UKC

I managed to get embroiled in a very vitriolic discussion on Twitter (as they always are) on the subject of how available epipens should be.  In the UK they are I believe prescription only and the person prescribed them basically needs to carry at least one (ideally 2) on their person at all times, but obviously they could forget or it could be a first time anaphylactic shock before they were prescribed. 

However presumably the idea of making them just available to purchase in first aid kits has risks (you can just imagine them becoming the next kids' Tiktok craze), and I believe they can cause injury if injected in the wrong place e.g. in a finger (quite a lot seems to be made of making sure it's the right way round on first aid courses).  And could people just buy them and hide another issue that needs properly diagnosing?

So perhaps we'd get a more sensible discussion on here as we tend to?  What is the right way to make sure one is available when it's needed, but they aren't misused if indeed there's scope for that?

One thought I had is that they (and a blue inhaler) should perhaps be kept in the box alongside AEDs, which could be pointed to and the unlock code given if the call handler felt it was appropriate?

Or should they just be in first aid kits?  What about blue asthma inhalers, which could be similarly urgently needed and forgotten, and are basically all the same in their effect?

Do e.g. Mountain Rescue carry them out of interest?

One observation is that they're not cheap (I have a ballpark figure of £50 in my head?) and have relatively short expiry dates. So unlikely to be something third parties would choose to carry speculatively in a first aid kit, even if available.

For that reason, many teams carry ampoules for injection, rather than epipens. Epipens are also approved as a delivery route though.

Reading this I thought "I'm sure they are more expensive than that", A quick google suggests £50 ish is about right in the UK but they cost a shocking $600-700 in the states.

Apparently the shelf life is about 1 yr but they do retain a significant amount of their activity for a long time beyond this date and the conclusion of a review was that an old epi pen is better than no epi pen.

Ah yes, I forgot about the US price-gouging: https://www.vox.com/policy/23658275/epipen-cost-price-how-much

Sums up what I was going to say.  MR absolutely carry adrenaline in ampules as anaphylaxis is a life threatening condition

You can buy epipens for first aid kits without a prescription in certain situations. For example, Schools often carry them and I've worked in other childcare situations where they have been available. Where they have been available, I have always received training about how to administer them correctly. Purchase is restricted - a random off the street would find it very hard to get hold of one without a prescription.

Also note that there is UK legislation allowing lay administration of adrenaline and certain other drugs in an emergency, but I don't believe this extends to asthma medication. See some information here: https://www.realfirstaid.co.uk/use-of-epi-pens

I've a nut allergy and carry epi-pens so folk having them in 1st aid kits would certainly be in my interest!  As poster above identified the main barrier is cost I suspect, plus as soon as you have drugs in a 1st aid kit you need to start worrying about record keeping, ensuring they are always in date etc.  Too much hassle for most folk I think and opens up other problems with people being given out of date drugs etc.

MR - we carry ampoules as standard though there is flex for teams to carry autoinjectors for drugs if they want to - same issues with cost and short shelf life tend to make it a less attractive option for most teams!  Would be nice though, drawing up under a group shelter in a hoolie is a total PITA!

There aren't many drugs you are allowed to administer as a first aider - adrenalin and aspirin are the only ones I think - a while since I did 1st aid at work rather than cascare qualification though so could be wrong on that.  As a result items like salbutamol inhalers wouldn't be allowed in any kind of bought kit unless regulations change.  Sadly, stashing them in similar ways to AEDs would likely just end up in them stolen and not get round the fact that people aren't allowed to prescribe and dispense under a first aid ticket - though perhaps a little wriggle room if being advised via phone by someone suitably qualified (a workaround I've seen in sailing and working offshore on vessels).

We do carry Salbutamol inhalers and nebules in our MR team for cascarers to administer.

Given the constraints on cost and shelf life probably more practical for employers to hold epi-pens rather than individuals (something I've suggested at our work) as the infrastructure is likely already there to support.  Doesn't help in the hills, but might work in city or built up areas.

Cheers

How many people a year die from anaphylaxis, that would have been saved if they had access to an epi-pen? I believe there are tens of thousands of out of hospital cardiac arrests every year, which is a good justification for the distribution of defibs.

You don't generally administer inhalers for people (other than very young kids), you give it to them and they do it.  If they can't breathe enough to use an inhaler it isn't going to work.

Interesting topic, as seems to come up at my FAAW re-quals.

One of my Cubs has a nut alergy, so always turns up with 2 Epipens - although they are "his", so I can't use them for another Cub if they suffered an anaphylactic shock.

However, if I know an EMS team is on the way, who would have spare on board, then would I use one to save a life? Would be a difficult situation - I'd take advice from emergency services on the end of the phone, at least.

While not totally universal (as there are other allergies that cause anaphylaxis like bee stings) most such allergies seem to be to food - so is there an argument that all food premises should keep one and staff there be trained in use?

Right - I have asthma so I know this. However, the point is that a lay first aider is also not allowed to decide when it is or isn't appropriate to use asthma medication. This decision must be made solely by the patient. The legislation around adrenaline says that a first aider is allowed to make this decision if adrenaline is available, and by extrapolation, potentially give it to someone who has not been prescribed it previously. 

