Emergency Departments on the Front Lines

Unintentional drug overdoses have increased exponentially over the past 38 years, and became the leading cause of death in people under 50 in 2016. Opioid overdoses claimed almost 50,000 lives nationwide last year. Baltimore City has been acutely affected, having the “highest age-adjusted overdose fatality rate of any metropolitan county in the United States”. 

City officials have taken and continue to take a number of steps to combat this public health crisis. Most recently, the city has taken an important step toward addressing the epidemic where so many people who use drugs often pass through: emergency rooms. 

Opioid-related visits to emergency departments nearly doubled from 2005 to 2014. Multiple studies have shown that initiating treatment for addiction before a patient leaves the emergency department drastically increases the likelihood that patients remain in treatment following the hospital visit. However, addiction treatment has traditionally remained separate from the rest of the healthcare system. Hospitals often refer patients with substance-use disorders to rehabilitation or community treatment centers. As common as this tactic has become, it is a suboptimal approach for caring for these patients – the health care system misses a critical opportunity to engage people who use drugs, and many patients fall through the cracks.

Recognizing the critical role emergency departments must play in a comprehensive strategy, in May 2018, Baltimore City initiated the Levels of Care program to aid the city’s hospitals response to the opioid epidemic. The program is proof that city leaders understand that in order to comprehensively address the opioid crisis, the health care system along with hospitals must be engaged in the city’s public health efforts. 

The Levels of Care program is based on a similar program in Rhode Island, which is one of the only places where overdose deaths decreased last year. Baltimore’s hospitals have already pioneered research and provided effective and innovative approaches to treating addiction. The Levels of Care builds on these achievements by enshrining best practices for responding to the epidemic and publicly recognizing hospitals that implement those practices.  Through active collaboration between the city and its hospitals, this program provides ranked levels that reflect how effectively a hospital can continue to be protagonists in the fight against the opioid epidemic. Levels are a reflection of each hospital’s ability to initiate treatment for addicted patients, distribute naloxone, connect patients to support services and community treatment centers, and ensure physicians are prescribing opioids judiciously. Hospitals are designated as a level 1, 2, or 3, with 1 representing the optimal care program. Application process instructions and further guidelines are provided here.

The Levels of Care program is the latest step by Baltimore City to aggressively address the opioid crisis. For example, in 2015, then-Baltimore City Health Commissioner Dr. Leana Wen issued a blanket prescription for anyone meeting training requirements to receive Naloxone, which reverses the effects of opioid overdoses. The city also opened up the state’s first Stabilization Center, a 24-hour urgent care center providing short-term medical care and other services for people under the influence of drugs or alcohol. Individuals admitted to the center have a safe environment to sober up and/or be transferred to emergency departments for additional health services. 

The Levels of Care application was introduced on August 15 and is currently accepting rolling submissions. The city hopes to announce the first round of hospitals to be certified by mid-December 2018. Baltimore’s health department already reports some improvements in hospital care for patients suffering from opioid use disorder (OUD). Perry Meyers from the Baltimore Health Department said, “We have already seen anecdotal improvements in care for those with OUD ranging from an increase in people eligible to prescribe buprenorphine in the emergency department to naloxone dispensation.” The Levels of Care program is a critical new tool in the city’s response to the opioid epidemic.