Combating the Frequency of

Substance Abuse Related ER Cases:

Specialized Treatment Procedures
Jessica Jiang
Intern/Mentor GT
Period 1
Mrs. Bagley

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The doctor, having read a brief report of his next patients symptoms, walked into the
examination room expecting to see a half-coherent, semi-conscious man, the standard
appearance of a man suffering from drug overdose induced stroke. What he saw, however, was
completely different. Certainly, this man fulfilled the original image and expectation, but he went
beyond that. The person that lay on the bed, instead, was a twitching, semi-conscious, barely
coherent man, with his arms and hands raised limp in front of him, almost as if he were
possessed. After performing a brief physical examination, the doctor determined that the stroke
had occurred on the left side. Unable to do anything other than prescribing the patient with a
clot-clearing medication to prevent further stroke due to the patients intoxication, the doctor left
the room. Upon returning to administer the medication with the nurse, the doctor noticed the
patient was behaving even more strangely than he had been previously. He was having more
difficulty speaking, slurring words, and had abundant twitching in the face. The doctor
immediately diagnosed that the patient was having another stroke on the right side in addition to
the one he was already experiencing on the left, concluding that the strokes were a resultant
adverse reaction to the drug the patient had been on, K2, or synthetic marijuana.
Incidents like this are not uncommon in the emergency department, especially in lowerincome urbanized regions, where violence and gang behavior contribute to spreading drug abuse
(Buss, Abdu, Walker). However, the overall rise in substance-abuse related emergency room
visitations is a national phenomenon, as seen through studies conducted and published by
branches of the U.S. Department of Health and Human Services, the Substance Abuse and
Mental Health Services Administration (SAMHSA) and Drug Abuse Warning Network
(DAWN). These agencies document that from 2004 to 2009, drug-related ER visits increased by
81-percent overall; specifically, ER visits due to nonmedical pharmaceutical usage went up by

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98.4-percent and visits due to ecstasy, an illicit drug, increased by 123.2-percent (Drug-Related
Hospital Emergency Room Visits). Two years later, in 2011, the results were just as shocking.
Out of 1.25 million ED visits in that year alone, 51-percent involved illicit drugs and 25-percent
involved both drugs and alcohol (Drug Abuse Warning Network, 2011: National Estimates od
Drug-Related Emergency Department Visits). The rise in these types of visits highlights an
overarching issue in the field of emergency care as a whole, the contribution of substance abuse
related cases to the frequency of nonurgent ER visits. Certainly, the aforementioned case of an
incapacitated man suffering from two strokes is an urgent one, but substance-abuse related cases
also include non-emergency situations; for example, a patient suffering from addiction may come
to the emergency room simply for withdrawal medication or for conjured up, imaginary
symptoms of chronic body pain to receive pain-relieving drugs such as morphine or Vicodin to
feed his or her addiction. Drawing physicians away from caring for patients with more dire
circumstances to prescribe medication for addicted drug-abusing patients inhibits the purpose of
the emergency department and sucks up valuable and expensive hospital resources. Fortunately,
hospitals all across the globe have begun conducting studies on methods to resolve this issue.
Studies have found that a very effective strategy in reducing the amount of substance abuse
related cases in the emergency department is to give these patients specialized care and a
separate, more extensive treatment procedure.
One method of curtailing substance abuse related cases is to set up individual care plans.
A study conducted by the Henry Ford Hospital in Detroit sought to decrease the amount of a
certain type of patient in their Emergency Department (ED), deemed a super-frequent user.
These types of patients are defined as those who visit the ED a minimum of ten times annually.
The study confirmed numerous hypotheses that the majority of these super-frequent users have

