It’s no secret that the United States is mired in an opioid abuse epidemic. The powerful opioid fentanyl has its roots in anesthesiology, and has affected medical professionals in a very unfortunate way. Hardly a day goes by without news articles addressing the issue.

In the medical field, with easy access to narcotics, abuse of opioids has become a major concern. Ethan Bryson, MD, wrote the book Addicted Healers after hearing lectures by addicted physicians while he was in his residency. During these talks, Bryson learned about drug diversion, and particularly about anesthesiologists who became addicted to fentanyl.1

Fentanyl is an opioid analgesic that’s 100 times more potent than heroin, and is generally regarded as an extremely powerful painkiller. Its origins go back to 1959, when it was synthesized by Belgian chemist Paul Janssen.2 Initially, it was developed for palliative care, but its use soon expanded to anesthesia. Transdermal use of the drug in the familiar “fentanyl patch” became common in the 1990s. About 10 years ago, EMS providers began using fentanyl in the prehospital setting for pain control.

Recent Cases of Abuse

In East St. Louis in early 2017, Jason Laut, a former paramedic, was charged with 37 felony crimes in federal court after it was found he was stealing fentanyl and morphine from Metro East ambulance.3 Laut wasn’t only a paramedic, but also a supervisor and dispatch manager with MedStar Ambulance Service. He’s also married, and the father of five children.

Laut falsified trip logs to show trips that were never taken and nonexistent patients, and documented orders from a physician who no longer worked at the hospital he claimed he got orders from. The criminal indictment charges Laut with “tampering, theft, misuse and abuse of controlled substances, including fentanyl and morphine.” He faces a potential 20 years in prison.

Interestingly, the listed crime victim is Memorial Hospital, which operates the Southwestern Illinois EMS system. Fentanyl diversion was suspected by service administrators there as early as 2014, and the drug was removed from ambulances at that time. It was re-initiated in 2015 after additional safeguards were put in place.

In April 2015, former Grand County Colorado EMS employee Matthew Holmes was sentenced to 90 days in jail after he was convicted of stealing drugs from EMS vehicles.4 The criminal complaint alleged that Holmes stole morphine and fentanyl from three different ambulances, replacing the drugs with an “imitation controlled substance.”

Holmes pled guilty to four felonies—burglary, possession of a controlled substance, distribution of an imitation controlled substance and embezzlement of public property—as well as one misdemeanor, reckless endangerment, as part of a plea bargain. He will also serve four years of probation after his release.

In this case, the Colorado Department of Public Health initially noted a diversion problem in 2013 and initiated its own investigation, but turned it over to the Colorado Bureau of Investigation.

Drug Diversion

Drug diversion is a tactful term used by the Drug Enforcement Agency for theft of medications, usually a misappropriation of controlled substances by medical providers for their own use.5 Diversion of medications meant for patients is both unethical and illegal.

Opioid abuse frequently begins with legitimate use of medications for pain control. Work-related injuries, such as back and knee injuries, can result in surgery and long-term recovery. All too often, after a course of pain medications, addiction quickly follows and the addict looks for access to more narcotics.6

Easy access to narcotic pain medications in EMS can lead quickly to diversion issues. Employees under unusual stress may also be at risk for addiction. Providers suffering from opioid addiction may even look to steal drugs from patients’ homes while on a call.

Legal Implications

The actions of EMS providers who abuse fentanyl can have life-threatening consequences for patients.  It can also have profound consequences for the EMS service and the service’s medical director.

Fentanyl is particularly well-suited to the high-functioning user because it delivers an intense but short-acting effect. Euphoria and analgesia last about an hour, making it also appropriate to use in the prehospital setting.

An EMS provider who engages in drug diversion could be subject to criminal liability for theft, embezzlement, battery or other crimes. In addition, the provider could be terminated from employment and could face a licensure action up to and including revocation from the licensing agency.

The EMS service could face legal problems including loss of certification, or penalties from the local pharmacy board if the agency failed to take proper precautions to prevent drug diversion. Agencies that fail to act when informed of drug diversion could face additional liability.

EMS agencies should make it clear to their employees that failure to report suspected diversion of narcotics is a serious breach of legal and ethical duties to patients.

The alteration of drug logs to mask diversion—which almost always accompanies diversion—can result in additional liability exposure. The level of risk to the agency may depend upon its controlled substance usage policies and the degree to which these policies are followed, as well as the service’s system for handling narcotics. The cost of an impaired employee can’t be overlooked. Use of sick time results in paying others overtime to cover shifts. There’s often decreased efficiency, and a failure to act can result in diminished morale within the service.

Another issue is whether your service requires a “reasonable suspicion” or “probable cause” standard to test an employee for suspected impairment. Collective bargaining to increase the level of suspicion needed may use this standard as leverage.

