Articles

Roneet Lev, MD
IEPC Executive Director

SB 864 Tyler’s Law was signed by Governor Newsome in September, 2022. Starting January 1, 2023, all hospitals in California must include fentanyl whenever a urine drug screen is ordered.

Tyler visited a emergency department in California and was assured that his drug screen was negative. Tyler’s mother Juli asked the emergency physician if the drug test included fentanyl and was given false reassurance. The emergency doctor did not realize that an opiate drug screen does not cover synthetic opioids such as fentanyl.

Juli Shamesh, Roneet Lev and Senator Melisssa Melendez are three mothers who came together
with difference expertise to carry and pass this law.

Tyler’s law does not require drug testing, it just requires fentanyl to be included along with THC, Methamphetamine, Benzodiazepines, or whatever the hospital is currently including. The fentanyl reagent costs 75 cents, a minimal financial investment. The California ACEP website includes a fentanyl testing tool kit to teach hospital laboratories how to test for fentanyl.

Here are some ways a positive fentanyl test can affect your clinical interaction with patients.

1. Inform your patient of their positive test. Some patients knowingly use fentanyl, but others may think they are using methamphetamine, cocaine, Xanax, Adderall, Marijuana, or something else. When you tell your patients that they tested positive for fentanyl,
   they may go home and act upon that information. They may dispose of counterfeit pills saving other people or decide to make a change in their life.
2. Provide a prescription for naloxone to the patient, family or friends. Anyone who uses drugs, any drugs, should have naloxone. Naloxone only works for opioids, but fentanyl has infected a vast part of all drugs and therefore is indicated. Just like giving antibiotics to STD partners, you should give naloxone to family and friends who use drugs.
3. A positive test for fentanyl is an opportunity to talk about addiction treatment. Patient may have an opioid use disorder and warrant connection to Medication Assistant Treatment. If not addicted to opioids, they may warrant treatment for substance use disorder. Starting this conversation in the emergency department can make a big impact, especially coming from the doctor.
   • New story from OC Register
   • Fox LA – California becomes 1st in US to include fentanyl testing in ER
   • High Truths on Drugs and Addiction Podcast #99 will feature the 3 Moms who helped pass Tyler’s law.

Dr. James Keaney, Emergency
Physician, Author The Rape of
Emergency Medicine

The sole purpose of the Institute for Justice in Emergency Medicine (IJEM) is to decolonize the nation’s emergency departments from the rapacious slumlords posing as Wall Street-traded corporations known as contract management groups (CMGs), hedge funds and pseudodemocracies offering so-called services which front for the imposition of unnecessary third-party middlemen. These exploitationists are not only toxic to emergency physician well-being and resiliency but also constitute a public-health detriment to the communities in which the hospitals are located.

We propose a federal lawsuit against the Centers for Medicare and Medicaid for violation of the original intent of the Medicare Act of 1965 passed by both houses of Congress and signed into law by President Lyndon Johnson. The current transmutation or misallocation of Medicare-approved, clinically generated fees by bedside emergency physicians into vast administrative wealth for nonclinical work-and-make-work provides zero-point-zero real benefit to the American patients or to the clinical emergency physicians. Moreover, it constitutes a public health detriment to the communities in which the hospitals are located.

This is the central premise of the lawsuit; Institute for Justice in Emergency Medicine (IJEM) versus United States Secretary of Health and Human Services.

The gross violation of the original intent of the Medicare Act of 1965 is the diverting of taxpayer money which is specifically designated to pay bedside physicians to provide healthcare to the “Joe-the-Plumbers” and “Rosie the Riveters” of America to corporations providing emergency medical care according to the dictums of Bernie Madoff rather than the Oaths of Hippocrates and Maimonides. Tens of millions of dollars of Medicare money is being wasted on slick advertisements by CMGs to send scores of men in crisp blue suits with red ties and women in well accessorized Saks Fifth Avenue outfits to traipse all over the nation trying to outwit and capsize stable independent emergency medicine groups knowing full well the CMGs gumbo of doctors and their “Kulture” offer nothing but profits for the mothership with staggering commissions for themselves. This phenomenon of Mad Men marketing is undermining quality emergency medical care.

