Abstract
Objectives
Efforts to improve substance use disorder (SUD) care in the emergency department (ED) include deploying peer recovery coaches (PRCs). PRCs operate through a window of lived experience, providing motivational interviewing and linkage to recovery resources. This may include placement into residential treatment, which can be difficult from the ED given time constraints. We describe a novel clinical decision unit (CDU) pathway wherein PRCs facilitated discharge to residential SUD treatment.
Methods
We performed a retrospective analysis of patients presenting to a single hospital between June 2023 and May 2024. The sample was drawn from the consult list of PRCs. Data were obtained through direct export and manual extraction from the medical record. We performed χ2 analyses to evaluate the effect of patient factors on pathway success.
Results
In total, 75 encounters were included: 49 men (65.3%), 26 women (34.7%); age range, 18 to 69 years (median, 45 years). Forty-nine (65.3%) encounters were identified as Black, 19 (25.3%) as White, and 7 (9.3%) as other; 24 (32%) had a primary ED diagnosis related to substance use, and 38 (50.6%) had a primary psychiatric diagnosis (eg, suicidal ideation). PRCs placed 53 patients (70.6%) in residential treatment. Three patients had a change in clinical status and were admitted to the hospital. Median CDU length of stay was 27 hours (IQR, 21-44 hours). Forty-five (85%) of those placed were insured. Of the 15 uninsured patients, 8 (53%) were placed. No differences in pathway success were observed based on race, insurance status, or primary substance used. The pathway was more successful for men than for women (difference between groups, 34%; 95% CI, 10%-56%). The most common reason for pathway failure was patient-directed discharge (10 [45.5%] pathway failures).
Conclusion
In this CDU pathway, PRCs were able to place the majority of patients into residential SUD treatment. Further study is required to examine long-term patient outcomes.
Keywords: substance-related disorders; emergency service, hospital; clinical observation units; patient navigation; peer support; peer recovery coaches; retrospective studies
The Bottom Line.
While the traditional pathway in our area requires patients to self-navigate the residential substance use treatment admission process, this is unfeasible for many. We utilized a novel emergency department (ED) clinical decision unit (CDU) pathway to facilitate rapid placement into intensive treatment using peer recovery coaches. In this single-center report including 75 patients, peer coaches using the CDU pathway placed 70% of patients without differences noted based on race, ethnicity, insurance status, or primary substance used. We did observe a decreased rate of placement for women, highlighting treatment disparities based on sex.
1. Introduction
1.1. Background
Substance use disorders (SUDs) are chronic medical conditions characterized by compulsive use of alcohol, drugs, and prescription medications despite negative consequences. In 2023 alone, there were approximately 105,000 deaths related to drug use.1 These numbers represent only a portion of the impact SUD has on the population. It is therefore important to optimally deploy available resources to manage SUDs. Patients with SUDs often use emergency departments (EDs) as a primary source of care.2 Guidance from the American Society of Addiction Medicine recommends not only medical management of SUDs but also involvement of social work and social support networks and referrals for further treatment and care.3 This includes supporting psychosocial needs via inpatient and outpatient treatment programs, as well as community and stakeholder support groups.4, 5, 6
Initiation of medications for opioid use disorder (MOUD) from the ED is highly effective. In a landmark trial of ED-initiated buprenorphine, 78% of patients receiving buprenorphine were engaged in treatment at 30 days vs 37% of patients who were referred for treatment without ED buprenoprhine.7 Nonetheless, more recent data suggest that only approximately 35% of patients started on buprenorphine in the ED receive a second prescription.8 Furthermore, medication-based treatment options are limited for substances other than opioids and alcohol, most notably cocaine and methamphetamine.9 Other prongs of SUD management, including social supports and linkage to more definitive care, can be difficult for the ED clinician to navigate. There is a positive correlation between higher social supports and rates of recovery, even in brief intervention.2,10,11 Thus, there is a need to enhance care navigation for ED patients desiring SUD treatment. One response to this is to deploy peer recovery coaches (PRCs) in the ED.
PRCs are individuals in long-term recovery from SUD, with training and certification in motivational interviewing and care linkage. They leverage their experience to act as liaisons among patients, clinicians, and recovery services.12 PRC implementation in the ED has been associated with improvements in ED utilization, overall hospitalization rate, provision of MOUD, engagement with outpatient resources, and reductions in substance use.13, 14, 15, 16, 17 This benefit has been shown regardless of substance in question.18 One recent study in a patient population similar to our institution found strong positive outcomes on psychosocial factors and patients’ perceived self-efficacy across all forms of SUDs.18,19
1.2. Importance
The period between ED discharge and engagement with SUD treatment presents a high-risk period for relapse or loss to follow up. Although PRCs are a resource for linkage to outpatient SUD treatment, there is limited evidence surrounding the feasibility of linkage from the ED to residential treatment centers as a disposition plan. Patients referred directly from an ED may be up to 30 times more likely to enroll in treatment compared with those with indirect referrals.2 Discharge to an unstable environment with pervasive substance use also increases likelihood of return to use. Similarly, an indirect referral relies on the patient to follow up independently with facilities regarding potential enrollment and to coordinate transportation upon acceptance.
