In the early 2010s, as a hospitalist at Oregon Health & Science University (OHSU), Honora Englander, M.D., was noticing more hospitalizations related to substance use disorder (SUD) complications. The system wasn’t equipped to handle them.
“Despite having a really committed staff and well-intended clinicians across disciplines, we really didn't have systems or structures in place to care for people with substance use disorder in the hospital,” Englander, founder and director of OHSU’s Improving Addiction Care Team (IMPACT), recalled.
OHSU conducted a needs assessment that surfaced how critical a touchpoint the hospital was for SUD patients. Up to two-thirds of patients with active drug use were interested in cutting back or quitting. Many reported interest in medications for opioid use disorder (MOUD), and they wanted to be able to start them in the hospital. It became clear that pathways to ongoing care after discharge in the community were missing.
In 2015, based on these learnings, Englander formed IMPACT, a multidisciplinary consult team of addiction medicine docs, advanced practice providers, social workers and others. One of the first of its kind in the country, it has grown to three dozen staff across multiple hospitals.
The results have been striking. OHSU has found patients who met with the IMPACT team while they were in the hospital were twice as likely to participate in treatment for SUD after going home. Research has also found IMPACT leads to decreased substance use after a hospital stay; lower costs associated with fewer days spent in the hospital; increased patient trust; and better hospital staff knowledge of addiction and treatment.
Overdose rates have diminished from the COVID-19 peaks of 2022 and 2023, but remain “unacceptably and tragically high,” Itai Danovitch, M.D., an addiction psychiatrist and chair of the American Society of Addiction Medicine (ASAM) Quality Improvement Council, said. More than 48 million Americans suffer from SUD, according to 2023 data. Black and Native Americans are disproportionately impacted by overdose deaths, reaching 1.4 times and 1.8 times the rate of white Americans, respectively. The vast majority of people do not receive treatment, largely due to many programs requiring abstinence.
Stigma is diminishing as more people in recovery publicly share their stories, which is also pushing up demand for services. At the same time, a younger generation of physicians are vocal about the need for SUD protocols in high-acuity settings. Two decades ago, this wasn’t the case, Danovitch said. “They would kind of tolerate the discussion with me,” he recalled of his peers. “Now, I have a hard time getting off the phone with them.”
The federal government has also indicated an interest in the issue, with the Department of Health and Human Services (HHS) announcing a $100 million investment earlier this year to improve homelessness, opioid addiction and public safety. Communities and pilot programs receiving the funding will build integrated care systems that will move people seamlessly between crisis, treatment and social supports, Health Secretary RFK Jr. said at the time.
Different models available to hospitals
In 2023, ASAM outlined the standard capabilities all hospitals should have to effectively care for SUD patients. Recognizing this is easier said than done, it followed up with an implementation guide earlier this year, put together by a special task force (on which both Danovitch and Englander served). The guide outlines core capabilities and care models hospitals can adopt.
“Increasingly, we have all come to recognize that hospitals and EDs are a critical central part of delivering care for people with substance use disorders,” Danovitch said. This also coincides with a time when medical and behavioral health services are less siloed. "Because for most patients, comorbidity is really common,” Danovitch said, “integrating those services is a big focus across the board.”
Luckily, hospitals already have many of the components needed to standardize SUD care: social workers, nurses and pharmacists. “The problem is those ingredients haven’t been organized to prioritize and focus on substance use disorder to the degree that is warranted,” Danovitch noted.
There are three different care models highlighted in the ASAM implementation guide—addiction consultation services, bridging services and hospital-based opioid treatment. They can take many forms, from leveraging external experts to drawing on existing expertise within an institution. “The model is less important than the commitment to the result,” Danovitch says.
Specialty consults yield positive outcomes
Melissa Weimer, D.O., founded Yale New Haven Hospital’s own consult team, the Yale Addiction Medicine Consult Service, in 2018. Its 1,500-plus-bed campuses serve a “huge need in a very diverse city with a very high prevalence of substance use disorder in the community,” Weimer, also an associate professor of medicine, said.
Weimer, who previously supported Englander in the creation of IMPACT at OHSU, was brought on to stand up Yale's consult program and found a hospital with a clear need. MOUD was underutilized, in part because clinicians were uncertain about the legality of prescribing the highly regulated drug methadone. The hospital needed specialists. There were SUD services in the community that staff didn’t know about. Today, the multidisciplinary consult team provides addiction assessment and treatment at both campuses of the hospital.
