By Tommy Baldwin and Tom Hales
Firefighters have hazardous jobsjobs that put them at risk for injury and illness.1-5 Many of these injuries/illnesses involve the musculoskeletal system, (2, 4, 5) whose treatment may involve the short-term prescription of painkilling medications, including narcotics. Typically, these injuries/illnesses resolve before work restrictions are needed. However, in some cases, the pain persists and work restrictions, for the condition or for the prescribed medications, are appropriate. This article highlights the potential dangers of taking pain medications by describing the on-duty deaths of two firefighters whose deaths were ascribed to prescribed narcotics and other painkillers. The article includes guidance on this topic as set forth in National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments.6
Case #1 involved a 31-year-old male volunteer firefighter who responded to his station during a 911 call for smoke in a basement. After arriving at his fire station, he waited for one of the fire department’s driver/operators to arrive and drive him and the engine to the scene. While he was waiting, the first assistant chief arrived at the residence, determined a full response was not needed, and cancelled the response. The driver/operator returned home without arriving at the fire station. About 30 minutes later, a civilian driving by the fire station noticed a collapsed firefighter just inside the station and notified 911. Despite cardiopulmonary resuscitation and advanced life support, the firefighter died. The death certificate and autopsy listed “acute intoxication by the combined effects of propoxyphene (Darvon®) and cyclobenzaprine (Flexeril®)” as the cause of death and “hypertension” as another condition.
The firefighter had a medical history of chronic strained back muscles (not duty related) and had been prescribed pain medications for five years.7 Prescriptions included narcotics (Darvon®, Percocet®, Oxycontin®) and a muscle relaxant (Flexeril®). At autopsy, the firefighter had a propoxyphene blood level of 3.3 milligrams per liter (mg/L), well above the therapeutic level of 0.42 mg/L. He also had a cyclobenzaprine blood level of 0.09 mg/L, well above the therapeutic level of 0.026 mg/L. (7)
The department requires preplacement medical evaluations for applicants and periodic medical evaluations for all members. The physician conducting the department’s periodic medical evaluations was unaware of the firefighter’s history of back pain or narcotic use and cleared him for unrestricted duty two years prior to his death. Medical records suggested the firefighter did not disclose his former and current prescription use or his history of chronic back pain to the department physician.
Case #2 involved a 28-year-old male volunteer chief attending an emergency medical services conference. The evening before the conference, the chief and his wife went to bed at 2230 hours. The next morning, at 0900 hours, the chief’s spouse awoke and found the chief unresponsive. She called 911, and an ambulance responded. From the chief’s clinical condition, it was obvious he had expired some time earlier. Cardiopulmonary resuscitation and advanced life support treatment were not performed, and he was pronounced dead at the scene. The death certificate and the autopsy, conducted by the chief medical examiner, listed “accidental multiple drug intoxication” as the cause of death.
The chief had a history of a back injury with subsequent surgery. He had been prescribed pain medications for eight years, which included narcotics (MS Contin®), muscle relaxants (Flexeril®, Robaxin®, Valium®), antidepressants (Effexor®, Paxil®), and sleeping pills (Ambien®).8 At autopsy, the chief had a morphine (MS Contin®) blood level of <50 nanograms per milliliter (ng/mL); well within the therapeutic level of 80 ng/mL. He also had a diazepam (Valium®) blood level of 514 ng/mL; well within the therapeutic level of 1,000 ng/mL. (8) Although both medicines were within therapeutic level, the chief medical examiner felt the interaction of the two drugs was responsible for the chief’s death.
The department did not require preplacement or periodic medical evaluations. However, according to the department, all firefighter applicants must be in self-reported excellent health and physically fit. The chief’s personal physician was aware of NFPA 1582 guidance regarding narcotic use but cleared the chief for light duty based on the chief’s self-assessment that he did not respond to “emergencies.”
These two cases illustrate the dangers of taking multiple pain medications. Table 1 lists the generic and brand names of the medications prescribed over a five- and eight-year period for these two firefighters. These medications are dangerous not only because of the risk of overdosing but because they also have side effects that can impair the performance of firefighting duties. Table 2 lists the side effects of the medications, which can affect firefighter work performance. Taking pain medications when working jeopardizes that firefighter’s safety as well as the safety of other firefighters operating at the emergency scene. This risk extends to the general public if the firefighter is operating apparatus under emergency conditions.