Fewer than 50% of patients seen by our PRC team have working phones, and approximately 50% of social work consults at our institution are for transportation needs.20 A previous initiative at our institution utilized the ED observation unit (clinical decision unit [CDU]) to facilitate safe disposition planning for victims of gender-based violence, noting a 70% success rate.20 We applied a similar approach to discharge individuals directly to SUD treatment centers.
1.3. Goals of this Investigation
In this study, we report our experience utilizing the ED CDU to link patients to residential SUD treatment. The primary outcome of this analysis was the number of patients transported directly from the CDU to a treatment facility.
2. Methods
2.1. Study Design and Setting
This is a retrospective cohort analysis of patients who presented to a single, urban, tertiary care hospital with more than 150,000 annual ED visits in Atlanta, Georgia, from June 2023 to May 2024. The hospital treats an underserved population with high rates of substance use, unstable housing, and lack of health insurance. Approximately 10,000 patients each year are assigned an SUD-related discharge diagnosis, although prior experience among our group in opioid use disorder (OUD)-specific studies suggest that this underestimates the true number by approximately 50%. A 5-member PRC team termed Linking Individuals Needing Care for Substance Use Disorders in Urban Emergency Departments (LINCS UP) was present in the ED during the study period from 8 am to 5 pm, Monday to Friday. Patients who presented outside these hours were unlikely to be seen by the team, although could be held in the ED at provider discretion while awaiting consultation. In Georgia, PRCs are trained and credentialed as Certified Peer Specialists in Addictive Disease (CPS-AD) by the Georgia Department of Behavioral Health and Developmental Disabilities.12
2.2. Selection of Participants
We included patients who were directed to our CDU pathway to obtain placement in residential SUD treatment. The list of eligible patients was obtained by reviewing the PRC consultation log and identifying patients who were transferred to the CDU. The date range represents 1 year from protocol implementation. This study was reviewed and approved by the Emory University institutional review board and follows STROBE guidelines for reporting observational studies.21
2.3. Intervention: CDU Protocol
The CDU is a 20-bed, short-stay observation unit. It is a protocol-driven extension of the ED, staffed by advanced practice providers (APPs) supervised by an ED physician. Between 2022 and 2024, our CDU saw approximately 3900 patients per year with an average length of stay of 20.8 hours. We developed a LINCS UP CDU protocol (Supplemental File) to bridge patients from the ED directly to residential SUD treatment. This protocol was developed collaboratively PRCs and CDU staff in response to a need identified shortly after the ED PRC team was deployed. Treating ED providers contact the LINCS UP team by phone or electronic medical record messaging to initiate consultation. PRCs respond to bedside and complete an assessment.
If the patient’s goals of care are consistent with residential treatment and they are otherwise appropriate for discharge from a medical and psychiatric standpoint, they are transferred to the CDU. For this review, residential treatment includes American Society of Addiction Medicine (ASAM) level 3 treatment programs and level 2.5 partial hospitalization programs provide adjacent supportive housing. Commonly, additional testing is performed to meet facilities’ admission requirements, including screening for syphilis and COVID-19 and chest x-ray for active pulmonary tuberculosis. The CDU team is responsible for medical care for 24 to 48 hours, while the PRCs coordinate placement. CDU staff can continue management of mild conditions such as acute kidney injury or mild withdrawal. Exclusion criteria include any condition prohibiting medical or psychiatric clearance, as well as conditions that are not accepted by any partnering residential treatment facility. This includes acute psychiatric instability, a potentially destabilizing psychiatric condition not managed by a medication for at least 2 weeks consistently, suicidal ideation, homicidal ideation, and moderate to severe withdrawal symptoms. Exclusion criteria also include wounds requiring medical management, mobility impairment, active infections requiring antibiotics, complex or poorly managed comorbidities, or multiple prior facility stays. These are assessed by the ED clinician and CDU staff prior to CDU transfer. Overall, the pathway was designed to serve patients who are otherwise stable for discharge from the ED after being provided referral information.
