I am an emergency room doctor who is also board-certified in addiction medicine. I work at many different hospitals, in different states, with different population densities and cultures. I drop in, work a shift or two and go home.
One thing that allows me to seamlessly join an ER staff is that the general approach to any medical problem or injury is well understood. The one major exception is in my area of specialization.
Let me explain. Typically, all the different levels of care needed, from outpatient follow-up to rapid surgical intervention, are either at the location where I am working, or rapidly available with one phone call.
For example, when I’m working the night shift in an emergency department and somebody comes in complaining of chest pain, I can match the patient with the appropriate level of care:
►If the patient is a 22-year-old having a panic attack, we can connect him or her to the appropriate outpatient treatment for non-cardiac chest pain.
►If the patient is older and has a low risk of heart attack, I can order an outpatient stress test or have the patient admitted, watched overnight and evaluated in the morning.
►If the patient is having a massive heart attack and needs to go directly to a heart catheterization, I can pick up the phone, call a cardiologist and make it happen.
►If I am in a small hospital in a rural area, that call may be to a larger center of care where I get the patient transported as fast as possible. In fact, we would call a helicopter to fly the patient to the nearest facility that has the ability to do a heart catheterization or a bypass.
This approach is similar if a patient shows up with a stroke or an overwhelming infection. The point is, I don’t have to reinvent the wheel every time I walk into a new hospital ER.
One major exception to this, however, is the disease of addiction. Most hospitals provide no care for patients with addiction. Some hospitals have a social worker that you call in to help “evaluate,” which often means handing the patient a piece of paper with a bunch of phone numbers on it. A very few facilities will have someone you can call who is specialty trained to treat patients with addiction.
All this makes it nearly impossible for someone who is not trained in addiction to have any idea how to handle these patients when they walk in the door. This is despite the fact that the No. 1 cause of death for people under the age of 50 is overdose!
Even if I go beyond the hospital and into the surrounding community, I am still stuck with whatever the community has available. This might be an inpatient detox facility, an outpatient treatment provider who can write prescriptions for medication-assisted treatment, an abstinence-based 12-step self-help program, or some version of a recovery center.
Addiction services and treatment are nothing like what we see in cardiology. In fact, the situation is like having the 22-year-old with non-cardiac chest pain coming to the ER and being given a double bypass because that is the only option available. Or, even worse, giving the massive heart attack patient a list of cardiologists to call.
Even with my training in addiction medicine, my options for patients are still limited. I can start them on a medication such as buprenorphine or methadone, which are approved for treating opioid addiction, only to discharge them with nowhere to follow up. I can admit them to the hospital to treat their withdrawal, only to have no specialty care available to start their addiction treatment.
None of this is happy, satisfying or even ethical.
If we are truly going to curb the overdose epidemic or adequately treat those with addiction, we must take actions that will make a difference. These include building an addiction treatment ecosystem that looks like every other medical specialty, and make its response just as predictable and effective as the treatment for a heart attack.