These deaths highlight the importance of periodic medical evaluations by fire departments. During these evaluations, firefighters must provide an accurate medical history to the examining physician. In Case #1, periodic medical evaluations were performed, but the firefighter did not report his medication use to the examining physician. In Case #2, the chief provided accurate information to his private physician, but the department did not require periodic medical evaluations. These recommendations apply to firefighters who respond to emergency calls as well as to some who have other rolesfor example, firefighters who don’t respond to real emergencies but participate in live-fire drills.
Propoxyphene (Darvon®) is a narcotic analgesic that has been in clinical use since 1963. It is somewhat less potent than codeine and bears a close structural relationship to methadone. It is available in oral formulations as the hydrochloride (Propoxyphene HCl) or the napsylate salt [Propoxyphene N (Darvocet-N®)]. Both formulations are often combined with aspirin or acetaminophen. Daily therapeutic oral doses of propoxyphene range from 128-390 mg for Propoxyphene HCl and from 200-600 mg for Propoxyphene N.9
Propoxyphene is metabolized to norpropoxyphene, which is one-fourth to one-half as active an analgesic as propoxyphene, but it accumulates in blood plasma because of a longer half-life. The contribution of norpropoxyphene to the efficacy or toxicity of the parent drug has not been thoroughly established (9),10 Propoxyphene has the usual respiratory depressant effects common to all beta-agonist narcotics. (10) Overdosage with propoxyphene can result in stupor, coma, convulsions, respiratory depression, cardiac arrhythmias, hypotension, pulmonary edema, and circulatory collapse.
Following a single 130-mg oral dose of propoxyphene HCl, plasma concentrations reach 0.23 milligrams per liter (mg/L) at two hours; the plasma concentration of its metabolite (norpropoxyphene) reaches 0.27 mg/L at four hours. Chronic daily doses of 195 mg of propoxyphene HCl were shown to produce average plasma concentrations of 0.42 mg/L propoxyphene and 1.45 mg/L norpropoxyphene two hours after the last administration. (9)
Generally, blood propoxyphene concentrations exceeding 1 mg/L are considered indicative of serious toxicity, and concentrations of 2 mg/L or more are consistent with death. However, fatalities have been reported with blood propoxyphene concentrations <1 mg/L.(9) Seven acutely intoxicated patients who survived because of hospital treatment were found to have average plasma propoxyphene and norpropoxyphene concentrations of 1.6 mg/L and 2.0 mg/L, respectively. (9) In another report of 72 cases in which acute propoxyphene overdosage was the sole cause of death, postmortem femoral blood concentrations averaged 2.8 mg/L (range, 1.3 8.1). In most specimens, norpropoxyphene concentrations exceed those of propoxyphene. (9)
To provide guidance for physicians and other health care providers for maintaining a comprehensive occupational medical program for fire departments, the NFPA developed NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. (6) Among other issues, NFPA 1582 provides guidance on medication use that should result in restricted duty. NFPA 1582 considers narcotics use to be a Category A condition for candidates, defined as “a medical condition that would preclude a person from performing as a member in a training or an emergency operational environment by presenting a significant risk to the safety and health of the person or others.”(6) Candidates’ use of psychiatric medications and muscle relaxants is considered a Category B condition, defined as “a medical condition that, based on its severity or degree, could preclude a person from performing as a member in a training or [an] emergency operational environment by presenting a significant risk to the safety and health of the person or others.”(6)
NFPA 1582 recommends that any prescription medicine (narcotics, muscle relaxants, sedatives, etc.) that alters mental status, vigilance, judgment, or other neurologic functions should result in temporary restrictions. These medications preclude a firefighter from safely performing the essential job tasks of firefighting (Table 3).
Other occupations whose job tasks involve public safety also restrict the use of prescription medications. For example, the U.S. Department of Transportation will not issue a commercial driver’s license to “a person taking narcotics unless the drug is prescribed by a licensed medical practitioner who is familiar with the driver’s medical history and assigned duties and has advised the driver that the prescribed drug will not adversely affect the driver’s ability to safely operate a commercial vehicle.”11
The Federal Aviation Administration (FAA) will defer medical certification for pilots taking mood-ameliorating, narcotic, or sedative medications unless the treatment has been previously cleared by FAA medical authority. During periods in which these medications are being used for treatment of acute illnesses, the airman is under obligation to refrain from exercising the privileges of his airman medical certificate unless cleared by the FAA.12
For police officers, the Commonwealth of Massachusetts considers the use of narcotics, sedatives, and psychoactive agents to be a “Category B” medical condition that could preclude a candidate from performing the essential functions of a police officer because of the safety risk.13
The State of California has determined that medication-induced impairment can place a patrol officer and others at substantial risk of harm. Consequently, all candidates who report the use of medications on a chronic or an intermittent basis must be carefully evaluated to determine their suitability for unrestricted duty.14
NFPA 1582 also addresses fitness-for-duty issues for candidates and members with spine disorders and back pain. For candidates, a history of spinal surgery involving fusion of two or more vertebrae and any spinal or skeletal condition causing pain that frequently or recurrently requires narcotic analgesic medication are considered Category A conditions, precluding them from becoming firefighters.