Formulations that incorporate physical or pharmacologic impediments to altering the recommended routes of administration may deter tampering, but there are advantages and disadvantages to temper resistant formulations. At present, only a few formulations of oral opiate analgesics with characteristics designed to oppose tampering for abuse have received approval by the U.S. Food and Drug Administration, and none has been permitted to include claims of abuse deterrence or tamper resistance in their labeling.7

John Sinclair, fire chief for Kittitas Valley (Wash.) Fire Rescue, detailed his agency’s response to their first case. “After a 42-year clean history, we experienced our first loss of narcotics. We immediately conducted an investigation with the police, with complete transparency and changed our policy.”

Sinclair says the agency also purchased medication vaults for each of their medic units. Each individual has their own personal access code, which is reviewed monthly along with the drug logs.

Patients who haven’t received appropriate medications as a result of drug tampering may have cause to file civil lawsuits against the EMS provider as well as the EMS agency for claims such as battery and lack of informed consent. If fentanyl is medically indicated for a patient but the patient receives only normal saline from a tampered vial, this could result in a negligence claim against the service.

The service medical director may also face civil liability in the form of licensure action and fines. Again, this will depend upon the level of involvement of the medical director and whether swift action was taken when the diversion was recognized.

Finally, and certainly not least, media coverage of drug diversion in EMS damages the reputation of the service in the community and breaches the public trust.

Preventing Abuse

Sinclair notes that it’s imperative for an organization to put energy into prevention efforts, including policies, supervision and swift action when an issue arises. 
Check which drugs are ordered by supervisors, and in what amounts. If some providers tend to use more analgesics than others, particularly for complaints of back pain or abdominal pain, a chart review should be performed.

Be on alert for employees who perform poorly, have a disheveled appearance and use excessive sick leave. Employees with family or financial problems are at considerable risk.

Supervisors should know what happens to wasted and expired meds. Access to narcotic pain medications should always require two providers, as it’s not uncommon for the addict to be the one person with uncontrolled access to the narcotics.

Suspected Abuse

An investigation into reports of diversion should be initiated, and should involve the service’s medical director. Carefully review drug logs and place suspect personnel on administrative leave. Law enforcement should also be involved as appropriate.

Services should create a culture of reporting, emphasizing that it’s the right thing to do. Keeping quiet when noticing signs of impairment in a colleague helps no one, and certainly doesn’t help the provider.

If an impaired provider is identified, ask for them to be evaluated by an addiction specialist. Your state may also require that the service identify the provider, and the licensing agency may initiate its own investigation. Some states have a program that can facilitate rehabilitation for the addicted provider. The provider should return to work only upon a physician’s release.

Conclusion

Fentanyl abuse and diversion is a growing problem in the EMS community. Easy access to this highly addictive medication can open the door to major problems for EMS services. “Learn from other’s experiences,” Sinclair advises. “An EMS provider who steals drugs from a patient is no longer a professional caregiver.”

Services need strict control over narcotics used in the prehospital settings, policies for use and wasting of drugs, and to maintain a culture of patient safety by encouraging reporting of suspected diversion. Our patients, and our co-workers, deserve nothing less.

References

  1. Bryson E. Addicted healers: 5 key signs your healthcare professional may be drug impaired. New Horizon Press: Far Hills, N.J., 2012.
  2. D’Souza R. (Oct. 23, 2016.) The first fentanyl addict. Tonic. Retrieved Sept. 28, 2017, from http://tonic.vice.com/en_us/article/4w3nmb/the-first-fentanyl-addict.
  3. Patrick R. (Jan. 25, 2017.) Charges say Metro East paramedic stole painkillers from ambulances. St. Louis Post-Dispatch. Retrieved Sept. 28, 2017, from www.stltoday.com/news/local/crime-and-courts/charges-say-metro-east-paramedic-stole-painkillers-from-ambulances/article_1e5bdc22-fb55-5bc3-b007-c1a47e55e053.html.
  4. Shell H. (Sept. 10, 2015.) Former Grand County EMS employee sentenced in drug diversion case. SkyHi Daily News. Retrieved Sept. 28, 2017, from www.skyhinews.com/news/former-grand-county-ems-employee-sentenced-in-drug-diversion-case.
  5. Stark R. (Nov. 10, 2016.) Drug diversion legal brief for EMS leaders. EMS1. Retrieved Sept. 28, 2017, from www.ems1.com/opioids/articles/142756048-drug-diversion-legal-brief-for-EMS-leaders.
  6. Givot D. (June 10, 2013.) Addiction in EMS: The real tragedy behind the headlines. EMS1. Retrieved Sept. 28, 2017, from www.ems1.com/health-and-wellness/articles/1456163-Addiction-in-EMS-The-real-tragedy-behind-the-headlines/.
  7. Stanos SP, Bruckenthal P, Barkin RL. Strategies to reduce the tampering and subsequent abuse of long-acting opioids: potential risks and benefits of formulations with physical or pharmacologic deterrents to tampering. Mayo Clin Proc. 2012;87(7):683–694.