The physician would then decide if any additional workup is needed to determine if an emergency condition exists. But every time known chronic pain patients or potential drug seekers present to the emergency department, they must be put through the usual process and physician examination to determine if an EMC is present.¹ Avoid the error of not providing these patients with your usual competent and thorough medical/neurological examination each and every time they present.

Once the MSE reveals the pain is not indicative of a serious medical condition needing immediate medical attention, the care from that point forward is not controlled by EMTALA. Therefore, the emergency physician has no risk under EMTALA for discharging paatients without prescribing requested narcotics or any other medication.

Dealing with chronic pain patients or drug seeking patients is always difficult. To address the issue, a number of states convened emergency provider workgroups to establish opioid management protocols for the emergency department. For one example, see the Washington State ACEP Chapter/Washington State Department of Health opioid prescribing guidelines available at www.washingtonacep.org/painmedication.html. ACEP released opioid prescribing guidelines last year, available online at: www.acep.org/Clinicalpolicies

Q: Is there any obligation under EMTALA to refill pain medication prescriptions?

A: No. “I lost my pain medicine prescription” is a frequent complaint in the emergency department. There is no legal obligation to refill anyone’s pain prescriptions. However, the patient with the “Rx Refill” complaint, whether it is for pain meds or any other medicine, must still undergo a medical screening examination to determine if an EMC exists.³ If there is no EMC, EMTALA ends, and the physician can use his or her medical judgment to decide whether or not to provide the prescription.

Q: During triage, can the triage nurse or a hospital case manager inform patients that they have X number of emergency department visits this year and they are being monitored by a statewide ED visit management system? Or, can a chronic pain patient be told in advance of the MSE by the emergency physician that his regular doctor has left instructions with the emergency department not to use opioids?

A: No! Only after the MSE has been completed and reveals no EMC can this type of information be given to the patient. CMS will not allow hospitals to do anything that may “unduly discourage” the patient from staying in the emergency department to receive a medical screening exam.⁸ There is no question that the hospital’s intent in providing this information, at least in part if not in total, is to discourage the patient from being seen. Furthermore, from a medical or patient safety perspective, how can you be sure that the patient doesn’t have a real EMC at this moment without conducting a proper medical examination? Even those who cry wolf will eventually experience a life-threatening event.