Ask Dr. Johnson

Administering Epinepherine
Q: What is the legality in administering epinephrine to someone? Are WFA certified individuals allowed to carry epi-pens to have someone use if in an emergency situation or can epi-pens only be used if they are prescribed to someone?

Like many questions, the answers depends. States vary in what they consider to be legal. Some have specific provisions for lay providers. Others strictly forbid administering medication to non-family members. Most are not clear. I believe that this is a first aid skill. So do the American Heart Association and the American Academy of Allergy, Asthma and Immunology. In Ontario, an Epi Pen can be purchased without a prescription. So where is the problem? It lies with the concept of the administration of a prescription medication by a non-licensed provider. Tens of thousands of people have been trained. I know that some of our graduates administer epinephrine each year. I am not aware of any bad outcomes, including adverse reactions or legal issues arising from administration of epinephrine by lay providers. Although many of us have written in defense of this procedure and organizations have lobbied on behalf of the training, a gray area still exists.

The most prudent approach when you are working for someone else would include the following:

1. Training. – Keep your certification current.
2. Authorization – Make sure that your employer knows about your level of training and has authorized you to administer the medication for any client should the need arise. Get your patient’s permission.
3. Medication – Make sure that you have unexpired medication that is the correct concentration (if you are not using an autoinjector). It should be clear, colorless and free of any particulates. Your organization should supply the medication.
4. Protocol/SOP – If you are using an organizational protocol (you should), make sure that it is current and approved. Review this at least yearly. In addition, there should be a regular accounting for the medication including the expiration date and disposal.
5. Review – Anytime epinephrine is used (or should have been used), your employer should do a comprehensive review of the event, report back to the principles involved with the findings, and modify policy as needed based on this review.

If you administer epinephrine outside of a work setting, you still have the same responsibility to practice competently – current certification, unexpired medication, familiarity with your training protocol and patient permission.

In the relatively unusual likelihood it is medically necessary, epinephrine injection has proven to be an extremely low risk procedure for a significant benefit. I personally believe that the appropriate use of epinephrine for anaphylaxis is ethical and medically appropriate even where the legality might be questionable. Your employer should seek a legal opinion for your state. For more information on our view of the legal implications including the Good Samaritan legislation, a sample protocol or other articles on this or other topics, go to here.

Q: Once a person has had an anaphylactic reaction to a substance, will all subsequent exposures invariably lead to similar or worse reactions?

There is no question that recurrent reactions can follow re-exposure. As it turns out, however, the probability as reported in the medical literature is considerably less, about 50% for bee stings, for example. These re-exposure reactions can be less severe than the prior reaction.
Taking reasonable steps to avoid re-exposure is as important as being prepared to recognize and treat a reaction should it occur. For some people with recurrent severe reactions, immunotherapy (aka desensitization) can be a very effective deterrent. It is equally important to remember, however, that based on these statistics, not everyone needs to be treated following a re-exposure. Only treat those who develop signs and symptoms consistent with a true anaphylactic reaction.