Four Barriers to Treating Substance Abuse Disorder in the Emergency Department and How to Overcome


Catherine Mather, Institute for Healthcare Improvement

We all know that the emergency department is the simplest, most relaxed place in a hospital. Given this, it should be easy to treat and refer patients with substance abuse disorder, right? Of course not!

In fact, it’s so complex that I have yet to find any U.S. hospital that allows patients to be identified, treated, and transferred with any degree of consistency and predictability. But it can be done.

To start, let’s walk through some of the four barriers that I hear most often, and talk about how to address them. Once you’re ready to get started, refer to this Play for step-by-step guidance

Barrier 1: Patients don’t want to be treated.

I hear this relatively often from nursing, clinical staff, and EMS. It’s unsurprising that patients would want to run away from the ED after a Narcan injection makes them feel like their entire bodies are on fire. Most patients with an opioid use disorder arrive to the ED after having been reversed from an overdose, and they’re in profound withdrawal. In addition, the stigma and frustration of addiction has led providers to blame patients for their disease, sometimes bringing a condescending and dismissive attitude into their conversations with patients, which doesn’t help. For the subset of patients in opioid withdrawal, immediate treatment for the physiological symptoms of withdrawal is of the utmost importance. In my experience, the clear majority of patients actually want to be treated, but they would like to be treated respectfully and with evidence-based medicine. Overall, just stabilizing a patient’s withdrawal and having an empathetic conversation with them will alleviate that immediate desire to go back out to the street in use.

Barrier 2: We don’t have the training for it.

This one is just funny to me, given that every time we have a new way to intubate patients, use ultrasound for a pain intervention, or pack a patient and in ice because there’s a possibility that it might improve cardiac outcomes, we whisk off half of the ED staff to get trained in these modalities. There are a plethora of online courses and in-person trainings covering treatment for substance use disorder.

Barrier 3: We don’t get paid for it.

Patients with some degree of insurance who arrive in the ED in need of emergency care can have their care paid for. The treatment of this disorder gets evaluated and billed no differently than any other disorder in the setting of the ED. It’s billed as a 992 code and a standard facility code.

Barrier 4: If we start treating it, then all “those patients” will show up to our emergency department.

Surprise, they are already there! We have just failed to set up the capacity and capability to treat them. This is also an interesting argument given that if we had any other large market desiring a certain type of medical intervention, then we would build out an entire line of service around it. This is where I believe health systems have not taken a good hard look at the business case for developing all the levels of treatment for substance abuse disorder in house.

These are just a few of the common questions that come up in regards to building out a full line of service in the emergency department for patients suffering from substance abuse disorder. This Play takes a much deeper dive into how to approach this patient population in the emergency department by looking at recently developed protocols that can be integrated relatively quickly into the ED. It also discusses questions of legality around the utilization of buprenorphine, as well as the personnel required to do an adequate job of evaluation and treatment of these patients.

For now, I’ll leave you with this thought: we’ve built protocols, pathways, and highly intricate interventions for some of the most complex diseases ever identified by man. This is the next problem to solve, and we have the capability and capacity to do it if we utilize the same techniques that allowed us to retrieve a clot out of the brain, put stints in the blood vessels around the heart, and to transplant organs. It won’t happen overnight, but it can be done.