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substance abuse addictions, specifically 77-percent. Among these 77-percent, 44-percent were
addicted to illicit drugs, 47-percent were addicted to pain-relief narcotics, and 35-percent were
addicted to alcohol. The study also calculated that the number of super-frequent users seeking
pain-relief narcotic drugs visited around 32.5 times a year. In 2004, the Henry Ford Hospital
created a program entitled the Community Resources for Emergency Department Overuse
(CREDO), to more effectively manage the amount of super-frequent users by providing
individualized care plans, or case management, for these patients. Research has indicated that the
community aspect of case management is imperative in its success, as it ensures the fostering of
a close relation of trust between the case manager and patient to aid in providing proper service
to best assist the patient (SAMHSA). Researchers, after examining data collected from each of
the patients electronic medical record, found that CREDO had fulfilled its purpose successfully.
The number of visits by general super-frequent users dropped from 33 to 11.6 visits annually,
and the amount of super-frequent users seeking pain-relief narcotics decreased from the 32.5 to
merely 13.8 yearly visits. These findings, as the studys lead author, registered nurse Jennifer
Peltzer-Jones, explains, indicate that a successful remedy to the issue of frequent ED users is the
case management approach utilized in CREDO, especially for the vast majority of these superfrequent users that are substance abuse addicts, especially of narcotics (Henry Ford Health
System). The significant difference between annual ED visits of the frequent user population
after the institution of CREDO indicates the success of individualized care plans in reducing the
amount of substance abuse related emergency room visitations.
Another study conducted by the Yale-New Haven Hospital and sponsored by the National
Institution of Drug Abuse (NIDA) underscored the importance and effectiveness of the
specialized drug addict care procedure in reducing substance abuse related ER visits. Dr. Gail

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DOnofrio, chief of emergency medicine at Yales medical school, dictated that drug addiction is
a chronic disorder, and can be remedied as one would for any other type of chronic medical
issue. She and her colleagues organized a study that implemented a more in-depth treatment for
drug-addicted patients. Instead of simply prescribing medication simply to resolve their
symptoms, often times of withdrawal, they combined medication with a brief counseling
intervention and a help referral. Ideally, the study would increase the likelihood of these patients
to seek and successfully enter into an addiction treatment program. Once in a program, these
patients have a higher chance of being able to resolve their addiction, and thereby visit the
emergency room less for symptoms caused by addiction, thus decreasing the amount of
substance abuse related ED visits as a whole. Dr. DOnofrios studys results, published in the
journal of the American Medical Association (JAMA), indicated the success of this type of care.
Over three-quarters of the people in a group that received withdrawal medication, called
buprenorphine plus naloxone, a ten-minute counseling intervention, and a referral to treatment
were in a treatment program thirty days later. By comparison, only 37-percent of the patients
who received solely a treatment referral were in a treatment program after thirty days, and only
45-percent of those who were given a brief counseling intervention and referral were in treatment
after thirty days (Hensley). These findings indicate that including a medication to provide
alleviation of uncomfortable withdrawal symptoms in combination with counseling and a referral
was the most successful tactic in bringing addicted patients into necessary treatment. Such a
discovery also suggests that, by default, with a higher chance of more patients receiving the
appropriate care for their addiction due to a more in-depth hospital treatment tactic that
effectively combined relief, counseling, and referral, less patients will suffer from addiction.

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Gradually, over time, with a smaller population of addicted patients, fewer patients will come to
the ER seeking care for substance abuse related symptoms.
At a hospital located in Oklahoma, researchers ran a study on the use and creation of a
new treatment procedure for substance abusing patients. Similar to the aforementioned
treatments, the program involved screening, brief intervention, referral, and treatment,
abbreviated simply as SBIRT. This program, especially the process of patient screening and brief
intervention, has proven to be very effective in helping patients reduce their substance abuse,
which, in turn, will also decrease the number of times they come to the emergency room seeking
treatment for symptoms related to drug use and abuse. A study by Gary Parker, Dane Libart,
Linda Fanning, Tracy Higgs, and Cathy Dirickson cites a report from 2009 that states how
patients have exhibited a 60-percent decrease in substance abuse after a single brief intervention
session. In order to validate these findings, these researchers conducted a study. To begin, 2083
adult patients seeking emergency room care were screened. 1319 screened negative for substance
abuse, and no longer continued in the study. After more patients were removed from the study
pool for various reasons, either being deemed medically unstable for the screening to take place
or refusing to participate, 365 remained who qualified to remain in the study, screening positive
for being at risk or greater for substance misuse. The patients were then brought in for a brief
five to ten-minute intervention session with a health educator. During the consultation, educators
discussed a myriad of health and legal consequences substance abusers frequently face. The
ultimate goal of the session was to utilize the discussed consequences in educating patients to
connect these risks to substance abuse, in the hopes that a change in behavior would result. After
the entire SBIRT process, follow-up with the patients indicated that the majority, all but two of
the 365, responded that they had modified their behavior due to the brief intervention. Examples

