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March 2018 President's Message - Substance Use Disorder Treatment in the ED
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4/19/2018 at 9:56:33 PM GMT
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March 2018 President's Message - Substance Use Disorder Treatment in the ED

Substance Use Disorder Treatment in the ED

By Aimee Moulin, MD, FACEP

When I was a resident at LA County Hospital, one of our frequently flyers - I’ll call her Janet - was an intermittently homeless women in her mid 40’s with bright blue eyes and wavy, gray brown hair. Janet would complement my earrings or shoes in a way that you could tell she had once cared a lot about her looks. She’d lived for many years with addiction to alcohol, benzos, and opiates. Perhaps Janet sold the Norco we gave her; she was once caught trying to buy another patient’s shoes in exchange for her Norco. Janet could be manipulative, belligerent, and occasionally combative; but we took care of her so often in the emergency department (ED) we’d come to adopt her. Sometimes on my way to work I’d give her $5 as I passed her panhandling in front of the hospital. She was a permanent fixture of my residency, until the day she was found dead alone in a hotel room. In the hundreds of times I had taken care of Janet not once did I talk to her about addiction, or offer treatment for her substance use disorder.


According to the 2014 National Survey of Drug Use and Health, 20.2 million Americans have a substance use disorder.1 It will not surprise anyone who has worked in an ED that substance use disorders are highly prevalent in ED populations.2 The Drug Abuse Warning Network (DAWN) estimated there were 5.1 million drug related ED visits in 2011.3 The actual number of ED patients with substance use disorders is likely much higher.4-6 In one multi-center study, as many as 64% of adult ED patients met criteria for problematic substance use.6 Yet, few are in treatment.4,7

Patients with untreated substance use disorders are 81% more likely to require hospitalization during their ED visit and 46% more likely to have had an ED visit in the prior year, with the estimated additional hospital charges numbering $777.2 million.7 Patients with substance use disorders are over represented in our high-utilizer populations.8,9 We often have multiple opportunities to intervene and address the underlying reasons for the ED visit.

There is a growing body of evidence to support ED interventions for substance use. Recent studies have shown cost-savings, decreased substance use, and increased engagement in treatment programs after Screening, Brief Intervention, and Referral to Treatment (SBIRT).10-13 Specifically for patients with opiate use disorders, medication-assisted treatment (MAT) has shown decreased mortality.14 For patients with opiate use disorders, EDs are often the primary access points. EDs already have an important role in opiate overdose reversal and treatment for complications related to opiate use.15 An ED intervention and initiation of treatment with Buprenorphine increases engagement in treatment.16

As much as the focus of opiate use disorders has been on physician prescribing practices, the causes of addiction are multi-factorial. However, EDs are perhaps uniquely positioned to participate in the solution. EDs have an important role in identifying patients with substance use disorders and linking patients to treatment. We are acutely aware of the consequences of substance use disorders and it is time that we intervene to prevent the inevitable consequences.

There are challenges. As a specialty we are facile with acute intoxication and withdrawal syndromes, but not screening and treatment. Finding the time in a busy ED shift to have a meaningful conversation on addiction and identifying appropriate outpatient follow-up can feel like an overwhelming barrier. Often, we are tempted to turn a blind eye rather than confront what we know to be true. We can’t do this alone; resources such as substance use counselors and tele-health are vital to filling these gaps. Our Chapter has taken on this challenge to bring tools and resources to our EDs to make this possible. As a first step we’ve put together information on buprenorphine with the California Healthcare Foundation, which you can find on the next page.

The Chapter is sponsoring a budget allocation to create a statewide pilot program that places certified drug and alcohol counselors in each of the roughly 325 EDs throughout California. At an estimated $50,000 per counselor, the cost of the pilot program would be $20 million. My ED has a certified drug and alcohol counselor, paid for by the University of California, and we have seen a remarkable impact. The patient testimonials motivate me to fight to expand access to substance use counselors across the state.

There is a lot of work to be done and I look forward to hearing from you about your experience. My patient from residency might not have been amenable to treatment, certainly not on her first visit, but she did give me multiple opportunities to intervene. It is time we start the conversation.




  1. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health Substance Abuse and Mental Health Services Administration; September 2015 2014.
  2. Wu LT, Swartz MS, Wu Z, Mannelli P, Yang C, Blazer DG. Alcohol and drug use disorders among adults in emergency department settings in the United States. Annals of emergency medicine. 2012;60(2):172-180.e175.
  3. Crane EH. Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. The CBHSQ Report. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2013:1-9.
  4. Rockett IR, Putnam SL, Jia H, Smith GS. Assessing substance abuse treatment need: a statewide hospital emergency department study. Annals of emergency medicine. 2003;41(6):802-813.
  5. Rockett IR, Putnam SL, Jia H, Smith GS. Declared and undeclared substance use among emergency department patients: a population based study. Addiction (Abingdon, England). 2006;101(5):706-712.
  6. Macias Konstantopoulos WL, Dreifuss JA, McDermott KA, et al. Identifying patients with problematic drug use in the emergency department: results of a multisite study. Annals of emergency medicine. 2014;64(5):516-525.
  7. Rockett IR, Putnam SL, Jia H, Chang CF, Smith GS. Unmet substance abuse treatment need, health services utilization, and cost: a population based emergency department study. Annals of emergency medicine. 2005;45(2):118-127.
  8. Capp R, Rosenthal MS, Desai MM, et al. Characteristics of Medicaid enrollees with frequent ED use. The American journal of emergency medicine. 2013;31(9):1333-1337.
  9. Urbanoski K, Cheng J, Rehm J, Kurdyak P. Frequent use of emergency departments for mental and substance use disorders. Emergency medicine journal : EMJ. 2018.
  10. Pringle JL, Kelley DK, Kearney SM, et al. Screening, Brief Intervention, and Referral to Treatment in the Emergency Department: An Examination of Health Care Utilization and Costs. Medical care. 2018;56(2):146-152.
  11. Barata IA, Shandro JR, Montgomery M, et al. Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review. The western journal of emergency medicine. 2017;18(6):1143-1152.
  12. Bruguera P, Barrio P, Oliveras C, et al. Effectiveness of a specialized brief intervention for at-risk drinkers in an Emergency Department. Short term results of a randomized controlled trial. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2018.
  13. D'Onofrio G, Fiellin DA, Pantalon MV, et al. A brief intervention reduces hazardous and harmful drinking in emergency department patients. Annals of emergency medicine. 2012;60(2):181-192.
  14. Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ (Clinical research ed). 2017;357:j1550.
  15. Weiss AJ, Bailey MK, O'Malley L, Barrett ML, Elixhauser A, Steiner CA. Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014: Statistical Brief #224. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006.
  16. D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. Jama. 2015;313(16):1636-1644.

Last edited Thursday, April 19, 2018
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