Pain Treatment in the ED

If you have spent any time at all in the ED, you have caught an earful about "drug seeking behavior." DSB is widely discussed though rarely quantifed (though you may see some interesting estimates on DSB in the ED concerning opioids here: http://www.medicine.wisc.edu/~williams/drugseeking.pdf) in part because we lack universal electronic medical records and in part  because we do not systematically track those who leave our EDs in search of help somewhere else. As for the latter, I have to wonder if if it is  because we do not want to know. There is some safety in not knowing.  Maybe we don't have to do anything about things we don't quantify.  And, if we don't qualify the DSB concept, we don't have to struggle with the fine line between health seeking behavior and drug seeking behavior.

Several months back,health law listserves were circulating a new kind of ED sign designed to warn those engaging in DSB away from certain EDs.  You can see a version of this sign as found in a hospital ED in Milwaukee, Wisconsin here:  http://www.jsonline.com/watchdog/watchdogreports/ers-in-milwaukee-county-restricting-opioid-prescriptions-if6m4m4-168328376.html.

What is interesting about the sign is that attempts to split the hair between reasonable and rational use of opioids in the ED with the requirements of EMTALA (the Emergency Medical Treatment and Labor Act). Severe pain, after all, deserves medical treatment as does its underlying condition, the latter of which can be masked by treating only the former.  So does drug addiction or drug withdrawal, though it is unclear whether the ED is the best place to provide treatment for any of these concerns.

Tapping into this dual nature of the ED — emergency care for some, sole source care for others– may have been what prompted HHS to indicate the linked sign might be problematic under EMTALA. CMS's Atlanta Regional Office indicated the sign might be problematic under EMTALA as far back as April, 2013.

And that's the rub. The ED is the only place for treatment for some individuals in our society.  This makes reasonable and rational signs, such as the one linked above,  designed to keep emergency medicine distinct from other kinds of specialty care problematic. We don't have a universal primary care system to plug people into, thereby rationalizing the limited role of ED physicians in chronic pain management.

We want it all from our EDs and those who staff them: genuinely emergent care and chronic care for those with nowhere else to go, all in one of the most expensive venues in which to receive health care in the world.