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range from one patient dictating that he had committed to sobriety since the session, having
learned that his liver problems were associated with his abundant alcohol intake, to another
stating the session may have saved his life, as he has since stopped drug and alcohol usage
completely, upon being made aware these substances were likely causing his seizures. The
evident success of the implementation of this SBIRT program in reducing substance-using
behaviors in their patients also indicates the success of these tactics in decreasing the overall
number of substance abuse related ER visits, since decreased usage will result in a fewer number
of patients coming to seek ED care for substance-use related symptoms (Parker, Libart, Fanning,
Higgs, Dirickson).
As seen in these studies conducted at various hospitals across the nation, a specialized
and more extensive treatment procedure for substance use related cases are very effective in
decreasing the frequency of these types of cases. Specifically, the studies cited have indicated
that treatment paired with a minimum of medication and a brief intervention session constitutes a
successful combination in reducing substance abuse for patients, which, correspondingly, will
reduce the number of substance abuse related cases, as fewer patients will come seeking
treatment as a result of overall reduced drug usage. This conclusion will help remedy a very
prevalent issue in the field of emergency medicine, general overuse of emergency care facilities,
as a large portion of these nonurgent cases are related to substance use and misuse. However, this
is not the only benefit of specialized and extensive care. Examining substance-abusing patients
with a procedure involving either case management or a combination of medication and
intervention is both more beneficial to the overall wellbeing and health of the patient, as testified
by Peter Cunningham (Nonurgent Use of Hospital Emergency Departments). Follow-up care
especially for addicted patients is most effective in ensuring their successful freedom from their

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addiction, which is most efficiently provided by either case management or treatment provided
by centers through patient referral. After all, by oath under the Declaration of Geneva, the
ultimate goal of all physicians is to assist and better the lives of those in need. Reducing the
frequency of substance abuse related cases in the ER and redirecting these patients to centers
where they may receive more fulfilling care through specialized treatment procedures is a step in
the correct direction towards achieving this goal.

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Works Cited
Buss, Terry F., Rashid Abdu, and James R. Walker. "Article: Alcohol, Drugs, and Urban Violence
in a Small City Trauma Center." Journal of Substance Abuse Treatment 12 (1995): 75-83.
Edselp. Print. 25 Oct. 2015.
Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency
Department Visits. Rep. Rockville: Substance Abuse and Mental Health Services
Administration, 2013. Web. 18 Oct. 2015.
"Drug-Related Hospital Emergency Room Visits." DrugFacts. National Institute on Drug Abuse,
May 2011. Web. 17 Oct. 2015.
Henry Ford Health System. "Most Emergency Department 'super-frequent Users' Have a
Substance Abuse Addiction." EurekAlert! Henry Ford Hospital, 17 May 2014. Web. 22
Oct. 2015.
Hensley, Scott. "Why Not Start Addiction Treatment Right In The ER?" NPR. NPR, 29 Apr.
2015. Web. 18 Oct. 2015.
Nonurgent Use of Hospital Emergency Departments, U.S. Senate Cong., 1-14 (2011) (testimony
of Peter Cunningham). Print.
Parker, Gary, Dane Libart, Linda Fanning, Tracy Higgs, and Cathy Dirickson. "Taking on
Substance Abuse in the Emergency Room: One Hospitals SBIRT Story." International
Journal of Mental Health and Addiction (2012): n. pag. Springer Science and Business
Media, LLC, 26 July 2012. Print. 25 Oct. 2015.
SAMHSA. "Chapter 2 - Applying Case Management to Substance Abuse
Treatment."Comprehensive Case Management for Substance Abuse Treatment. Vol. 27.
Rockville, MD: Substance Abuse and Mental Health Services Administration, 1998. N.
pag. Print. Treatment Improvement Protocols.

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