Sixty years of “separate but equal” didn’t work but ended up with Brown v Board of Education; sixty-five years of communism collapsed with the fall of the Berlin Wall; 45 years of CMGs hasn’t worked now requiring IJEM v HHS.

Currently, the attempts to reverse engineer the current perverse system which provides maximum passive income for a few shareholders and speculative hedge-funders have not been fruitful. The neurosurgeons who clip the most aneurysms and remove the most brain tumors have the highest income but the emergency physicians seeing the fewest emergencies make the most money. In the upside-down world of EM, making incremental changes is like Waiting for Godot. The medical crime of the century is happening before our eyes. And, in only one specialty. We need to reweigh the payment system for the benefit of patients and clinical physicians. A single court order would change the system into a civilized delivery of emergency medical care overnight which, indeed, was the original intent of the congressional act.

Methamphetamine (meth) is the number one killer in San Diego County among those using drugs, and a significant driver of violence in the community. Nationwide, meth is the fastest growing drug of abuse, representing over 798,000 annual emergency department (ED) visits, with deaths increasing 14-fold since 2015 (32,856 deaths in 2021 alone), yet no therapeutics are available. There is an urgent need for a safe rapidly acting antidote for methamphetamine.

With support from the National Institute on Drug Abuse (NIDA), Cambridge, MA-based Clear Scientific (www.clearsci.com) is developing an antidote for meth for use in the ED. This small molecule therapeutic, CS-1103, reverses meth intoxication by sequestering it in the plasma compartment and removing it from the central nervous system effect site. The now ‘inactive’ meth is eliminated from the body by filtration in the kidney. Rapid sequestration and clearance of meth reverses its effects. This mechanism of action is similar to Sugammadex (BRIDION®), a reversal agent for neuromuscular blockade. Unlike antibody-based treatments, CS-1103 not only binds harmful substances, but also rapidly removes them from the body – “Remove the Cause, Remove the EffectTM”. CS-1103 is formulated for intravenous injection for use in the ED.

In nonclinical studies, CS-1103 was highly effective in lowering the level of meth and rapidly reversing its toxic effects. CS-1103 has an excellent safety profile in Good Laboratory Practice (GLP) studies with rapid clearance and has been produced at scale under Current By Clear Scientific Good Manufacturing Practice (cGMP).

It is anticipated that the Phase 1 and 2/3 Clinical Trials will be completed in 2023 and 2024, respectively, with availability to ED physicians by late 2024.

For more information, please listen to the discussion between Dr. Roneet Lev and the Clear Scientific team on the High Truths podcast [Episode 91 September 19,2022].

IEPC is proud to present the 2022 Speaker Series! This free speaker series welcomes leaders in the field to cover timely and engaging topics that are important to independent emergency physicians. The sessions will precede each monthly conference call and are open to all IEPC members and those who may be interested in joining.

In May, IEPC welcomed Sheree Lowe from the California hospital Association to discuss updates and insights for the future.

This series is presented on the fourth Monday of the month January – November. Advance registration is required and can be completed by registering through the monthly email invitation. After registering, you will receive a confirmation email containing information about joining the meeting.

To view the full July 2022 newsletter click here.

Andrew Fenton, MD, FACEP was elected Chief of Staff at Queen of the Valley Medical Center serving nearly 400 medical staff members. Queen of the Valley is a full-service diagnostic and therapeutic hospital with 191 licensed acute care medical beds that employs over 1,200 people. Dr. Fenton is a partner of Napa Valley Emergency Medical Group which has provided acute care to the Napa community since 1974, and was one of the founding groups of IEPC.

To view the full July 2022 newsletter click here.