By administer, in this context, I meant "to make the decision that a medication should be taken and to provide it when the patient may not already have access to it" rather than to physcially administer it. I realise that wasn't entirely clear - my apologies.

In relation to your point about keeping asthma medication available with an AED or similar, the reason this is not allowed is related to the distinction made above.

True, but if someone with asthma is having an attack and is asking between pained breaths for an inhaler (but doesn't have theirs) then isn't there a case for that availability?  I get that it might not be possible under the current legislation, but I can see how that legislation should perhaps change.

There are multiple types of blue inhaler but all do the same basic thing, people do switch between them because one works better than another for them but in an emergency any will do.

I suppose to be fair that unlike anaphylactic shock asthma patients will still usually be alive when the ambulance arrives, but some might not particularly if a long way from the road?

Hopefully, as a professional first aid trainer and someone who also writes/decides upon assessment for national first aid qualifications, I can bring some clarity here.

Both Adrenaline Auto-injectors (e.g. the marker leader Epipen) and asthma inhalers are prescription only in the UK, courtesy of the Supply of Medicines Regulations, i.e. the law.  There are however, exemptions for both medications for schools - NB only schools.  Asthma Inhalers since 2014 - https://www.gov.uk/government/publications/emergency-asthma-inhalers-for-us... and Adrenaline Auto-injectors since 2017 - https://www.gov.uk/government/publications/using-emergency-adrenaline-auto-... .

These exemptions are for both state and private schools, but not actually private nurseries.  A nursery school attached to a primary can have them, but private businesses, such as Little Darlings Nursery Ltd. can't have them.  

So, what if somebody has a big first time reaction (rare, but possible) to a wasp sting for example, that results in what looks like an anaphylactic reaction?  You dial 999 and tell them what has happened and help will come quickly - a high priority call.  If another person of similar age and size was nearby and they had a pair of AAIs due to their peanut allergy, we could explain this to the Ambulance Call Handler and if a health care professional in the control room told us (on a recorded phone call) to use the other person's AAIs, we could legally do as we are told.  Legally, we can't just use our own judgement and break the law, but doctors and nurses with prescribing rights could make that decision on their own.  It doesn't come down to the casualty or the donor of the AAI or their respective parents giving consent, legally it has to come from the control room.  That is the legal "way around" a potential life threatening situation.

If any of you carry around a spare asthma inhaler, just in case others need it, technically, you are breaking the law, as you are not allowed to deal in drugs, as I am sure that you know.

Cost wise, the school can buy theirs cheaper than an adult would pay but in terms of actual cost rather than how much is charged at the pharmacy, I believe they are hundreds of pounds.

Happy to answer further questions from a first aid point of view.

In terms of making sure people have their medication with them, with youngsters, it is easier - show me your medication or you don't come on your trip (although they must be allowed into school).  For adults, you ask them to show others who will be with them whereabouts they keep their medication, e.g. which part of their rucksack or which pocket of their coat, so that we can verify that have got what they need.  Generally people are happy to do this and you can establish who hasn't got what they need. This is also a good ploy for establishing that teenagers have them rather than them assuming you don't trust them, when you demand to see it.

Don't assume that adults will always carry around their life saving medication at all times.  I regularly train groups of school staff, who in theory should know better, and when asking who has asthma and then where do they keep their medication, find that they do not have it with them, perhaps it's in the car, at home, in the pocket of their running jacket, etc. or if they do have it with them, it is out of date.  People can be very blase about their life threatening illnesses, as "its never a problem" until of course it is.

Vials of adrenaline and saline or water for injection to dilute are cheap. Surely this would be the best thing for medically trained people to use. The time to expiry is much longer as well. 

For Epipens, there is no need for faff and the affected person has a good chance of self-medicating.

There was fairly recently (before COVID) a shortage of supply of Epipens and the expiry dates were extended from memory - they are about £70-80. These are all POM and unless a medic with the requisite licence or the patient you cannot hold such drugs speculatively as Bingers says. 

I would be absolutely astonished if such a case got to Court, and if it did even if they were forced to convict I would be similarly absolutely astonished if the outcome was anything other than an unconditional discharge, assuming the inhaler was provided for free to a person who was at the time experiencing an asthma attack.

Obviously schools etc have to follow the letter of the law though.

(Carrying two wouldn't in itself be a crime, you're allowed a spare for yourself!)

The shortage lasted a long time and there were extensions allowed for the expiry date, but those world wide shortages of Epipens have now been resolved.  However, there was a recall of Emerade (a different brand) injectors last month.  It was concluded that there were enough alternatives in the country to allow for all who have one to take them back to get a replacement.

For many years I have trained a retired police superintendent who has been very vocal about the CPS not touching a suggestion of prosecuting such an "offence" as it would not be in the public interest.  However, that is his opinion, rather than the law.  As yet, there is no case history, to my knowledge, to put this to the test.

There is a legal way around it, make the 999 call.  What if there is no phone signal in a remote place?  I have no idea what actions you might chose to do in that situation.   My retired police officer has a plan, but I must stick to telling you the law.

You are right, carrying two yourself is no crime.  I do sometimes come across outdoor instructors who are happy to tell me they carry one for others' use, even though they are not asthmatic and the inhaler had never been prescribed to themselves.  Drug dealers to the letter of the law!