sleep either during shift or on off-days.

1. Long-acting baseline coverage. Traditional, long-acting stimulant formulations will provide sustained alertness and smooth onset/offset for those needing to maximize effects during the daytime. The limitation of these medications alone is that there may not be enough residual effect for clinicians who are regularly required to perform at a high level for a full 24-hour period. In some cases, a change from a long-acting stimulant to a long-acting non-stimulant medication may provide better baseline coverage with fewer side effects that can be more easily supplemented with short-acting medications.
2. Short-acting medication for “coverage gaps.” Addition of short-acting stimulant medications, either regularly or as needed, is ideal to address consistent coverage gaps in the current regimen. A specific discussion of dose timing for long-acting medication and the operational demands that frequently extend beyond this taper is important. This allows better alignment of medication peaks/valleys and provides a prescriber with enough detail to document the clinical rationale for additional medications, especially with the modern rigors of controlled substance prescribing.
3. Per month dose quantity. The usual 30-doses in 30-days quantity for many of these medications does not adequately reflect the needs of prehospital clinicians that work a 24-on/48-off schedule but still require medication dose-per-day pattern on their “off-days”. Additionally, this 1 may fall short in extended deployments, disaster response, mandatory holdovers, or long-distance transport. Unfortunately, regulators and insurance often limit the number of doses allowed on a single prescription, elevating the need for strategic prescribing and use of supplemental medications. EMS clinicians should never be put in the position of rationing, double-dosing or borrowing medication from others to address shortfalls in the medication management plan.
4. Wakefulness-promoting agents and diagnosis-specific therapies. Clinicians with sleep disorders in isolation (or combined with traditional ADD/ADHD) may benefit from medications better designed to specifically address those conditions. Modafinil, armodafinil and others are better designed for patients with narcolepsy, shift-work sleep disorder and idiopathic hypersomnia. Fatigue related to untreated obstructive sleep apnea is best addressed with CPAP as the primary modality and additional pharmacotherapy as needed. Fatigue related to insomnia, anxiety, depression, poor sleep hygiene, hormonal changes (perimenopause or hypotestosteronemia), or a snoring bed partner are best addressed on a problem-focused basis and not with new or increased stimulant medications.
5. Non-stimulant ADD/ADHD medications and adjunctive therapies. Behavioral changes used in combination with non-stimulant ADD/ADHD medications like atomoxetine, guanfacine, clonidine, bupropion and others can help many EMS clinicians, especially when stimulants are not well-tolerated or are contraindicated. While not immediate, the reduction of baseline symptoms from these therapies can reduce the highs and lows related to scheduled stimulant use. Additionally, with these medications being either non-scheduled or Schedule IV, there is more latitude for prescribers to combine these with stimulant agents, write refills and reduce required clinic visits.

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Specific questions for EMS clinicians to discuss with prescribers

1. What diagnosis/diagnoses are we treating?
2. Am I currently taking the best medication for my diagnosis?
3. Is my current medication regimen covering the hours when I am required to make critical/high-intensity decisions?
4. Does the medication interfere with my sleep during mandatory rest periods or off days?
5. Would a different medication or combination better address the symptoms I am experiencing at work/home?
6. Should/can my monthly quantity of medication be adjusted to reflect the number of 24-hour shifts I work in addition to my daily medication needs?
7. Do I need a formal sleep medicine evaluation or a repeat study?
8. What side effects or symptoms should make me call, discontinue, adjust my medications or avoid high-intensity work until reassessed?
9. How should I coordinate with the licensure authorities, my employer, my insurance company and the controlled substance rules?

The role of the employer

Medications for ADD/ADHD and sleep disorders are designed to address symptoms for these patients and are not to mitigate unsafe scheduling practices. Systemwide fatigue mitigation strategies including evidence-based scheduling practices, access to caffeine, naps, fatigue education and safe post-shift commute planning are critical components. Ultimately, creation of a culture where clinicians feel safe reporting fatigue-related impairment without fear of retaliation is the primary responsibility of EMS employers and cannot be solved with a prescription pad.

The bottom line

The modern prehospital workforce can benefit tremendously from more open and detail-oriented discussions with their physicians regarding work environment and the demands of the profession.

• Prescribers must take the extra time to analyze and alter the medication strategy in the context of actual work hours and cognitive load.
• EMS clinicians must clearly communicate the strengths and weaknesses in their current treatment plan and be honest about inadequacies in their traditional fatigue mitigation strategies in combination with pharmacotherapy.
• Employers should acknowledge that medication is never a substitute for humane scheduling and adequate rest.

Statistically, more of our prehospital colleagues are affected by these conditions than not. Therefore, it is imperative that all involved in the care of our EMS colleagues understand and embrace the nuances and unique aspects of caring for this group.

References

1. Song P, Zha M, Yang Q, Zhang Y, et al. (2021). “The prevalence of adult attention-deficit hyperactivity disorder: A global systematic review and meta-analysis.” Journal of Global Health, 11, 04009. https://doi.org/10.7189/jogh.11.04009
2. Hansen N, Foat C. (2026). “Self-reported ADHD in a convenience sample of EMS clinicians.” International Journal of Paramedicine. (14). 113-127. https://doi.org/10.56068/BGSR7685
3. Patterson PD, Weaver MD, Frank RC, Warner CW, et al. (2012). “Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers.” Prehospital Emergency Care, 16(1), 86-97.

ABOUT THE AUTHOR
Melissa W. Costello, MD, MS-HCD, FACEP, FAEMS is an emergency physician and EMS medical director based in Mobile, AL. Originally from Connecticut where she began her career as a volunteer EMT, she has been active in EMS as a clinician and medical director for more than 30 years. She is currently employed as the national medical director for patient advocacy and revenue cycle for Global Medical Response and is the interim lead physician for Air Evac LifeTeam. She continues to work clinically with her EM group in Alabama, with local EMS, fire and law enforcement agencies providing medical support.