Weimer’s consult team is made up of addiction medicine docs, advanced practice practitioners, fellows, residents, care coordinators and social workers. Consultations are available every day of the year during business hours, and requests come in every day from primary medical or surgical teams. The consult team steps in to do a full addiction medicine evaluation and diagnosis, the same way a cardiologist would be involved for someone admitted for a heart attack, and gives treatment recommendations to the primary team. It also helps connect the patient to ongoing care, make appointments and follow them through their hospitalization.
Among the outcomes Yale tracks for SUD patients are ED admissions, length of stay and 30-day hospital readmissions. All have improved since the consult service began, Weimer said. The effort has also saved the health system money. A 2022 rule allowing hospitals to dispense up to three days of methadone has saved Yale over $300,000 in the past year. Previously, patients were required to come back for each daily dose of methadone, potentially prolonging their hospital stay.
The team’s broader goal is to train as many clinicians and residents as possible. It has created care pathways and guidance to ensure everyone gets evidence-based addiction medicine, no matter the setting or time—for instance, when the consult service is down for the night. The team also works closely with the hospital pharmacist to ensure MOUD is on the formulary, including the newer injectable buprenorphine.
Similarly, IMPACT at OHSU has served a critical role in transforming systems. The team has developed order sets and protocols for MOUD initiation, including low-dose buprenorphine and rapid methadone protocols. It does a lot of bedside work, bringing support staff like social workers and nurses in on care delivery. As an example of the changes, Englander recently cared for a patient who needed more methadone than usual to disrupt their drug use. In the past, they may have gotten discharged mid-withdrawal. Now, teams take a more trauma-informed approach.
Expanding efforts outside the hospital
Beyond support at the bedside, IMPACT offers a physician advice line for providers across the state, plus one focused on SUD in pregnancy. It also has a telementoring program known as ECHO supporting interprofessional hospital clinicians with education and case discussions. That has served over 700 participants to date. IMPACT helped develop and partners with OHSU’s bridge clinic, offering virtual and in-person addiction services.
A study evaluating IMPACT revealed that, previously, hospital clinicians at OHSU felt hospitalization didn’t address addiction, led to untreated withdrawal, and had patients leaving against medical advice. Since then, IMPACT “completely reframes” addiction as a treatable chronic disease and humanizes care. Providers feel having systems in place to address SUD reduces burnout.
OHSU is one of over 100 accredited addiction medicine fellowships in the country, with fellows rotating on the IMPACT team. IMPACT also supports a chief resident program, developed by Englander, to train other disciplines on addiction care. Chief residents are typically near the end of their training and teach other residents and students while developing their own leadership and teaching skills.
Englander stressed the importance of combining education efforts with expanded treatment infrastructure: “If there’s not the combination, I think we fall short because so much of it is really understanding addiction from a different perspective.”
Danovitch agrees. Consult services are important to help educate others, but there will never be enough addiction medicine specialists for all the need. Once clinicians engage with a consult, they can learn what quality SUD care is for the future. For broader standardization of SUD care at hospitals, Danovitch believes it would be useful for them to report on more SUD quality measures. Doing so would encourage quality improvement, in his view, especially for a service line that doesn’t necessarily drive revenue.
“What drives them to address these things is quality reporting and wanting to perform well,” Danovitch said. “That’s really what’s going to drive further uptake of models and innovation of new models to really shape and improve the care that patients receive.”
It’s also crucial for a hospital to have at least one physician championing the importance of SUD care, Weimer, who recently co-authored a textbook on the subject, said. They should ideally have a year of training from an addiction medicine fellowship. “You need somebody who has the specific experience treating people with substance use disorders and again that passion for wanting to improve health systems, which can be hard work,” Weimer said.
At an institutional level, it’s important to have buy-in from people who understand how having this care will benefit the community. “The argument at Yale really was about quality of care,” Weimer noted. “If you only try to make the business case, it probably will fall flat.”
Yale collaborates with outpatient providers and a street medicine team through a federally qualified health center. “If you’re starting a medication, you want to make sure your patient has ongoing access,” Weimer explained. “The majority of the care and the recovery is going to happen outside of the hospital setting, so it’s important that we’re collaborating with our partners.” To help expand access to SUD care in skilled nursing facilities, Weimer sits on a committee with the state Department of Public Health and Department of Mental Health & Addiction Services. She also
OHSU’s IMPACT team also focuses on community engagement, working with the Mental Health & Addiction Association of Oregon, housing organizations, coordinated care organizations and other community partners.
“We really set out in our development to get past the traditional silos,” Englander said. “That’s a critical piece of what we do.”