The number of referrals completed by the PRC depends on several factors, including insurance, location of the facility, and services requested by the patient. Commonly, 3 to 4 referrals are sent. Although the team works with many facilities, approximately 10 centers receive most CDU transfers. Following a review of medical documents, facilities typically require a phone assessment with the peer to determine overall fitness for their program. PRCs facilitate these screenings at bedside and provide coaching beforehand. Facility staff further review records, discuss patient-specific factors, and make an admission decision based on their own internal criteria. Following acceptance, transportation is arranged by either the receiving facility or ED social workers.
CDU staff observe patients for changes in their medical status; they should meet medical admission criteria while in CDU care—for example, owing to the emergence of benzodiazepine-resistant alcohol withdrawal—they are removed from the pathway and admitted to the hospital. The determination of whether the patient’s withdrawal symptoms or other medical conditions are appropriate for the CDU or require admission to the hospital is at the discretion of the ED and CDU staff.
2.4. Outcomes
Data were obtained through direct export and manual extraction from the electronic medical record. Manually extracted information included CDU disposition, primary substance used, and reason(s) why placement was unsuccessful. To address any ambiguous or conflicting data, where manual extraction was performed, a senior attending emergency physician abstracted data directly into a standardized form, which was then rereviewed and verified by the senior author, also an attending emergency physician. No discrepancies were noted. Missing data were not encountered.
2.5. Statistical Analysis
Results are reported descriptively (eg, means, medians, and IQRs). Differences in placements based on clinical presentations and demographics were examined by computing 95% CIs and comparing point and interval estimates. Analyses were conducted in the R software (R Foundation).
3. Results
3.1. Characteristics of Study Subjects
During the study period, there were 75 CDU encounters using the LINCS UP CDU protocol, representing 1.6% (75/4692) of CDU stays. Forty-nine were men (65.3%), 26 were women (34.7%) (Table 1). The median age was 45 years (range, 18-69 years); 49 (65.3%) patients were identified as Black, 19 (25.3%) as White, and 7 (9.3%) as other, multiracial, or unknown. The most common primary substance used was cocaine (27, 36%). Other substances used by participants included γ-hydroxybutyrate (GHB), opioids, methamphetamine, and alcohol. Two patients entered the CDU pathway twice. Since this was an evaluation of the CDU pathway rather than downstream patient-oriented outcomes, we included these encounters in the analysis.
Table 1.
Patients entering CDU pathway across the 75 encounters.
| Variable | All encounters | Encounters resulting in placement | Encounters resulting in not being placed | Differencea (%; 95% CI) |
|---|---|---|---|---|
| n | 75 | 53 | 22 | |
| Age (y), mean (SD) | 45.28 (12.51) | 46.55 (13.45) | 42.23 (9.49) | 4.32 (−1.96 to 10.61) |
| Sex | 34 (10-56) | |||
| Female | 26 (34.7) | 13 (24.5) | 13 (59.1) | |
| Male | 49 (65.3) | 40 (75.5) | 9 (40.9) | |
| Race | ||||
| Black | 49 (65.3) | 35 (66.0) | 14 (63.6) | 2 (−21 to 26) |
| White | 19 (25.3) | 12 (22.6) | 7 (31.8) | −9 (−32 to 13) |
| Other | 6 (8.0) | 5 (9.4) | 1 (4.5) | 5 (−7 to 17) |
| Unknown | 1 (1.3) | 1 (1.9) | 0 (0.0) | 1.9 (0-0) |
| Ethnicity | ||||
| Latino | 4 (5.3) | 4 (7.5) | 0 (0.0) | 7.5 (0-0) |
| Non-Latino | 70 (93.3) | 48 (90.6) | 22 (100.0) | −9 (−17 to −2) |
| Unknown | 1 (1.3) | 1 (1.9) | 0 (0.0) | 1.9 (0-0) |
| Insurance | 16 (−3 to 39) | |||
| Yes | 60 (80.0) | 45 (84.9) | 15 (68.2) | |
| No | 15 (20.0) | 8 (15.1) | 7 (31.8) | |
| Primary substance used | ||||
| Cocaine | 36 (48.0) | 25 (47.2) | 11 (50.0) | −3 (−28 to 22) |
| Alcohol | 11 (14.7) | 11 (20.8) | 0 (0.0) | 20.8 (0-0) |
| GHB | 1 (1.3) | 0 (0.0) | 1 (4.5) | −4.5 (0-0) |
| Methamphetamine | 13 (17.3) | 8 (15.1) | 5 (22.7) | −8 (−28 to 12) |
| Opioids | 14 (18.7) | 9 (17.0) | 5 (22.7) | −6 (−26 to 15) |
| ED LOS (h), mean (SD) | 8.06 (4.55) | 7.76 (4.21) | 8.79 (5.30) | −1.02 (−3.32 to 1.28) |
| CDU LOS (h), mean (SD) | 31.02 (15.12) | 31.78 (15.51) | 29.19 (14.33) | 2.59 (−5.09 to 10.26) |
Values are n (% of column) unless specified.
