Peer-Based Substance Use Disorder and Recovery Interventions in Rural Emergency Departments:An Evaluation of the GCSA Community Connections Program
The current opioid crisis has necessitated timely, grassroots social entrepreneurship from stakeholders involved in the substance-use disorder and recovery fields. One such innovation involves the use of peer-recovery-support services in acute settings in which points of contact are made with high-risk substance-using populations. These programs have emerged organically in emergency departments (EDs) across the country.
The Georgia Council on Substance Abuse, Northeast Georgia Community Connections Program is a peer-recovery-support service (PRSS) that uses certified addiction-recovery empowerment specialists (CARES) in rural EDs in Georgia, a Medicaid non-expansion state. In this study, we reviewed initial data from the Community Connections Program captured at rural EDs. Patients (N 205) met the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5) criteria for substance-use disorder.
Participants recruited for the study were patients seen at one of the three rural Georgia EDs (mentioned above) participating in the NECCP. Participants were considered eligible for inclusion in the program if they received an SUD diagnosis, according to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American Psychiatric Association, 2013) criteria, by the attending qualified mental health professional. A screening professional, qualified to make DSM–5 diagnoses for SUD, was dispatched from the Laurelwood psychiatric unit located within the NGMC in Gainesville to complete patient screenings.
- Substance use disorder screening
Upon a positive SUD screening, the SUD diagnosis was entered into the electronic health record (EHR) and a PRSS specialist was notified to begin engagement with the patient..
- Data collection
All data analyzed for this study were collected and entered by the peer specialists from the initial contact, along with any follow-up engagements. Archival data provided for this exploratory evaluation did not include specific SUD-diagnoses (e.g., opioid-use disorder, alcohol-use disorder [AUD]), as the only EHR information provided was a proxy, binary variable of yes/no for “received a SUD DX during ED visit.”
- Using peer engagements for multiple substance types
This study demonstrated that peer interventions can be beneficial for all types of drug use, not just for individuals who experience accidental opioid drug poisoning (i.e., overdose).
- Bringing innovation to rural areas
In addition, results suggest that both clinical and community-based supports can be used for referrals to appropriate levels of care. These findings also highlight the utility of innovative and adaptive peer-recovery-support programs in rural EDs across the United States.
The strength of the NECCP stems from the successful engagement rate of peers to patients, the capacity to address both opioid-specific and other SUDs, and the bridging of gaps between social support and formal clinical support. As a grassroots model developed within a rural health-care system, the program is sensitive to the myriad demographic variables specific to the setting and fills a needed gap in service delivery within EDs. Identification of population-specific needs, coupled with a responsiveness to such needs, is critically important for any localized peer-based mechanism of support.
- Filling the gaps
Treatment-capacity gaps pose risks to particularly vulnerable Medicaid patients and the uninsured (Wen, Druss, & Cummings, 2015). For those with Medicaid, referral to SUD treatment does occur; however, referral to services such as withdrawal management in lieu of comprehensive or long-term care reflects serious gaps in service provision and coverage. This is a particularly dangerous phenomenon for those with OUD or in danger of accidental overdose following acute care (Strang, 2015). In the current study, participants with private insurance coverage were more likely to be referred to more comprehensive levels of clinical care, whereas those with Medicaid (or with no insurance) were more likely to be referred to withdrawal management services. Peer-based intervention programs should carefully evaluate the risk and benefits of each referral and balance community-based support referrals to mitigate gaps in clinical care because of insurance or underinsurance.