Should Emergency Rooms Follow this Model for Treating Addiction?

Should Emergency Rooms Follow this Model for Treating Addiction?


There are a few hospitals out there today, including one in New York, that is attempting to divert potential opiate addicts into treatment–right when they discover an inkling of the problem at the emergency room.

The New York Times says about one particular ER: “Their aim is to plug a gaping hole in a medical system that consistently fails to provide treatment on demand, or any evidence-based treatment at all, even as more than two million Americans suffer from opioid addiction. ”

So the idea is that if someone comes into the emergency room and they have obviously, for example, cut themselves in order to try to seek opiate based medication, then we should not be ignoring this situation completely. The ER workers will handle such a situation and in some cases they will turn the drug seeker away without any opiates, and other times they will go ahead and pump them full of painkillers and maybe even write a prescription for Vicodin. But either way, what is not happening (yet) in most hospitals is that there is no intervention done at this time.

This is a missed opportunity in the fight against opiate addiction.

So what some hospitals are trying to do is to create an intervention opportunity right at this first point of contact, when the addict comes into the emergency room.

So they are doing that through various tactics: First, they start to train their ER workers to notice certain signs of potential addiction, such as drug seeking behavior or self harm injuries. Then they can also try to use a more sophisticated pain scale, so that they can objectively measure the real pain of a person who might be “putting on a show” in order to try to seek out stronger drugs.

The hospital may need to have more social workers on hand, potentially at any and all hours of the day and night, in order to facilitate such an intervention. So if someone shows up and they believe that they are a good candidate to be diverted into some form of treatment, they can have a social worker available to work that out.

Ideally, the hospital would have treatment services right on site. This is somewhat rare, however, so most hospitals–if they are truly trying to set up this type of intervention–would need to partner with local inpatient treatment centers, so that they have a place to divert a potential addict to.

So it might work out like this: An ER worker at the hospital has a patient who has come in and is obviously very drug seeking. They are complaining of severe headaches and they are arguing that non-opiate medications do not help them at all. They also have track marks on their arms and the ER worker has also caught a glimpse of what looks like a “rig,” or the needle and spoon kit that is used to shoot heroin. At this point, the ER worker could summon a social worker or interventionist that specializes in this kind of situation, and that person would come in and try to convince the addict to seek help immediately.

If the addict agrees, arrangement could then be made for instant transport to an inpatient treatment facility. The current system and standard of care would typically send such a person home with a phone number on a business card, hoping that they will call a rehab center on Monday morning to make an appointment for intake. As you can imagine, sending the addict home for the remainder of the weekend and hoping they will call on Monday is not exactly ideal.

So some people (and hospitals) are saying: We need to do better. Intervention needs to be more consistent, and we need to be able to follow through immediately. If we want to divert addicts early on and get better results then we need to step up our game, so to speak.

Believe it or not, there is a counter argument to all of this. Being more aggressive with an intervention system such as described above would seem like there is no downside at all, right? But the truth is, arranging for more efficient interventions like this is going to have a cost, and that extra cost needs to be justified. You are, at the minimum, having to bear the cost of more social worker availability, some additional training for ER staff, and some potential lost opportunity cost at the rehab center that may need to keep a floating slot available for unexpected ER diversions.
Those costs might be justified if such a program could show that we are saving more addict lives, and doing so at a decent rate (not just 1 out of every 500 people that this early intervention is done with).

The counter argument, then, is sort of the “tough love” mindset that is sometimes found in traditional recovery circles, which basically says that “addicts and alcoholics will recover only when they are ready to recover.” Another way to say that is: Don’t bother trying to force an addict or an alcoholic to change, they will only change when they come crawling to AA or rehab on their knees, begging for help. And even then, some of them will still relapse and fail to really change their lives.

It sounds like a great idea to set up more of a “net” to try to catch struggling opiate addicts, including people who may be in the early stages of dabbling with drugs. The idea is that if we can catch it early then we can better control it, and limit the amount of pain and suffering that occurs.

But the counter to this is what many traditional people in recovery believe, which is that you cannot deny an addict of their pain, even if you yank them out of their life and stick them in rehab (or jail), because that person has an addiction burning inside of them and it is going to manifest itself no matter how hard you try to control it. Then, they argue, the only way the addict is going to seek help is when they have experienced “enough” pain and suffering at the hands of their addiction, and they reach that turning point and finally surrender. And a struggling addict is either at the point of total surrender, or they are not.

So my feelings are mixed when it comes to the early intervention idea in hospitals–I am not so sure that the benefits (which are questionable due to a lack of surrender) are really worth the added cost and hassle.