CDU, clinical decision unit; ED, emergency department; GHB, γ-hydroxybutyrate; LOS, length of stay.
Differences are shown as mean differences for continuous variables and percentage differences for categorical variables, with 95% CIs. For groups with 0 encounters, CIs were not calculated.
3.2. Main Results
PRCs placed patients into residential SUD treatment in 53 encounters (70.7%). The mean CDU length of stay was 31.78 hours for patients placed and 29.19 hours for all patients in the pathway.
Of the 53 placed, 35 (66%) were identified as Black and 12 (22.7%) as White. We did not observe a difference in placement rate when comparing Black (71.4%) and White (63%) patients. Forty of 49 male patients were placed vs 13 of 26 female patients, an absolute difference of 34% (95% CI, 10%-56%).
Forty-five of the 53 encounters resulting in placement were insured. Of the 15 uninsured patients, 8 (53% of uninsured patients) were successfully placed. We did not observe a difference in placement rates between insured and uninsured patients, nor across substances of use.
Of the 22 instances of nonplacement, the most common reason was patient-directed discharge after arrival to the CDU (10/22 patients not placed and 10/75 of the total patient population) (Table 2). Among patient-directed discharges, no cases of untreated or undertreated withdrawal were noted. Four patients walked away without notifying staff. Prior clinical notes indicated they were doing well. Two patients refused to talk to the peer coaches once in the CDU. One was accepted to a treatment center but walked away while awaiting transportation. One was nearing the maximum time in the CDU without securing placement and elected to leave. One decided to live with their family out of state and pursue treatment there. One felt much better after starting buprenorphine and elected for outpatient treatment. Three patients had a change in clinical status unrelated to SUD and were admitted to the hospital (eg, worsening of chronic obstructive pulmonary disease [COPD] symptoms). Therefore, only 9 patients (12% of the total group) were unable to be placed because no accepting facility was found. In 4 cases, no treatment beds were available across referred organizations (5.3% of total patient sample and 18% of the individuals not placed). Of the 5 patients who did not qualify for residential programming, 2 were White. Specifically, 1 individual was involved in a study that prevented participation in additional programming; 1 individual’s insurance (Medicaid) was not accepted at the referred to centers, and 3 individuals were deemed too medically complex. Of the denials citing medical complexity, 1 participant had multiple spinal fractures requiring a thoracic–lumbar–sacral orthosis (TLSO) and was largely nonadherent with prescribed medications for comorbid conditions, including heart failure with reduced ejection fraction, hypertension, and diabetes mellitus. The second had a calcaneus fracture and was using a walker, and the third used a wheelchair and had made passive suicidal statements. Although the third patient had been evaluated and cleared by psychiatry, the treatment center deemed this would require a higher level of care than available at their facility.
Table 2.
Reported reasons for encounters not resulting in a successful placement (n = 22).
| Reason for not being placed | Value, n (%) |
|---|---|
| Patient directed discharge | 10 (45.5) |
| Did not qualify for residential treatment | 5 (22.7) |
| No treatment beds available | 4 (18.2) |
| Admitted to hospital | 3 (13.6) |
4. Limitations
This is a single-center observational study performed in a non-Medicaid expansion state. Results are not necessarily generalizable, nor applicable to all EDs, depending on resource availability. PRCs were available on weekdays during the day. Patients presenting outside these hours may have been discharged before the team was available, contributing to selection bias. This study was performed retrospectively, and we could not record the total number of patients nor the characteristics of patients that might have qualified for the CDU pathway if it were available at all times, nor the total number of patients with SUDs desiring residential treatment that required hospital admission and were ineligible. Our hospital has a 20-bed CDU staffed by 1 to 2 providers at any time. Although the average CDU length of stay (LOS) for patients in this protocol was 26.9 hours (median, 31 hours), this varied widely, ranging from 3.4 to 69.3 hours. While our patient population represented only 1.6% of CDU stays during the study period, a median LOS exceeding 24 hours may be unfeasible at some institutions. We also note that interprovider variability for interpretation of medical complexity and CDU LOS allowances exist, and we are unable to quantify this variability.
