A few weeks ago a friend of mine lost his 32 old son to an opiate overdose. That strikes close to home as I have a 33 year old son of my own and a college student daughter. Even more crushing for my friend — his best friend lost a child to an overdose as well two weeks later. My town has deaths listed almost daily from overdoses.
I also understand the fear that providers have over DEA enforcement and their frustration with “drug seekers.”
And all around us, concerned patients are calling for more laws to try to stop these tragedies.
But, before you join the rush to slap up signs, pass restrictive policies and procedures for pain meds, and start confronting every chronic pain patient as the enemy in the Emergency Department, you need to take a deep breath and remember that you first MUST comply with EMTALA.
I have a question for you to think about:
Let’s say a patient comes in with chronic pain complaints and you determine the patient has indicators, flags, or symptoms that suggest to you that they are “drug seeking”. Does that mean you can bounce them out with no further care to their primary care physician?
If you are using some of the policies floating around out there, you are probably going to get nailed for violating EMTALA because they are circulating bad information about your EMTALA duties by giving an outdated definition of emergency medical condition. Many give a one line nod of the head to EMTALA and dive into how to never see another pain patient. This is a medical and legal recipe for disaster.
Here is the current definition that has been in place for years:
42 CFR 489.24
Emergency medical condition means—
(1) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in—
(i) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
(ii) Serious impairment to bodily functions; or
(iii) Serious dysfunction of any bodily organ or part; or
(2) With respect to a pregnant woman who is having contractions—
(i) That there is inadequate time to effect a safe transfer to another hospital before delivery; or
(ii) That transfer may pose a threat to the health or safety of the woman or the unborn child.
OK, so you have “drug seeking” and that is a symptom of substance abuse — ergo an emergency medical condition. You now have to ask yourself how you are going to “resolve” or “stabilize” the emergency medical condition and demonstrate a reduction in pain prior to discharge in order to meet CMS expectations under EMTALA, or for that matter, was your Medical Screening Exam adequate either. You might recall the repeated visit cases where patients were forced out of the ED with pain complaints only to die in the waiting area or on the street from real medical conditions that had been missed or ignored. CMS is quick to cite those, not just for the fatal visit, but also for all the priors where they determine that full EMTALA compliant assessments were not provided.
Blog posts like this are not sufficient to offer any effective guidance on how to meet EMTALA and still reduce opioid issues, so I am currently working on a white paper that should be out within 21 days in which I can offer more detailed suggestions — but being a risk manager is like the ED — you get unscheduled emergencies that disrupt your intended schedule — so don’t hold me to the 21 days.
Steve:
Under EMTALA, I don’t have to “resolve” the pain complaint, I have to address the issue to determine there is no condition that will destabilize.
I don’t resolve a fx or fix a cold.
The real danger here is that I ascribe the patient’s complaint to drug seeking and miss their appy.
Cognitive biases are my current fetish!
tom
Even patients with substance abuse issues deserve appropriate pain control. Nonetheless, “symptoms of substance abuse” are necessary, but not sufficient, to qualify as emergency medical conditions under the statute. There are three criteria that follow, at least one of which would have to be met by the alleged drug seeker, in order to meet EMTALA’s definition of an emergency medical condition. One could argue about whether or not just the act of seeking pain medication for secondary gain is a “symptom” at all.
In any case, any symptom of substance abuse by itself may not result in placing the health of the individual in serious jeopardy, in serious impairment to bodily functions; or in a serious dysfunction of a bodily organ or part. An assessment can usually be readily made, depending on the nature of the substance sought, the overall health and condition of the patient, and whether or not there are objective signs of an acute abstinence syndrome.
A patient seeking opioids with no withdrawal symptoms and a normal exam would not qualify as having an emergency medical condition and could be referred to the appropriate resources. “Stabilizing” a patient cannot be interpreted as requiring providing rehabilitation or future detoxification services. And even in borderline cases, where there are signs of a mild abstinence syndrome, a very short term prescription of the pain medication sought (if taken as directed) would stabilize the patient until longer term care could be arranged.
Clearly patients seeking substances such as benzodiazepines or barbiturates are at higher risk for life-threatening complications of withdrawal, but that is beyond the scope of the pain medication issue raised here.