Patients with opioid use disorder often present to the ED, sometimes after overdosing, and other times with completely unrelated conditions.
“The emergency medicine community is certainly at the forefront of this patient struggle with narcotic use disorder,” says Rade Vukmir, MD, JD, FCCP, FACEP, FACHE, president of Critical Care Medicine Associates.
Failure to adhere to established care protocols is the most significant legal risk for ED providers. “This may manifest as a broad range of allegations, typically including standard negligence theories — failure to diagnose or failure to treat,” Vukmir says.
There also could be EMTALA-based allegations concerning failure to stabilize or transfer. The mindset in the ED needs to change, says Vukmir, “to view opioid use disorder as a long-term, pervasive illness. Our goal is really to get people in the right treatment category.”
Patients with pneumonia or chest pain are treated according to diagnostic and treatment protocols. “This situation [opioid use disorder] should be no different,” Vukmir says.
However, an extrinsic regulatory requirement adds to the difficulty of treating these patients. Currently, any EP who wants to prescribe buprenorphine after discharge has to take an eight-hour educational course, apply for a license addition with the DEA, and receive an X-waiver. “Not all EPs are interested in applying for this waiver, and are limited to dispensing doses in the ED for up to 72 hours, as opposed to writing ongoing care prescriptions,” Vukmir says.
Removing barriers to care for patients struggling with opioid use disorder is a priority for the American College of Emergency Physicians (ACEP). “The rate of overdose deaths during the pandemic has accelerated. Now is the time to make sure that frontline physicians are well positioned to continue efforts to reduce overdose rates and save lives,” says Jeffrey Davis, ACEP’s director of regulatory affairs.
“There are clear outcome data that shows mortality is less for patients in medication-assistant treatment,” Vukmir notes. This raises the possibility that EPs who do not offer medication-assisted treatment to patients who present with opioid use disorder face potential legal exposure for failing to meet a perceived standard of care.
The plaintiff could argue that a reasonable EP would have offered medication-assisted treatment to the patient. Now that there is an established treatment pathway, EPs will be held to the perceived standard of care. “However, it is crucial to realize these pathways are complicated. They require significant individualization to patients’ condition, institutional resources, and significant patient compliance,” Vukmir says.
In addition, the standard of care still may be regional in some respects, depending on available resources and government financial support. Some EPs met the requirements, chose to become certified, and provided medication-assisted treatment, while others opted out. Originally, the certification process was directed toward established outpatient clinics with care provided by addiction medicine specialists.
“We now have an ED care standard that may be established,” Vukmir says. “It’s not an individual variation situation anymore. Saying you are just not going to participate in this is probably not a viable pathway forward.”
EDs will need treatment guidelines for medication-assisted treatment, just as with any other disease-driven protocol. “The sooner that the facility tackles this and gives EPs a clear pathway to approach this, the better,” Vukmir offers.
Dosage is highly variable depending on the individual patient. It is not enough to come up with a one-time dose and send the patient home. “It’s a brand-new, exciting area of medicine, but it’s extremely complicated medicine. It will require time and investment to master and become proficient in,” Vukmir observes.
ED providers still should complete the certification training, regardless of whether it continues to be required in the future, according to Vukmir. “It would demonstrate added commitment, which is always a good thing,” he adds.
For a patient who presents after an overdose, ideally, the EP can give medication in the ED, then discharge the patient with an initial prescription and follow-up with an outpatient treatment source. “You can’t just give the medicine and discharge the patient without adequate follow-up,” Vukmir says. “It’s essential that the entire facility system be geared up to treat this disease condition.”
That means a treatment program with addiction experts and counseling. However, the patient has to be able to access it, and the programs need to be adequately funded. If there is a three-month delay in the outpatient psychiatry network, or the patient cannot afford the treatment, “that’s not going to work,” Vukmir warns.
Involvement from case management and social services is needed to enhance the outpatient clinic transition and prevent frequent ED visits. “The goal is to not have the patient necessarily return to the ED every day,” Vukmir says.
Some programs may use the ED to stabilize the patient on an episodic basis over a 72-hour period. “However, once they are stabilized, it’s best if they are treated in an outpatient setting,” Vukmir suggests.
A well-run program will allow the providers to do what they do best. That means the ED provides immediate stabilizing care, and the outpatient system provides outgoing maintenance, counseling, and psychological support. The ED is not operating in a vacuum within the hospital. “This is a bridge program. It is not the endpoint. And it’s helping the patients bear responsibility here as well. We will provide medication-assisted treatment pathways under the assumption that they complete the rest of the protocol,” Vukmir says.
An ED visit from someone with opioid use disorder is an opportunity to put that person in treatment. People do not present to the ED when things are going well; they present at times of crisis. “Sometimes, in that crisis, there’s a little bit of a wakeup,” Vukmir observes. “If the system offers some approaches and a treatment pathway, then everybody benefits.”