For Kansas EMS, and national health care in general, narcotic diversion can be plainly stated as the theft of DEA scheduled medications; medications meant to treat pain, various cardiac conditions or seizures, medications that are by their nature, highly addictive.  

 

While theft is generally frowned upon, occult theft like occult bleeding can be difficult to diagnose as well as difficult to manage.  The occult theft of narcotics is called tampering or substitution, it is the diversion of narcotics done in a manner as to make it appear as if they were never stolen.  In essence they are made counterfeit.  They can remain in the system, to be used by an unsuspecting health care professional (Paramedic, RN, RT, MD), on an unsuspecting patient.  

 

Of all the forms of narcotic diversion out there (such as prescription forgery, doctor shopping or out right theft), tampering with or substituting saline for a narcotic is nearly the most insidious.  The only thing worse would be to replace the narcotic with something harmful.  Earlier this year, a Paramedic Captain from Southern Washington State was arrested for doing just that.  He admitted to replacing department fentanyl with tap water taken from the janitor’s sink.  Incidents such as this have made local news across the county.  They occur more frequently than we’d like, and I dare say they occur more frequently than most suspect.  More about that story and others can be found at www.stopnarcotictampering.org.

 

In the general population, chemical dependency is a growing problem.  Chemical Dependency is a growing problem in health care as well, just because we are Fire and EMS doesn’t mean it doesn’t happen to us either.  One bad call, a heavy patient, a strained back, injury, Vicodin, Oxycontin, Soma, coupled with the adrenalin seeking addictive personalities often found in our field and we have the foundation for addiction.

 

To the chemically addicted mind, their fix (insert your DOC here) is a matter of life or death.  Should we be surprised then when we hear one of our own has tampered with narcotics to treat their addiction?  No, it is the nature of the disease that is addiction. 

 

A common denominator in those that divert narcotics is “access”.  Records show that both men and women divert, young and old, rookie and preceptor, firefighter and chief.  Those that divert can have unsupervised access to narcotics or know how to.  Many times, controlled substance accountability systems are built to prevent field personnel from having direct physical access to narcotics except for times they are needed for a patient.  Often, narcotics are stored inside a container on an ambulance or fire engine, tamper-evident lock boxes being a preferred method.  Narcotics restock are usually stored in cabinet behind locked doors.  If a single person can access these, unsupervised, at any hour, day or night, that would be a system asking for trouble.  

 

A more secure approach would be to have narcotic drug cabinets utilize two keys:  one key for supervisors and another key for field personnel or administration.  Another approach is the utilization of electronic, event recording locks that require two separate combinations, codes or electronic key cards.

 

No supervisor or administrator, for their own sake, should ever have single person, unrestricted access to narcotics.  I believe that the vast majority of people that work in EMS are good and ethical.  We are none the less, all susceptible to injury and temptation.  Our narcotic control and accountability systems need to be strong and secure, not because we don’t trust the individuals we work with, but because we know the fallibility of human nature.  

 

Another technique to better safeguard our controlled substances is to utilize reverse distribution.  Reverse distribution is utilized by Charleston County EMS in South Carolina as well as a growing number of agencies in the Western United States.  In this system, all narcotic containers are returned to headquarters.  Instead of wasting any unused medication, it is returned for analysis.  When this system is used, all parts of the narcotic container should be returned, especially the lids from vials, and the plastic tubes that held  Carpujects®.

 

Benefits to this type of system are that potential evidence is retained, rather than discarded, and personnel  know that all returned stock or fraction thereof will be analyzed.  Fear of getting caught will cause an addict to tamper with narcotics rather than outright steal them; fear of having returned narcotics come back as saline, have prevented further cases of diversion from being discovered in Charleston.

 

When a narcotic tampering case is made known, it is common for field personnel to question why they didn’t take greater notice that the narcotics they were giving failed to deliver the expected results.  We rationalize that we thought the patient was a drug seeker, or that they had a low tolerance for pain.  Some thought the drug stopped working because of the high or low temperatures in the rig, or that not all patients get relief from narcotics.  Sadly, in the aftermath we realize our patients weren’t getting relief from our narcotics, because, we weren’t giving them any.  If we track patient relief as well as we track CPR compression:ventilation ratios, would we find indications that our narcotics were not working?  If so, that would be a trigger that our narcotics need to be analyzed for efficacy and possible tampering.

 

These are just a few examples of what systems can do to insure the efficacy and safety of our narcotics.  Awareness of past history, jealously protecting our industry’s integrity and the health and well being of our people are key to not repeating it.

 

We strive to give our patients the best care possible.  We’re trained to verify the correct drug, check indications, contraindications and expiration dates.  Have we been trained to look for signs of tampering?  Have we been informed of the techniques used by others to tamper with drugs?  In my little corner of the world, this was not discussed, and never taught.  In this vacuum of knowledge, a well respected, well connected and high ranking committed addict (addicts are often committed to maintaining their addiction in secret) was successful in tampering with an unfathomable amount of narcotics for an unbelievable amount of time.  Finding evidence of this, reporting it, being discounted and then learning the truth, put me on a path to educate the curious, promote prevention and rehabilitation with the goal to Stop Narcotic Tampering Through Awareness & Prevention.