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Episode 4: Substance Use Disorder in the Wake of COVID-19

An analysis of hospitals on the Collective network shows that overdose visits as a proportion to overall emergency department visits have increased by about 35 percent since lockdown began across the nation.

Join Dr. Enrique Enguidanos, CEO and Founder of Community Based Coordination Solutions and Kat McDavitt, Chief of External Affairs at Collective Medical and as they interview Anne Zink, MD, FACEP and Chief Medical Officer for the State of Alaska and Hon. Nathaniel Schlicher, MD, JD, MBA, FACEP, Regional Director of Quality Assurance for Franciscan Health System and Associate Director of the TeamHealth Litigation Support Department.

Key topics:

  • Obstacles to patients receiving substance use disorder treatment
  • Silver linings coming from the pandemic
  • What it takes to implement a successful SUD program

Listen to the full episode here, on Spotify, or Apple Podcasts. Below, you’ll find excerpts from the conversation (edited for length and clarity).


Enguidanos: Can you both provide some of your day-to-day experiences related to substance use disorder as emergency physicians?

Zink: I think those of us working in the emergency department see, know, and almost feel [SUD] either through interactions with individuals or through overall patterns of what’s happening in the emergency department.

It’s important to be thinking about the whole person—it fascinates me how we separate the mind and body in the way that we pay for and deliver care. But they are integrally part of who we are as one person. Thinking about adverse childhood experiences, the way that trauma and stress impact people, and the way that manifests itself into both physician complaints and mental struggles. And then in the way people use coping skills, including addiction and alcohol, which add additional levels of burdens and barriers to treatments and success.

In the emergency department, I always thought I’d be dealing with heart attacks and car accidents—now I find myself talking about everything from adverse childhood experiences to social determinants of health.

Schlicher: As an inner city ER doctor, substance use disorder represents a large bulk of our patients. And it manifests in so many ways. It’s not just somebody coming in for addiction and dealing with an overdose event—it’s the cocaine-induced heart attack, the methamphetamine-induced stroke or psychosis, the heroin-induced abscess.

There have been days where 60-70 percent of my patients may have a substance use disorder involved in their presentation but not be the reason they’re in the ER. When we include alcohol, that number can get even higher.

When we think about substance use disorder, it’s also important to remember that these are everyday people in our lives—they’re somebody’s mother, brother, son, or daughter.


Enguidanos: 8.5 million adults have co-occurring substance use and mental health disorders, yet half don’t receive treatment for either. What are some of the obstacles to folks not receiving the care they need?

Zink: There are a couple of big categories. The first is compassion. Treating people as people. This is a disease and there’s a cultural aspect that permeates the way we have individual interactions with our patients—along with how nurses, the front desk staff, and even the janitors have interactions. There’s a cultural change that we continue to need to go through to be able to provide compassionate care at every step to encourage people to get treatment. 

Second, there are real challenges in the way we pay for care. We’ve separated mental and physical care. The way we’ve broken things apart have left people falling between the cracks in those systems of care. There’s a fundamental disconnect.

Schlicher: The overlap is so critical. With the ER is for Emergencies program, when we looked at patients visiting the ER more than three times per year, we found that over 80 percent had mental health and over 45 percent had substance use disorders.

The reality is that there’s a huge co-occurring nature to these disorders and that patients are not getting access to the healthcare they need in outpatient treatment programs, in supportive housing, and so many other venues. Oftentimes, they’re coming to the only place left to care for them—the emergency department.


McDavitt: Analysis of hospitals on the Collective network shows that overdose visits as a proportion to overall ED visits have increased by about 35 percent since the lockdown. Can we use approaches like better integration or addressing health equity and social determinants—or is this something different that needs to be approached in a very different way?

Schlicher: There was a statistic early in the lockdown that alcohol sales were up 55 percent over historical averages, and I would assume other illicit substances had a similar rise.

What was interesting to me was that in the first month of lockdown, our visits for substance use disorders went down. I think people of all stripes—whether the parent coping with alcohol or the person on the street dealing with methamphetamine use—were scared straight. And then life started to settle back in and people became just scared. They started to cope with that in the no-so-functional way many people do—alcohol, substance use disorder, and even eating their feelings.

I think this is different in the sense that it’s not a singular event that led to your crisis, it’s that all of your life is in crisis. Your whole world has changed. There’s a loss of normalcy.

Zink: I think there’s also a component of designer drugs that’s also affecting these numbers that we may have seen regardless of COVID. I was just on our state call looking at our overdoses and some of the national numbers and the amount of spice, bath salts, and designer fentanyl drugs where one pill or one exposure can kill. The effects of that are probably playing a role in the overdoses and numbers. That isn’t to, in any way, to take out or minimize the impact that COVID has had and the challenges.

However, we’re seeing mental health no-show appointments plummet because people are finding telehealth as an acceptable way to get mental health treatment. We’re seeing legislative movement to allow things like MAT appointments to happen via telehealth rather than in person, which is allowing rural areas to get MAT therapy in places that have never been able to get it or where it’s been much more limited.


McDavitt: Are there any other silver linings coming out of the pandemic that can help address the opioid epidemic in a way that we didn’t have or consider before?

Zink: There’s a new focus on prevention and also on involvement in community and realizing how interconnected we are. The challenges in testing have emphasized the fractured healthcare system that we work and deliver care in.

