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An emergency medical services (EMS) agency medical director usually focuses primarily on the oversight of the care provided directly to patients and their families. One of the medical director's other main concerns is that of the health and safety of the EMS providers. These concerns overlap in a number of ways. This chapter specifically deals with diversion issues and identifying and managing potentially impaired providers. The more an EMS physician knows about diversion of narcotics and other substances, the more likely they are to be able to properly oversee the EMS agency–controlled substance program and to help safeguard the health and safety of patients and EMS providers alike.


  • Describe the components of an EMS agency narcotics control program.

  • Describe the process by which EMS agencies obtain, stock, and utilize controlled substances.

  • Discuss DEA regulations and the differences between using a personal DEA registration versus an agency DEA registration.

  • Discuss state narcotics laws and regulations that affect EMS agencies.

  • Describe proper storage and handling of controlled substances.

  • Discuss wasting and accountability for controlled substances.

  • Discuss diversion of controlled substances by providers, how surveillance may prevent and/or identify a problem, and what to do when a diversion issue has been identified.

  • Discuss risk factors and warning signals associated with a provider who is impaired by drugs and/or alcohol use/abuse.


Diversion means different things to different people. In its strictest sense, diversion means to move attention away from themselves through ­finger pointing, nit picking, manipulation, sleight of hand, or misdirection. For law enforcement purposes, diversion means the misappropriation of DEA scheduled medications from approved and/or legitimate patient usage, through doctor shopping, prescription forgery, theft, or substitution. Those who divert drugs often utilize skills mentioned in the above definition. EMS providers are not immune to diversion and agencies and medical directors need to be vigilant to ensure that such is not occurring in their systems. Drug addiction is an occupational hazard among EMS professionals, who have easy access to controlled substances such as Fentanyl, Morphine, Demerol, Versed, and other highly addicted drugs. Tampering is the diversion of medications done in such a way that it looks like drugs were never stolen. The tampered medication is then left in the system, to be used by an unsuspecting health care professional. EMS provider reports of patients not experiencing pain relief after the administration of pain medication may be a red flag indicating drug tampering.

Structured programs should be in place to account for and stocking, use, and restocking of controlled medications. EMS professionals cannot consistently divert drugs if the system has adequate physical security and an effective record-keeping system with a comprehensive audit trail. Most EMS health care professionals are unaware of the magnitude of the legal hazard associated with failing to provide adequate security and maintaining complete and accurate controlled substance ...

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