The emergency department (ED) can be the “first, and sometimes only” interaction that people with substance use disorders (SUDs) have with the health care system.
Integrating SUD care into EDs can connect these patients to crucial long-term care. Still, co-occurring conditions, stigma and polysubstance use are among the main barriers preventing efficient integration.
The ED is a crucial link to getting patients into long-term SUD care, Dr. Jarrett Burns, an emergency physician and a medical toxicologist at Tidelands Health, told Addiction Treatment Business. Burns approximates that 10% of the patients he encounters have a SUD.
“The emergency department is the only place that has the lights on and the doors open 24 hours a day,” Burns said. “On a day-to-day basis, there’s probably not an overnight shift that goes by that I don’t see patients with substance use disorder of some sort.”
Tidelands Health is a health care provider with four hospitals and 70 outpatient locations in South Carolina.
How to care for SUD patients in EDs
Integrating SUD care into EDs starts with screening. Screening processes often begin with nurses asking patients about their substance use to begin the process of determining if a patient has an SUD.
Vituity, an acute care provider that partners with emergency departments and other health care organizations, integrates SUD offerings into its ED services through an approach called SBIRT, which stands for screening, brief intervention, and referral to treatment.
“This model ensures that patients presenting with SUDs are identified early and provided with immediate care and resources,” Dr. Herbert Harman, associate vice president of psychiatry at Vituity, told ATB in an email.
Emeryville, California-based Vituity partners with hospitals, health systems, clinics, payers, employers and state and local governments to provide services, including acute psychiatry, telehealth and outpatient medicine. The company has a network of 5,000 clinicians and cares for more than nine million patients.
Vituity also leverages medication-assisted treatment (MAT) protocols to initiate SUD care while a patient is still in the ED.
In some circumstances, an ED clinician can prescribe a single dose of buprenorphine, a practice that is widely recommended. In these cases, patients ideally receive a follow-up appointment the next day before the dose of buprenorphine has worn off.
However, offering patients life-saving medicines is only the start of sufficient SUD care in EDs.
“I’ll prescribe all the pharmacologic things like Narcan and buprenorphine, but that’s [just] the immediate effects,” Burns said. “Layering with social workers, addiction navigators and specialists is really the key. Getting all hospitals to have the resources and the funding to have those people on site is huge.”
At Tidelands Health, peer recovery coaches and navigators work directly with patients to screen patients at risk for SUD or meet with patients who came to the ED for an overdose.
These professionals can follow up with patients who receive medication and check to see if they are getting their refills, ensure they have transportation for outpatient health visits and help connect patients with local SUD care.
Building relationships between EDs and local treatment organizations is essential to promote long-term recovery, Harman said.
It’s difficult to tell how many patients who present with SUDs in the ED are actually connected to care, Burns said. He approximates 10% to 20% of SUD patients have high rates of recidivism, but otherwise, he can’t tell who successfully initiates a treatment program.
Barriers to SUD integration
Providing SUD care and connections to further treatment in the ED is crucial, but comes with significant challenges.
EDs face limited resources, insufficient staffing and a lack of specialized training, according to Harman.
“There are also systemic barriers, such as inadequate follow-up care and fragmented coordination between emergency and outpatient services,” Harman told ATB in an email. “Additionally, the fast-paced, high-pressure environment of the ED can make it difficult to provide the comprehensive support needed for SUD patients.”
Clinicians also must grapple with patients who present with multiple behavioral health conditions, including SUD and mental health conditions.
People with SUDs are more likely to develop mental health conditions as well as primary conditions or chronic diseases, according to SAMHSA. Diagnosis of multiple conditions, known as co-occurring disorders, leaves ED clinicians juggling multiple variables while trying to maintain a quick pace.
As well as being likely to have co-occurring disorders, patients also often have polysubstance use, which involves regularly using more than one type of drug, Dr. Arun Gopal, national medical director of outpatient care and consultation and liaison psychiatry at Access TeleCare, told ATB.
“Polysubstance use is usually the norm more so than one drug,” Gopal said. “These folks can come in very psychotic. They can be paranoid, they can be having hallucinations.”
Dallas, Texas-based Access TeleCare provides acute and specialty telehealth services by working with hospitals, outpatient clinics and physician practices. Access TeleCare includes care in various specialties, including behavioral health, neurology and endocrinology.
Issues like polysubstance use and co-occurring conditions can be even more difficult in the fast-paced environment of the ED.
On top of those issues, ED clinicians themselves can have preconceived notions that hinder effective care for patients with SUD, Harman told ATB.
“Whether it’s a fancy academic medical center or you’re talking about a rural hospital, there’s a lot of bad perceptions about polysubstance use, drug use, opioid use in the medical staff in general,” Gopal agreed.
Clinicians and staff do receive education designed to mitigate stigma and bias. Almost every state requires continuing education when clinicians renew their licenses, Burns said.
To address problems including stigma, SUD programs require more funding, ED staff need enhanced training and standardized protocols must be established, Harman said.
“When all clinicians and staff show up expecting that identifying patients at risk and initiating MAT will be part of their day, it becomes natural and automatic,” Harman said. “It cannot be something that might be misunderstood as unnecessary, something that slows things down. Nobody wants to slow down the ED, so everyone has to be educated and agree to participate.”
