Kelly D. says that when she was 21 years old and using heroin, she oke up in emergency rooms more times than she can count. Regaining consciousness in the hospital after an overdose was unpleasant enough, but the lack of compassion made the experience even worse.
“All I got in the hospital was an IV and judgment,” says Kelly, who asked that her last name not be used. She is now 30, drug-free, and a musician and receptionist in Santa Cruz, California. She recalls that nurses would sometimes ask her, “Know how you got here?” alongside snide remarks about her drug use.
“It was always an alienating experience because the ER staff was so cold,” she says.
Worse than the judgment, she says she was never offered any help or information about treatment options. Thousands of people are spit back into society — sometimes over and over — after the trauma of a drug overdose and an emergency room visit, without getting information about where to get help. Like Kelly, thousands of them are young people.
The opioid crisis in the US is now epidemic — drug overdoses took more lives in 2016 than the entire Vietnam War. As the hardest hit states scramble for answers, emergency rooms might be one of them. Opioid-related emergency room visits rose over 99 percent between 2005 and 2014. This includes over 100 children and young people every day, according to the American Academy of Pediatrics.
For many of these young people, the only doctors they ever see are in the ER. In fact, young people use ERs as their main source of healthcare more than any other group. But ER staff aren’t trained in addiction counseling. And generally, they’re too busy to provide it anyway.
But what if emergency rooms underwent a shift, and offered some basic services and connections that many young people addicted to opioids are otherwise not able to access? Could that help turn the tide on the opioid crisis?
AAcross the country from Kelly, in the Boston Medical Center, someone who lands in the ER after an overdose will likely not experience judgment. Instead, they’ll be approached by a “Health Promotion Advocate” who simply asks, “What is a typical day like for you?” Rather than scolding them to stop using, advocates will ask, “On a scale of 1 to 10, how ready do you think you are to change your drug or alcohol use?” They’ll also help them come up with a harm-reduction plan. That might be using heroin one less time per day, or only drinking a six-pack, without the additional fifth of bourbon every night. Or, if they’re ready, they’ll help get them into treatment immediately.
It’s called Project ASSERT, and while it’s had promising results with older adults for decades, recent years have shown its efficacy in connecting young people to help. Of over 600 patients between 2009 and 2013, 546 were connected to substance abuse treatment services, researchers found.
Patients directly referred by Project ASSERT are twice as likely to enroll in a specialized treatment center, says Gail D’Onofrio, professor of emergency medicine at Yale School of Medicine and one of the directors of Project ASSERT.
“You can’t just hand [patients] a resource list and say, ‘Here you go,’” she says. “Most won’t call treatment facilities on their own.”
Even when young people are willing to call, dealing with the shame of addiction on top of physical withdrawal means any obstacle makes it easy to give up trying to get help. That’s what happened to Tom (not his real name), who ended up in the emergency room last year after overdosing on carfentanil in Salisbury, Maryland. He had tried to Google doctors listed as resources for Suboxone or naloxone — detox medications to help with the physical withdrawal symptoms of getting off opiates — on his own, but many had left or weren’t accepting new patients. Other times, the numbers were disconnected. So he kept using.
This is why it’s so important to have someone knowledgeable about treatment options help steer you through the process, advocates say. Tom got lucky — a man named Curtis Paul met him in the ER and offered him help, not judgment.
“After I OD’d and Curtis showed up, I was kind of at my wit’s end,” Tom says.
Paul is a peer advocate in the Community Outreach Addictions Team (COAT), a program that started in 2016 in Wicomico County, Maryland, a state with one of the highest rates of opioid-related ER visits in the country.
Similar to ASSERT, COAT peers do outreach in area ERs. But COAT peers are all recovering addicts —which helps them connect more authentically with young people struggling.
ER staff will call COAT when they have an overdose case. If the patient is open to talking, COAT members will gauge whether they’re ready for treatment. And if they are, they’ll help get them there.
“As an ex-addict myself, I can relate and understand how extremely difficult it is getting help,” says Paul, who is 38 and has been clean for five years. He stopped doing drugs when he ended up in jail. But when he was still using, he says, “I had no idea of the resources that were out there. It’s really difficult to get that kind of info, so that’s what the COAT team is doing. Having a facilitator makes a big difference.”
Paul and the other COAT peers are in touch with inpatient and outpatient treatment centers, nearby and out-of-state, to give them the best chance of finding one with space when a young person needs it.
They’ll drive their clients to whatever services they need, such as the Social Security office or veteran’s hospital. They’ll also help find space in a shelter if it’s needed, or deal with logistical issues like getting an ID card, or applying for insurance and food stamps.
But the emotional support from someone who has experienced addiction is also invaluable, Tom says.
It was the first time he’d ever overdosed, and learning he’d technically died twice before being revived was traumatic for him, he says. Curtis helped him deal with the trauma and kept him focused in the period between his treatment intake session and actually seeing a doctor for prescription detox drugs to help him safely withdraw, time that can stretch to a couple of weeks or more.
“We do follow-up calls and try to stay in touch [after initial contact], as the process to get into treatment is usually not short or effortless,” says Kelly McColligan, another COAT peer counselor. McColligan has been clean for seven years and like Paul, is studying dependency counseling and working toward a bachelor’s degree.
“When we stay in touch continually, it helps make sure clients don’t get frustrated and give up while they’re waiting for a bed in a treatment facility,” she says.
Like Kelly D., McColligan woke up in emergency rooms many times after overdosing on heroin: “It always went the same way,” she says. “They’d say, ‘OK, you ready to go now?’ never ‘Let me call someone to help’ or offer any advice to get help.”
AAs more data show that advocacy programs can work, D’Onofrio hopes that more hospitals might be willing to try them. But it takes time to show hospitaladministrators that offering this kind of help in an ER might reduce the number of repeat customers — which would save money as well as boost the quality of care, she says.
Most experts agree that this kind of help is important, but some caution that reaching young people earlier on, before they become chronic ER patients, could be more effective.
“There’s no one easy answer,” says Ari Kenney, a registered nurse in an emergency department in Methuen, Massachusetts. “The emergency department is often a great place to identify at-risk people, but is not necessarily the best place to access the various resources available. And emergency providers can’t solve the problem independently.”
Substance misusers have to be accountable for their own behavior, she adds. And the chances of spiriting someone into treatment who isn’t ready are slim, many addiction counselors say. Kelly D., who eventually entered treatment on her own, says she’s not sure whether an advocate intervention in the hospital would have gotten her to quit heroin any faster: “An advocate in the ER who was in recovery would definitely have made me feel less alone and alienated, but it wouldn’t have necessarily helped me get my shit together any sooner.”
Kicking opiates is so difficult that treatment won’t be an easy sell for a lot of people, no matter how dedicated their peer advocate is. COAT peer supervisor Tasha Jamison says that her staff is successful getting clients into treatment only about half the time, but this is still higher than government statistics, which indicate that only 18.5 percent of people who need treatment will get it, she says.
It’s difficult, frustrating work, but her counselors are driven to help people, D’Onofrio says.
“They’re the boots on the ground. They want to do this,” she says.
A COAT counselor for a little over a year, McColligan seems to embody that drive. Half of the people she deals with won’t talk to doctors or nurses about their drug use, she suspects out of embarrassment or fear. But once they learn that she was an addict for 18 years and got clean, their guards come down.
“There have been clients who weren’t ready [when we first talked] and did not want the help but who call weeks or even months later saying, ‘Hey, remember me? Is it too late to get help?’” she says. “I love getting those calls, even if it’s on my day off. We always let them know it’s never too late.”
