Columns, Operations

We Need to Change Our Approach to Substance Abuse in EMS

Issue 10 and Volume 42.

Diversion policies may be thought of as the downstream side of a system’s approach to controlled substance management. The upstream side, including human resources and occupational health processes for recognizing and testing individuals at risk, may be worth some attention, too.

Long-term Consequences

Discovering and reporting drug diversions may result in career-ending consequences for our friends and colleagues. However, closing our eyes to this problem may result in even more devastating consequences, including loss of life.

It may also lead to potential injury and death of partners, patients, and bystanders, when emergency response vehicles are operated under the influence of legally prescribed or illegally diverted medications.

Diversion at Its Source

Our jobs are stressful and, at times, painfully repetitive, boring and even backbreaking. Many of us get into this work at a young age, often in the absence of a lot of other life experience. Suddenly, we find ourselves face to face with unspeakable tragedy and trauma. We’re exposed to the suffering of our patients, and we experience our own physical and emotional pain as well.

Although many of us enter into this profession with a desire to help others, we bring to the job an entire spectrum of personalities and coping mechanisms.

We also have relationships, families and financial responsibilities. These things are challenging enough to navigate on their own, let alone when they are impacted by-and have an impact on-our work.

Although it can be helpful to analyze the uncomfortable emotional and psychological states we often find ourselves in, ultimately, we have to find ways to adapt or alter our response to stress-if we want to be able to reasonably function at work and at home.

Coping & Its Limitations

In some cases, we may seek professional counseling and treatment, as well as the support of friends, colleagues and loved ones. However, all too often we titrate anxiety, depression and post-traumatic stress by self-medicating with tobacco, alcohol or caffeine. Some may slip into non-recreational use of pot, as well as the use of opiates, benzodiazepines, or anesthetic agents like propofol and ketamine.

To make matters more complicated, these substances typically induce tolerance and addiction. Thus, one needs more and more to achieve the same degree of baseline function or happiness, if not outright euphoria -something that’s especially dangerous in the face of low tolerance to side effects like respiratory depression.

Trying to get off these substances is also difficult, whether it’s due to psychological dependence or true physiologic symptoms of withdrawal.

Our work is a kind of double-edged sword, in that it may not only amplify our tendencies for substance abuse but, perhaps more insidiously, it also provides an environment where accessing these substances may be tempting-if not altogether unavoidable.

Prevention

Although we can’t predict how different individuals will react to the combined stress of their lives and jobs, simply trying to manage the potential for substance use and diversion on the downstream side, is insufficient.

Further upstream, human resources and occupational health services may be able to provide a degree of prevention, in addition to improving our work environments and providing a variety of support services.

For example, hiring policies can address whether personnel who require chronic opiates or benzodiazepines for “normal” daily function should be driving response vehicles and treating patients in the first place-let alone whether they should have ongoing access to drugs.

Individuals who are “cleared” by personal physicians or occupational health providers to return to work following illnesses or injuries that require treatment with controlled medications, might be required to submit to drug testing for a period of time. This may not entirely mitigate the likelihood of diversion, but it might provide a more realistic transition period between prior prescription use and potential future abuse.

System occupational health processes should also be carefully reviewed and not taken for granted. Drug testing doesn’t mean that certain opioids or other substances are necessarily included.

Personnel may test positive for drugs and then be reported as “negative”-if they can provide prescriptions for their use. Even though the use of these drugs may be legal, the risk of personnel taking them while driving response vehicles or making critical patient decisions may go undetected.

Putting it All Together

Typically, policies for diversion operate on the downstream side of controlled substance management, when it’s already too late. If we could couple them with meaningful policies on the upstream side, they may just make a difference.

The subject of drug diversion will be discussed in the November issue, as will one system’s approach (MedStar Mobile Healthcare, Texas) to tracking and monitoring controlled substance use.