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How to Treat Substance Use Disorder in the Emergency Department

Analysis  |  By Christopher Cheney  
   March 20, 2023

Presbyterian Healthcare Services emergency departments are following best practices for substance use disorder treatment and management.

Three Presbyterian Healthcare Services (PHS) hospitals have been awarded gold level Pain and Addiction Care accreditation from the American College of Emergency Physicians.

Overdoses, particularly involving opioids, are a national crisis, according to the Centers for Disease Control and Prevention (CDC). There were an estimated 107,622 drug overdose deaths in 2021, an increase of nearly 15% from 2020.

The ability to provide buprenorphine for opioid withdrawal in emergency departments is a gigantic leap forward in substance use disorder care, says Natasha Kolb, MD, emergency medicine program medical director at Presbyterian Medical Group.

"Historically, when we would see patients in the emergency department in opioid withdrawal, we would give them medications to try to cover up the symptoms of withdrawal and they were suboptimal. You would give a patient something for nausea and it would help a little bit, but nothing we gave them helped with the craving for opioids. Now, while a patient is in the ED and in crisis, we can start them on a medication that not only treats the symptoms of withdrawal but also treats the craving for opioids. So, they leave the ED feeling normal and they are more likely to follow through on appointments to get continued prescriptions for buprenorphine or make it to an inpatient treatment center or outpatient care. The success rates went way up to keep people in treatment," she says.

Providing naloxone for opioid overdose

In addition to providing buprenorphine in PHS emergency departments, the health system is dispensing naloxone to patients as well as family members in EDs, Kolb says. "What we do when a patient is in the ED and has suffered a near-death experience because they have overdosed on an opioid, we actually put a Narcan atomizer in their hand or the hand of a family member. We say they have something that can save their life if there is another overdose, and they walk out of the ED with that life-saving medication. It is part of their ER visit, they do not have to pay for it, and they do not have to go to a pharmacy to fill a prescription."

Filling a prescription for naloxone at a pharmacy can be daunting, she says. "It can be difficult to fill a prescription for naloxone. If you go to the pharmacy to fill the prescription, the cost is $90 with insurance."

Interdisciplinary approach

PHS emergency departments are providing evidence-based treatment for opiate and alcohol use disorder through an interdisciplinary workgroup that includes peer support specialists, pharmacists, informaticists, addiction specialists, and emergency medicine clinicians, Kolb says.

The peer support specialists are crucial, she says. "We have peer support specialists—many of them were formerly addicted to substances themselves and are in recovery. So, they are the perfect people to connect with patients, and they work in our EDs. They get a list of patients who have checked in with certain acute complaints such as withdrawal, then they talk with the patients; and if we initiate treatment, they will circle back with the patient within 24 hours to see how the patient is doing. They help patients with the next step to get treatment in an inpatient or outpatient setting. They also come to our interdisciplinary meetings on substance use disorder."

The pharmacists are also key members of the interdisciplinary team for substance use disorders, Kolb says. "Pharmacy has also been critical in coming to these meetings, too. They talk about stocking naloxone, so we have it in our drug cabinets to dispense. They make sure we have the right formulations of buprenorphine—is it going to be a pill or is it going to be the dissolvable strips?"

Opioid stewardship

PHS emergency departments practice opioid stewardship to reduce addiction to opiates, she says.

"We have worked on making our order sets to take providers to non-opioid pain management strategies first, then work down to opioids as the last option. It's not that we never use opioids—if there is a bone sticking out of a patient's leg, you are probably going to have to use morphine for that patient. But we try to start at the safest and easiest modalities first. So, you start at the top of the order set with old-school therapies such as ice or a heat pad, then you might go to topicals such as patches with lidocaine for someone with back pain. Then you move to non-opioid medications such as acetaminophen and ibuprofen. Opioids are used as the last resort."

PHS hospitals are also using technology to promote opioid stewardship, Kolb says. "If a provider writes a prescription for a patient to go home with an opiate, our electronic medical record is integrated with our Prescription Monitoring Drug Program system. So, when a provider wants to write a prescription, you get a pop up with a link to the patient's prescription history. If there is any indication that the patient is not using opioids in a safe manner, the provider gets that information before the prescription is written."

Related: Opioid Use Disorder Plays Significant Role in Many Sepsis Cases

Christopher Cheney is the CMO editor at HealthLeaders.


Buprenorphine is an ideal medication for opioid withdrawal because it not only treats withdrawal symptoms but also reduces the craving for opiates.

Dispensing naloxone for opioid overdose in an emergency department provides a life-saving medication that avoids the barrier of filling a prescription at a pharmacy.

Presbyterian Healthcare Services emergency departments practice opioid stewardship to reduce addiction to opiates.

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