Today’s correspondent has:
… a question that I’ve been stewing on for a little while regarding over the counter medications. I work as a private paramedic and as a tour guide in Queensland and often work in rural and remote environments. As a tour guide our kits are stocked with pretty much every OTC medication we can get our hands on for when those small things crop up on a tour; as a paramedic however I generally have a very narrow scope of emergency medications I am authorised to deliver. Most places I have worked with stick to the standard list of medications included in the general approval (emergency first aid), although there is an option to amend this with additional medications.
My question is this:
When I am employed as a paramedic, what are the rules that govern the way I administer or provide common OTC medications? Is it unlawful for me (as a guide or paramedic) to be handing out these medications without authorisation?
The question is complicated by the various employers that could be involved. As a general rule if one is employed as a paramedic the rules that govern what medications are carried and the circumstances of their use will be set by the employer. The issue is really about the use of the drugs as a guide. I’m told or infer:
- My correspondent is a paramedic;
- They work as a tour guide;
- They carry various non-scheduled medication;
- They want to know about using those drugs in their capacity as a tour guide.
Schedule 2 and 3 drugs
Schedule 2 and 3 drugs can be bought ‘over the counter’ at a pharmacist but they are still scheduled drugs. They cannot be bought to be delivered ‘just in case’ to an as yet unidentified patient unless the purchaser has a relevant authority. For a detailed discussion on those drugs, see The last word on scheduled drugs? (September 29, 2019).
If my correspondent is planning to carry schedule 2 or 3 drugs then they must have a relevant authority under the state poisons legislation. They may well have that if they have completed a necessary course but they must have it. These are not ‘over the counter’ drugs.
Non-scheduled drugs
By over the counter drugs, I mean drugs that are not listed in the Poisons Schedule, for example, paracetamol. The Poisons Standard (June 2022) listsparacetamol, in various forms, in schedules 2, 3 and 4. Paracetamol is not, however scheduled (ie it can be bought over the counter) when it is:
… in tablets or capsules each containing 500 mg or less of paracetamol as the only therapeutically active constituent (other than caffeine, phenylephrine and/or guaifenesin or when combined with effervescent agents) when:
(A) packed in blister or strip packaging or in a container with a child-resistant closure,
(B) in a primary pack containing not more than 20 tablets or capsules,
(C) compliant with the requirements of the Required Advisory Statements for Medicine Labels,
(D) not labelled for the treatment of children 6 years of age or less, and
(E) not labelled for the treatment of children under 12 years of age when combined with caffeine, phenylephrine and/or guaifenesin.
You can see an example of Paracetamol, available from Coles, that meets these requirements. If my correspondent is carrying a packet of paracetamol, bought from a supermarket, that is a non-scheduled or over the counter drug.
The First aid in the workplace: Code of Practice, published by WorkSafe Australia says (at p. 31):
Medication including analgesics like paracetamol and aspirin should not be included in first aid kits because of their potential to cause adverse health effects in some people including pregnant women and people with medical conditions like asthma. The supply of these medications may also be controlled by drugs and poisons laws. Workers requiring prescribed and over-the-counter medications should carry their own medication for their personal use as necessary.
That is not however prescriptive. Each Person Conducting a Business or Undertaking (each PCBU) has to consider the risks associated with their own business and form their own view as to what is required. A company that takes people to remote areas, under the supervision of a paramedic, is entitled to take the view that such medication is indeed warranted as the paramedic should be aware of the drug’s ‘potential to cause adverse health effects in some people’.
The AHPRA Shared Code of Conduct (29 June 2022) has been adopted by the Paramedicine Board and therefore applies to paramedics. It says that a paramedic must ([1.2]):
a. maintain adequate knowledge and skills to provide safe and effective care …
d. consider the balance of potential benefit and harm in all clinical management decisions …
f. provide treatment options that are based on the best available information …
g. practise within an evidence-based and patient-centred framework [and]
h. take steps to alleviate the symptoms and distress of patients…
In order to use paracetamol to ‘alleviate the symptoms … of patients’ a paramedic would need to know when paracetamol is likely to be ‘safe and effective’, the benefit is likely to outweigh any potential harm and when it is a good treatment based on the best available information, the current evidence and an assessment of the patient’s needs. In short the paramedic will need to know when the drug is indicated and when it is contraindicated.
As an example, ACT Ambulance publish their clinical practice and pharmacology guidelines online. The paracetamol pharmacology lists when the drug is indicated, contraindicated and when caution is required. For a paramedic to carry and use the drug and in order to show that they are engaged in good paramedic practice they would need to know those sorts of details and consider them when making a decision in any particular case to give the patient paracetamol.
Conclusion
The rules that what are the rules that govern the way a paramedic provides over the counter medications (ie medication that is not listed in any of the schedules of the Poisons Standard) depends first on their employers’ protocols and guidelines. As a tour guide however, I assume that there are no such guidelines and my correspondent’s status as a paramedic is incidental to the role as a tour guide. Even so my correspondent is a paramedic and will be providing health care to clients. In that role they need to practice as a competent paramedic given good paramedic care. They need to know about the drug – what it’s for, when it’s indicated, when it’s contra-indicated and any warnings and limitations.
A paramedic cannot buy, carry and use schedule 2 or 3 drugs unless that is authorised by their state poisons legislation.
This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.
Australian Emergency Law 
Dear Michael, as a related follow on to this post, I pose the question whether it would be lawful for this paramedic acting in these circumstances (acting as guide and not subject to any employers protocol or policy) to sell non-scheduled paracetamol (say purchased rom Coles) to the person requesting same? And if so, would there still be an onus on the paramedic (duty of care) to only sell if it’s indicated, and not when it’s contra-indicated and advise on any warnings and limitations. Coles doesn’t but the paramedic may (depending on circumstances) owe duty of care obligations.
I think it would depend on the business model. If they’re selling first aid kits with a pack of 20 paracetamol in it then no. If they are providing any sort of medical service so selling rather than giving them because the customer complains of a headache then yes, their duty would be to at least have a discussion with the person to see if the drugs are indicated, or more importantly, contra-indicated.