5. Discussion
Peer coaching and linkage to care are increasingly recognized as key components of treatment for substance-related ED encounters.18 We have previously demonstrated the feasibility of PRCs in linking patients with varying degrees of SUD care in our ED.12 To address gaps in care on discharge and address both systemic and institutional barriers, we utilized PRCs in conjunction with the CDU to link patients directly to treatment centers. We saw broad success: this CDU protocol had a successful placement rate of 70.6%. Further supporting this finding is a study from our institution utilizing the CDU to facilitate safe discharge for victims of domestic violence; utilizing social workers and the CDU, they were able to discharge 70.7% of patients to a secure location.20 This is evidence of broader applicability of the CDU as a resource for the ED physician to overcome social barriers to care.
We observed a lower pathway success rate for women than that for men. This likely reflects the limited number of residential treatment centers accepting women in our area. The etiology of SUDs often differs in women and men, including a higher prevalence of sexual violence, intimate partner violence, and adverse childhood experiences among women.22 While this requires a targeted treatment approach, research and treatment availability for women with SUDs continue to lag nationally, with bed availability particularly limited for pregnant and postpartum women.23,24 Further, while men have traditionally been diagnosed with SUDs at a higher rate than women, this gap is rapidly narrowing.25 There remains a tremendous need to increase research and treatment availability for women with SUDs.
When considering race, ethnicity, and insurance status, we did not observe differential placement rates. These results are reassuring that no clinically significant racial bias existed in linkage to SUD treatment. One individual did not qualify for placement based on their insurance (Medicaid), which was not accepted at the facility to which they were best matched. Three other patients with Medicaid were placed with different programs. Therefore, we believe that specific insurance carried by the individual is less important than factors that can be unique to each patient; for example, facilities with open space at the time of inquiry, facilities that have geographical restrictions, and presence of comorbid conditions . Similarly, the majority of our uninsured patients (53%) were successfully placed.
The CDU is designed to be a short stay unit. Ideally, diagnostic and therapeutic care can be completed, and patients can either declare themselves as ready for discharge or needing admission within 24 hours. The average CDU LOS during the study period was 20.8 hours, which is consistent with other published reports.26 Average LOS for patients on the LINCS-UP pathway was 26.9 hours, with the longest LOS being 69.3 hours. Much of the increase in LOS can be explained by the complexity of the referral process and setting up transportation. Frequently, transportation is provided by the receiving facility, whose driver(s) may be with another client and/or hours away. When the facility is unable to provide transportation, it is typically secured using a commercial rideshare provider; however, this can be challenging if the treatment facility is far from the hospital. PRCs were not available overnight or on weekends, so placement and transportation arrangements did not occur during these hours. Decisions to extend patients’ LOS past 24 hours were made jointly between the CDU provider, PRC, and the patient. Patients could be held for additional time if facility acceptance was deemed to be likely the next day or if facility acceptance had been finalized, but transportation could not be arranged until the next day.
In all situations where a patient was not transitioned directly to a treatment program, including those who chose to leave in a patient-directed manner, peer specialists provided written information on available community resources. Continued research and advocacy are needed to identify patient factors that contribute to successful placement and address barriers to successful linkage to care.
In summary, PRCs effectively assist patients in gaining timely access to residential SUD treatment from the ED. In this CDU pathway, PRCs were able to place most interested patients regardless of insurance status or race; however, we did note a lower success rate for women, likely reflecting a lack of local residential treatment beds for women. Patients on this pathway had a longer-than-average CDU LOS, but few required hospital admission. Further study is required to examine efficacy of this program, as well as effects on patient-centered outcomes, including recovery from substance use and subsequent hospital admissions.
Conflict of Interest
Joseph Carpenter, Tatiana Getz, Alaina Steck, Lakeisha Johnson, Sydney McKee, Nicholas Giordano, and Umedjon Ibragimov report that financial support was provided by Centers for Disease Control and Prevention. Matthew Wheatley is a decision editor for JACEP Open. Given his role as decision editor, he had no involvement in the peer review of this article and had no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to another journal editor. All other authors have affirmed they have no conflicts of interest to declare.
Acknowledgments
The authors are grateful to the additional staff members and peer coaches who contributed to this project: Berlinda Jackson, Beth Lambert, Mikayla Allen, Michael Mintz, Yan Li, Roesheen McGilvery, Samayah Boynton, and Lauryn McCray.
Financial Support
This study was supported by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (grant number 5R01CE003509). The views and opinions expressed in this manuscript are those of the authors only and do not necessarily represent the views, official policy, or position of the US Department of Health and Human Services or any of its affiliated institutions or agencies.
Footnotes
Supervising Editor: Christopher Baugh, MD, MBA
Supplementary material associated with this article can be found in the online version at https://doi.org/10.1016/j.acepjo.2026.100359.
Supplementary Materials
References
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Associated Data
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