Thursday, July 5, 2018

Annotated Guidance and Recommendations for the Role and Actions of Emergency Medical Services Systems in the Current Opioid Epidemic

David P. Keseg MD; James J. Augustine MD; Raymond L. Fowler MD; Kenneth A. Scheppke MD; Paul E. Pepe, MD, MPH (primary writing group for the metropolitan cities emergency medical services medical directors coalition*).

*The metropolitan municipalities EMS medical directors group is a de facto coalition of the designated jurisdictional emergency medical services (EMS) medical directors for most of the United States’ 50 or so most populous cities. It also includes medical director counterparts in Europe and many other countries globally as well as key federal agencies and the leadership from several applicable professional medical societies including the National Association of EMS Physicians (NAEMSP), the American College of Emergency Physicians (ACEP) and others. (



Paul E. Pepe, MD, MPH
Global Coordinator, Metropolitan EMS Medical Directors Coalition
c/o Department of Emergency Medicine, Mail Code 8579
The University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard, Dallas TX 75390-8579


Phone: 1.469.442.9382

Key Words: Opiate, Opioid, Opioid Analog, EMS, Drug Overdose, Epidemic, Heroin, Fentanyl, Carfentanil, Naloxone



Background: The current opioid epidemic has a death toll that rivals all other causes of premature death across the United States (U.S.) and elsewhere. The medical discipline of emergency medical services (EMS) has a special place within the collective of all interested parties hoping to provide solutions to this crisis and all other drug-related epidemics.

Methods: A cadre of EMS medical directors from the largest U.S. cities and several global counterparts shared opinions in a discussion panel designed to create an assimilated inventory of observations and best practices derived from their experiences in their respective high-volume, high-risk cities where approximately 114 million citizens reside. An annotated list of suggestions for best practices in EMS medical management was created as well as suggested strategies for EMS system participation in addiction recovery programs.

Results: A 15-point annotated list was developed that addressed medical management including a primary focus on respiratory support, a secondary focus on naloxone use (and its potential limitations) coupled with early electrocardiographic assessment.  The list also specified avoidance of tunnel vision approaches in assessment, a renewed focus on protective equipment procedures to avoid exposures and self-protection from violence. It also included standardized and collaborative data collection, collaborative training with law enforcement and it emphasized partnering with public and mental health agencies, the medical community, in-hospital facilities and other key stakeholders to facilitate a continuum of care and recovery. They also emphasized training and education of EMS professions in terms of addiction intervention techniques and how to optimally refer and facilitate retention of patients to recovery programs.

Conclusions: In addition to intervening acutely to rescue patients from real-time opioid-related events, EMS agencies must also be strongly invested in partnering with key stakeholders to develop mechanisms to end the recidivist revolving door of emergency care and the usual immediate return to addictive behaviors, overdoses and related complications. As part of that partnership, EMS providers should be trained to optimally communicate, encourage and refer/direct the affected individuals to those appropriate resources that will provide viable and evidenced-based pathways directed toward sustained recovery from this pernicious affliction.

Complete Guidance (PDF) here