By Leslie Suen
Emergency departments diagnose and treat the most serious medical conditions — heart attacks, car accidents, strokes and, in pandemic times, COVID-19. Although emergency visits for alcohol and other substance use disorders are just as common and life-threatening, they remain largely unaddressed by hospitals.
In our University of California, San Francisco, study, we found from 2014 to 2018, people with alcohol and other substance use disorders made up about one in 11 emergency department visits and one in nine hospitalizations across the nation. These numbers are similar to other common conditions that hospitals routinely treat, like heart failure. Hospital visits among people with substance use disorders have also likely increased during the pandemic, paralleling the country’s record number of drug overdose deaths seen in 2020.
Substance related emergency visits show no sign of slowing down for many reasons. Access to substance treatment programs was disrupted by the pandemic. Isolation and economic uncertainty worsened depression and anxiety, leading more people to turn to substances to cope. Moreover, fentanyl is quickly saturating the drug supply. As fentanyl is 50 to 100 times more potent than other opioids like heroin, its overdose risk is much higher. Fentanyl is also increasingly contaminating other drugs like cocaine and methamphetamine, driving up overdose rates.
These grim statistics aren’t surprising to hospital clinicians like me. In San Francisco, we’ve seen a surge of emergency visits and hospitalizations related to substance use. The City experienced a record-shattering 712 overdose deaths in 2020, more than twice the number of deaths from COVID-19. This year is on track to be no different, as over 400 people have already died in San Francisco in 2021.
Despite the commonality of substance use disorders, few hospital systems and clinicians are equipped to address them. Reasons include insufficient training among the health care workforce and hospitals’ lack of adequate addiction treatment infrastructure. This is a shame, especially as addiction is still highly stigmatized, including in medical settings. This stigma can prevent people from accessing care, as patients report delaying seeking medical care for fear of mistreatment until their illness becomes severe.
However, San Francisco is also at the forefront of addressing these issues, developing innovative models for hospital-based care for substance use disorders.
At San Francisco General Hospital, one of the hospitals where I work, any clinician in the hospital or emergency department can call the Addiction Care Team, also known as ACT. ACT has addiction medicine physicians, nurses and patient navigators. They engage patients in discussing their substance use goals, offer and initiate evidence-based, life-saving medications to reduce substance use, and connect patients to community resources and treatment programs.
Another emergency department-based intervention is the CA Bridge program. SF General is the first among over 130 hospitals in the state participating in CA Bridge, where emergency clinicians are trained to start patients on buprenorphine, a long-term medication to treat opioid use disorder. Anyone who comes into the emergency department because of an opioid overdose, withdrawal or another medical reason can immediately access this life-saving medication.
Before, patients going to the hospital for substance-related reasons had their acute symptoms treated, but all too often, the underlying addiction remained unaddressed. At best, patients were given a handout of community resources to call. Barriers to insurance, transportation, limited appointments and the onset of excruciating withdrawal symptoms are just a few reasons patients would fall through the cracks.
Both ACT and CA Bridge help save lives by lowering barriers to addiction treatment, starting medications right away and linking patients to resources outside of the hospital. This last piece is critical, as systems of mental, behavioral and physical health are siloed, especially in San Francisco. The programs work to streamline connections to community-based programs and enable treatment to begin during hospitalization. Early studies of ACT and CA Bridge show promise, as patients who participate are more likely to engage in treatment after discharge. These programs are also quickly becoming the standard of care across the country.
I have seen firsthand how providing addiction treatment in the hospital can improve care and reduce stigma for patients. By making humanizing, non-stigmatizing, care for people with substance use disorders everyone’s responsibility, specialized addiction treatment teams in the hospital can be reserved for the most complex cases. An “all-hands-on-deck” approach is a must if we are to address the high need for substance use treatment and to destigmatize care.
Although care models like ACT and CA Bridge are an important first step toward reframing alcohol and substance use disorders as emergency medical conditions (rather than as individual moral failings), hospital-based addiction treatment can only succeed in the long-term if systemic changes also happen in parallel at local city, state and federal levels.
State and federal governments can provide long-term funding to support hospital-based addiction treatment programs through public insurance programs like Medicaid and Medicare. This type of support can also help advance education for medical staff and can pave the way for developing new substance-use focused initiatives.
Further, having a robust infrastructure of local resources and treatment programs outside of the hospital is necessary for people to stay healthy after discharge. Currently, San Francisco has committed to investing $13.2 million to address the overdose crisis. Efforts must be focused on creating long-term solutions that address the root of addiction. These include rapidly expanding the number of desperately needed mental health and addiction treatment beds, developing better pathways into long-term housing for individuals experiencing homelessness and addiction, and supporting evidence-based programs proven to prevent overdose.
Safe consumption sites are one example of the latter. Evidence from over 100 sites around the world show that safe consumption sites reduce overdose deaths, increase entry into treatment and improve public safety by decreasing public drug use and discarded paraphernalia in open spaces. Members of the Board of Supervisors have already called for Mayor London Breed to declare overdoses a state of emergency. Doing so would authorize San Francisco to establish a safe consumption site, allowing The City take immediate action toward curbing its sky-high overdose rate.
Though this is a complex issue without a single solution, one fact is clear: Alcohol and other substance use disorders are killing Americans at epidemic proportions. Health care systems must treat these disorders as life-threatening emergency medical conditions with evidenced-based treatment and connection to community care. The time to act is now.
Dr. Leslie Suen is a board-certified internal medicine physician and addiction medicine specialist, where she provides care for patients at UCSF, San Francisco General Hospital and the San Francisco Veteran Affairs Medical Center. She is also a health services researcher in the UCSF National Clinician Scholars Program.