“My son Michael asked for help with his addiction to heroin,” a mother wrote in response to a Legal Action Center survey about addiction care. “He was having withdrawal symptoms so I took him to the emergency room, but after a 12 hour wait he was turned away. We were told his withdrawal was not bad enough. Today he is dead.”
Michael’s experience is tragically common. In 2020, nearly 93,000 people died from drug overdoses and every week 15,000 individuals visited emergency departments across the country for substance-use-related health crises.
For many of the 19 million Americans struggling with addiction, emergency department visits may be the only health care they receive.
Instead of being refused care, what if Michael had been offered a Food and Drug Administration-approved medication to alleviate his withdrawal symptoms and help suppress his craving for heroin? What if he and his parents had been given a prescription for naloxone, the overdose reversal drug, before leaving the hospital? What if he had been referred directly to a community practitioner or an opioid treatment program for ongoing addiction care?
In short, what if the emergency department had done its job?
The treatment a person receives in an emergency department can often make the difference between life and death. This is particularly true for people with addiction. Yet far too many emergency departments fail to provide essential evidence-based and lifesaving care for these patients.
That must change. Hospital emergency departments have an obligation to provide equitable care for all patients. Addiction is a treatable, medical illness. When patients come to emergency departments for overdose or other addiction-related health crises, hospitals can and must provide the evidence-based interventions that are backed by data, recommended by federal agencies, and endorsed by medical associations like the American College of Emergency Physicians, which this summer published consensus guidelines on treating opioid use disorder in the emergency department that one of us (G.D.) helped write.
But stigma and institutional inertia lead many emergency departments to not seeing the urgent health care needs of these patients. These key clinical settings miss a key opportunity to improve health outcomes, save lives, and reduce racial disparities.
They may also be violating several federal laws designed to ensure that hospitals provide emergency medical care and do not discriminate based on disability and race, as one of us (S.Y-S.) demonstrated in a report by the Legal Action Center.
Under the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must examine all patients seeking care in an emergency department for conditions that pose a serious health risk and stabilize any such condition before discharging them. In Michael’s case, the law required the emergency department to assess him for a substance use disorder, offer buprenorphine (a medication to stabilize his acute withdrawal symptoms and suppress cravings for heroin), connect him to the ongoing medical care needed to treat his life-threatening illness, and provide him with naloxone to reverse any future opioid-involved overdoses. Of course, not all individuals with addictions are ready to accept treatment, but they should be given community referrals should they change their minds.
When hospitals fail to comply with EMTALA rules about addiction care, discrimination may also be at play, and this may violate other federal civil rights laws.
Individuals with substance use disorders are protected against disability-based discrimination. The Americans with Disabilities Act and the Rehabilitation Act prohibit hospitals from denying care because of a patient’s substance use disorder or drug use. By denying clinically recommended care based on negative stereotypes about individuals who use drugs, hospitals violate these laws.
Failure to provide evidence-based care for substance use disorders may also open emergency departments to legitimate claims of racial or ethnic discrimination under Title VI of the Civil Rights Act.
It is well-documented that Black and Latinx individuals are more reliant than white individuals on emergency departments due to more limited access to primary care in their communities. Moreover, national data show alarming increases in the rates of overdose deaths among Black and Latinx people, with the highest prevalence of opioid misuse among Indigenous people. As a result, when an emergency department fails to offer and provide clinically recommended care for substance use disorder, it can disproportionately harm Black, Latinx and/or Indigenous communities in violation of discrimination laws.
The moral and clinical imperative for emergency departments to address substance use disorders is clear and pressing. The opportunity to save lives, curb a public health emergency, and reduce health care costs and racial disparities should be enough to change practice.
But if those are not compelling enough reasons for hospitals to review their policies and ensure their emergency departments are doing their job in caring for patients with substance use disorder, perhaps the threat of legal liability will spur long overdue change.
Sika Yeboah-Sampong is a staff attorney at the Legal Action Center, a nonprofit law and policy organization fighting discrimination against people with histories of addiction, HIV/AIDS, and criminal records. Gail D’Onofrio is physician-in-chief of emergency services at Yale-New Haven Hospital and professor and chair of the Department of Emergency Medicine at Yale University School of Medicine.