For members, spinal fusion at two or more levels and a spinal condition with significant radiculopathy resulting in peripheral motor weakness, loss of strength, sensation, and reflexes affecting endurance, strength, flexibility, pain, and/or gait disturbances compromises the member’s ability to safely perform essential job tasks 1, 2, 4, 5, 6, 7, 8, and 13 (Table 3).
To ensure the safety of firefighters and the public whose lives they protect and to address prescription medication use in firefighters, fire departments should do the following:
- Provide post-offer/preplacement medical evaluations to candidates and annual medical evaluations to members in accordance with NFPA 1582.
- Ensure members are knowledgeable of, and comply with, fire department requirements regarding reporting any medical condition that could interfere with their ability to safely perform essential job tasks. This must include all medications, prescription and over-the-counter.
- Ensure that firefighters are cleared for duty by a physician knowledgeable about the physical demands of firefighting and the various components of NFPA 1582.
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2. Matticks CA, JJ Westwater, HN Himel, RF Morgan, RF Edlich, “Health risks to firefighters,” J Burn Care Rehab, 1992; 13:223-235.
3. Guidotti, TL, “Human factors in firefighting: ergonomic-, cardiopulmonary-, and psychogenic stress-related issues,” Int Arch Occup Environ Health, 1992; 64:1-12.
4. Magnetti, SM, WD Wyant, J Greenwood, NJ Roder, JC Linton, AM Ducatman, “Injuries to volunteer firefighters in West Virginia,” JOEM, 1998; 41(2):104-110.
5. Reichelt, PA, KM Conrad,”Musculosckeletal injury: ergonomics and physical fitness in firefighters.” In: Orris P, J Melius, RM Duffy, eds. Occupational medicine, firefighter’s safety and health. (Philadelphia, PA: Hanley and Belfus, 1995), (10)4: 735-746.
6. NFPA 1582: Standard on Comprehensive Occupational Medical Program for Fire Departments. Quincy MA: National Fire Protection Association.
7. “Fire Fighter Dies After Responding to a CallNew York.” Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Safety Research. Fire Fighter Fatality Investigation and Prevention Program Report No. F2005-24. http://www.cdc.gov/niosh/fire/reports/face200524.html.
8. “Fire Chief Suffers Sudden Death During TrainingAlabama,” Morgantown, WV: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Safety Research. Fire Fighter Fatality Investigation and Prevention Program Report No. F2006-01. http://www.cdc.gov/niosh/fire/reports/face200601.html.
9. Baselt RC. Disposition of Toxic Drugs and Chemicals in Man. (Foster City, CA: Biomedical Publications. 7th Edition, 2004), 953-956.
10. Karch SB. Karch’s Pathology of Drug Abuse. (Boca Raton, FL: CRC Press. 3rd Edition, 2002), 372-373.
11. CFR. 49 CFR 391.41, Physical Qualifications for Drivers. Code of Federal Regulations. Washington, DC: National Archives and Records Administration, Office of the Federal Register.
12. Guide for aviation medical examiners: application process for medical certification. [http://www.faa.gov/about/office_org/
app_history/item17a/index.cfm?print=go]. FAA, 2006. Date accessed: January 2007.
13. Municipal police officers’ medical standards and essential functions. Public Employee Retirement Administration Commission. Commonwealth of Massachusetts: Sommerville, Mass., 2004.
14. Medical Screening Manual for California Law Enforcement. California Commission on Peace Officer Standards and Training. Sacramento, Ca., 2004.
TOMMY BALDWIN, MS, is with the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Cardiovascular Disease Component, Cincinnati, Ohio. He is a National Association of Fire Investigators (NAFI)-certified fire and explosion investigator, an International Fire Service Accreditation Congress (IFSAC)-certified fire officer I, and a former firefighter/EMT and chief. He has a B.S. in fire investigation and an M.S. in loss prevention and safety from Eastern Kentucky University.
TOM HALES, MD, MPH, is the team leader for the NIOSH Fire Fighter Fatality Investigation and Prevention Program, Cardiovascular Disease Component, Cincinnati, Ohio. He is board certified in internal medicine and occupational medicine and is a member of the NFPA Technical Committee Fire Service Occupational Safety and Health.