The emergency department (ED) often serves as the first, and sometimes only, point of contact with the healthcare system for individuals struggling with substance use disorders (SUDs). For many, this is their first interaction with medical professionals, and for others, it may be their only chance to receive the care and resources they need. Yet, integrating SUD care into EDs is far from straightforward, as it comes with a host of barriers, including co-occurring conditions, stigma, and polysubstance use. However, integrating this care offers a vital opportunity to connect patients with long-term treatment options, making it a critical element of the healthcare system.
The Role of Emergency Departments in Addressing SUDs
Dr. Jarrett Burns, an emergency physician and medical toxicologist at Tidelands Health in South Carolina, is one of the many healthcare professionals who see firsthand the significant role emergency departments play in the care of individuals with substance use disorders. According to Dr. Burns, approximately 10% of the patients he encounters in the ED have a substance use disorder. As he points out, the ED is often the only healthcare facility with the doors open 24 hours a day, 7 days a week, making it a critical access point for those who need immediate assistance.
“The emergency department is the only place that has the lights on and the doors open 24 hours a day,” said Dr. Burns. “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.”
Given the unique position of EDs as a constant source of care, they have the potential to provide crucial interventions that can bridge the gap between emergency treatment and long-term recovery for individuals with SUDs. Yet, integrating care for substance use disorders into the ED presents a number of complex challenges.
How to Care for SUD Patients in EDs
Effective integration of SUD care begins with comprehensive screening. In many hospitals, nurses start the process by asking patients about their substance use as part of the initial assessment. Early identification of SUDs is vital for determining the most appropriate course of treatment.
Dr. Herbert Harman, associate vice president of psychiatry at Vituity, an acute care provider that partners with emergency departments, describes the importance of the SBIRT model in integrating SUD care. SBIRT stands for screening, brief intervention, and referral to treatment, and it ensures that patients who present with substance use disorders are not only identified early but also provided with immediate care and resources.
“SBIRT ensures that patients presenting with SUDs are identified early and provided with immediate care and resources,” Dr. Harman explained.
In addition to the screening process, some emergency departments, such as those working with Vituity, also offer medication-assisted treatment (MAT) protocols, which allow clinicians to initiate care while the patient is still in the ED. Buprenorphine, a medication often used to treat opioid addiction, can be administered as a single dose to help manage withdrawal symptoms, with follow-up appointments arranged the following day to ensure continuity of care.
However, while prescribing life-saving medications like buprenorphine is a key step in immediate care, Dr. Burns emphasizes that it’s not the complete solution. For long-term success, EDs must ensure that patients have access to the full range of support services, such as social workers, addiction navigators, and specialists, who can provide more comprehensive assistance.
“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.”
At Tidelands Health, peer recovery coaches and navigators play a central role in connecting patients with the resources they need after their ED visit. These professionals work directly with patients at risk for SUD or those who came to the ED for an overdose, helping them access follow-up care, ensure they have transportation to outpatient appointments, and connect them with local treatment programs.
Building Relationships with Local Treatment Providers
While immediate interventions in the ED are critical, long-term recovery is most successful when there is ongoing support and a connection to appropriate treatment programs. Dr. Harman stresses the importance of building strong relationships between emergency departments and local SUD care organizations. These partnerships are essential for creating a seamless pathway from emergency care to recovery.
Yet, according to Dr. Burns, it remains challenging to track how many patients who present with SUDs in the ED are successfully connected to long-term care. He estimates that between 10% to 20% of patients with substance use disorders experience high rates of recidivism, returning to the ED multiple times, but it’s difficult to ascertain how many successfully initiate a treatment program.
Barriers to Effective Integration of SUD Care in EDs
Integrating substance use disorder care into emergency departments is crucial, but it comes with several significant barriers that can hinder its effectiveness. Dr. Harman highlights several challenges, including limited resources, insufficient staffing, and a lack of specialized training for ED clinicians. In addition, the fast-paced, high-pressure environment of the ED can make it difficult to provide the level of comprehensive care that patients with SUDs often require.
Another major challenge is the prevalence of co-occurring disorders. People with SUDs often suffer from other behavioral health conditions, including mental health disorders, making diagnosis and treatment even more complicated. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), individuals with SUDs are at a higher risk for developing mental health conditions, chronic diseases, and other primary conditions, leaving ED clinicians to juggle multiple health issues at once.
Adding to the complexity is the issue of polysubstance use. Patients often use more than one substance, which can lead to more severe symptoms and higher levels of intoxication. Dr. Arun Gopal, national medical director of outpatient care and consultation at Access TeleCare, notes that polysubstance use is common among those with substance use disorders and can complicate both diagnosis and treatment.
“Polysubstance use is usually the norm more so than one drug,” Dr. Gopal said. “These folks can come in very psychotic. They can be paranoid, they can be having hallucinations.”
This makes it even more difficult to provide the necessary care in a fast-paced ED environment. Polysubstance use, along with co-occurring mental health conditions, can make it harder for clinicians to effectively assess and treat patients within the constraints of time and resources available in the ED.
Addressing Stigma and Bias in SUD Treatment
An often-overlooked barrier to integrating substance use disorder care into the ED is the stigma that patients with SUDs face. Many ED clinicians harbor preconceived notions or biases about people with substance use disorders, which can interfere with the provision of effective care. Both Dr. Harman and Dr. Gopal point out that negative perceptions of drug use, particularly opioid use, are prevalent among healthcare providers.
“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,” Dr. Gopal observed.
To combat this, it is critical that ED staff receive ongoing education about substance use disorders and the importance of treating patients with respect and empathy. Dr. Burns notes that almost every state mandates continuing education for clinicians when they renew their licenses, and this often includes training on how to mitigate bias and stigma.
According to Dr. Harman, one key to reducing stigma and improving care is having standardized protocols in place, ensuring that identifying patients at risk and initiating treatment becomes a natural part of the ED workflow.
“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,” Dr. Harman said.
Conclusion: The Path Forward
Integrating substance use disorder care into emergency departments is a vital step in bridging the gap between immediate treatment and long-term recovery. While the process is not without its challenges, including limited resources, co-occurring conditions, and stigma, EDs have a unique opportunity to connect patients with the care they need. By embracing screening, medication-assisted treatment, and partnerships with local treatment providers, emergency departments can play a key role in improving the long-term outcomes for individuals with substance use disorders.
As the healthcare landscape continues to evolve, it is essential that EDs receive the support, resources, and training necessary to address substance use disorders in a compassionate and effective manner. By doing so, we can help ensure that those struggling with addiction are not just treated in the moment but are also given the tools they need to succeed in their long-term recovery journey.
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