I think there’s also a whole new appreciation from many legislators, politicians, and policymakers at all levels about the complexity of healthcare delivery in the country as a whole—and if you’re wanting to have a unified approach, how challenging it is in a fractured healthcare system.

Schlicher: This crisis has really laid bare our challenges of how we’ve lived with denial and defensiveness in our personal lives as well as in the way we’ve delivered healthcare for the last 50 years.

For example, a lot of people are having a real fear attached to their smoking that they never did before because it worsens outcomes with COVID. Same thing for obesity, high blood pressure, heart disease, substance use disorder, and so many other things that impact their lives. It’s allowed us a window into that conversation to say, ‘these choices actually matter in your life, this isn’t something to get around to in 20 years.’

I think it’s had the same impact on the healthcare system itself to say, ‘we just can’t keep doing things the way we were, we can’t keep overfilling hospitals and quickly turning patients out of the ER.’ But instead, think more holistically about the care that’s getting delivered and working as part of the broader health system to solve some of these population health problems in a way we haven’t historically been doing.

I’m encouraged that we’ll hopefully seize the hardship of this crisis to make real change for our patients and move the ball forward on some of these social determinants. I tell my patients that ‘80 percent of your health is determined by the decisions you make in your life, very little of it has to do with what I’m going to do for you today. So what can we do to fix those?’ That conversation is starting to happen in the country and in our health system and that’s a good thing.


Enguidanos: You have each been involved in implementing extremely successful programs in each of your states, which have been taken to other states and proven to be successful. What have you found that makes a difference?

Schlicher: A lot of it has to do with coming up with a solution that works for everybody involved. ER is for Emergencies went to tackle the problem of spending a lot of money on healthcare that the state felt was unnecessary, but was really a reflection of the brokenness of the system—and also worked to help the patients and the clinicians. It was a win-win-win solution.

Zink: I would also add, take good ideas and copy them. I borrowed Dr. Schicher’s and took some of them up here. Additionally, it’s really centered around what’s best for patients—that’s much easier to get people behind and advocate for.

I would also argue that you need to involve multiple stakeholders. It really takes all of us to create solutions. You need the five Ps—providers, patients, policymakers, the public, and the press to all come on board.

Lastly, not being afraid to ask hard questions as long as you’re willing to come to the table with good solutions. The moment someone comes to me with a solution, I’m all over it. Coming with solutions can make a big difference in moving the ball.


About the Speakers

Anne Zink, MD, FACEP and Chief Medical Officer for the State of Alaska  

Dr. Zink grew up in Colorado and moved through her training from College in Philadelphia to Medical School at Stanford and then Residency at University at Utah. She then decided to take a leap of faith to try a job in Alaska for a few years. She fell in love with the people and the place, but also the medicine. Alaska is a small isolated microcosm on the US health care market where certain forces like the distance, lack of referral centers, and no managed care challenge individual providers to help create better systems of care that are directly related to bedside care. In 2016, she helped Alaska pass legislation similar to Washington state’s “Seven Best Practices” and has been working closely with state and federal agencies since then to expand and extend its work to include VA, DOD, and IHS facilities (and more!).

Hon. Nathaniel Schlicher, MD, JD, MBA, FACEP, St. Joseph’s Medical Center, Regional Director of Quality Assurance for Franciscan Health System and Associate Director of the TeamHealth Litigation Support Department.

Dr. Schlicher attended Law School and then Medical School at the University of Washington before completing an EM residency at Wright State in Dayton, Ohio, with board certification in Emergency Medicine. He recently completed his Masters in Business Administration with an emphasis in Health Care.

As Legislative Affairs Chairman of the Washington State Chapter of Emergency Physicians, Dr. Schlicher spearheaded the “ER for Emergencies” program to replace the State’s plan to deny ER services to Medicaid patients. He created and has edited five editions of a textbook on the importance of advocacy by physicians, “The Emergency Medicine Advocacy Handbook.” He currently serves as the President Elect of the Washington State Medical Association and is a Past President of the Washington Chapter of the American College of Emergency Physicians. He has previously served as the Legislative Advisor on the Board of Directors of the Emergency Medicine Residents’ Association. He also spent a year in the Washington State Senate, representing the 26th District, where he continued his work on healthcare advocacy. He continues to work with interested parties on health policy topics, including renewed focus on the opiate and mental health crises affecting the state.

About the Podcast

The Collective Conscious is a monthly podcast aimed at addressing gaps in healthcare for some of our nation’s most vulnerable patients. Each month, we’ll meet with healthcare leaders to discuss what care teams, communities, and government agencies are doing to better support individuals with unique care needs—this includes mental and behavioral diagnoses, substance use disorder, homelessness and social determinants of health, and other complexities of care. 

About the Hosts

Enrique Enguidanos, MD, MBA has over 20 years of clinical experience in emergency medicine—much of which has been spent also serving in organizational and systems management roles. As CEO and founder of Community Based Coordination Solutions and a practicing ED physician, he has spent over a decade developing and fine-tuning systems of care and community management systems that have proven very effective for frequent utilizers. He has organized these systems in a manner that allows CBCS to continuously reproduce care results across varying communities and healthcare systems.

Kat McDavitt is Chief of External Affairs at Collective Medical. With over ten years of experience in healthcare marketing, communications, corporate, and government strategy, she has positioned healthcare companies from small angel-funded start-ups to multi-vertical public corporations. Her knowledge of the healthcare industry spans both clinical and administrative innovations—as well as professional services—in the patient, physician, institutional and payer markets.