Fentanyl, mental health, homelessness: They intersect in the ER

“In the history of emergency medicine, this has to be one of the most challenging times,” said one emergency physician in Tacoma.

The COVID-19 pandemic was a truly unprecedented moment for our hospitals, but the overlapping crises of homelessness, substance use disorder (especially fentanyl), and mental health challenges have created a new crisis epicenter: our hospital emergency departments.

Each of these crises has been steadily building for years, and COVID, in part, masked these growing issues in our EDs. With the rise of chronic homelessness, ED utilization by unhoused people has increased by 80% in the last 10 years. In our state, mental health conditions have grown to affect more than 1.2 million Washingtonians, and no state in the U.S. saw a more significant increase in drug overdose deaths than Washington, with an increase of 38.5% from 2022 to 2023. Fentanyl is now the leading cause of death among individuals under 45, and the fentanyl crisis has disproportionately impacted homeless individuals.

We all rely on our hospital emergency departments to provide immediate care for ourselves and our families when we experience a health emergency, like a heart attack or an accident. Yet today, our EDs are overwhelmed with patients who do not necessarily need emergency medical care. Often, EDs are the only source of health care for unhoused individuals, and while some visits are for true medical emergencies, law enforcement and first responders are increasingly bringing people to the ED because no other alternative exists. Our EDs are designed to care for acutely ill and injured patients, not to provide shelter, routine medical visits, or long-term care for unhoused patients also experiencing mental health and/or substance use disorder issues. In our state, one out of every 10 ED visits are by unhoused individuals, according to new data by the Washington State Hospital Association.

Washington’s hospitals are committed to ensuring every patient who walks through the doors gets the care they need. Emergency rooms are designed to provide the most intensive and expensive care for emergency conditions 24/7 and 365 days a year. As our doctors, nurses, and staff are currently navigating these complex issues, our EDs are already under significant stress, overcrowded, and confronting safety issues. One physician in Tacoma highlighted the impact on those in need of emergency care saying, “We are starting to treat heart attack and stroke patients or pregnant women in the waiting room chairs because we don’t have capacity in the ED.” Managing the difficult situations and the complex needs of patients is understandably leading to burnout by our doctors, nurses, and staff in EDs.

We need an emergency response to these crises while we build more long-term treatment and housing solutions. Time is of the essence. Challenge Seattle, in partnership with the Washington State Hospital Association, has created 10 recommendations that can be implemented now. Looking across the country at successful solutions, here are three cost-effective ideas that can get off the ground in weeks or months — rather than years:

∙ Launch street medicine teams. Individuals are in crisis on our streets and storefronts, under bridges, or in encampments. Communities across the country have created new programs to deploy physicians, nurses, counselors and peers to provide health care to unsheltered individuals where they are. Given the high prevalence and complexity of co-occurring mental health and substance use disorders and medical needs, street medicine programs have the potential to directly deliver needed care in the field, avoid crises, and prevent unnecessary visits to the ED. In the first year of a street medicine program in Los Angeles, the program saw a 32% decline in repeat ED visits from high-risk patients. Communities like Seattle, Spokane, Tacoma, Everett and others are ready to put additional street medicine teams in place within weeks or months with new pilot funding from the Legislature.

∙ Establish emergency stabilization facilities. Local and tribal governments, hospitals, and providers know the need for additional alternatives to our emergency departments to address mental health and/or substance use disorders. There have been major investments — such as the $1 billion Crisis Care Centers Levy in King County and hundreds of millions of dollars by the state Legislature — but many of these facilities are new construction projects that won’t be operational for years.

We propose a new approach: low-barrier stabilization sites with new capital funding to convert underutilized wings of hospitals, vacant medical facilities or new spaces at current shelters to address behavioral health with particular focus on the fentanyl crisis.

We need more options for treatment and interventions like the proposed Opioid Recovery and Care Access Center led by the Downtown Emergency Service Center in Seattle, and we can’t afford to wait. The Legislature can create an Emergency Stabilization Facility Fund that would allow communities across the state to create rapid alternatives to EDs to open this year. In Boston, they opened a 24/7 stabilization clinic at a hotel in less than two months. In the first year, they served 1,722 patients who had 7,468 visits and average stays of 11.5 hours.

∙ Authorize EMTs and paramedics to administer opioid treatment. Treatment must be foundational and more accessible than a $3 fentanyl pill. When a patient is at risk of overdosing or has overdosed, their first point of contact is often with a paramedic or an EMT. In places across the country — including Camden, Pittsburgh, and Minneapolis — paramedics or EMTs responding to overdoses engage patients to start treatment immediately by administering Suboxone. This reduces the initial severity of withdrawals and increases the likelihood that an individual may seek further treatment. Patients seen by a Suboxone-equipped ambulance crew were at least six times more likely to visit a treatment clinic. In partnership with the Department of Health, Seattle paramedics are expected to be the first in the state to deploy treatment, but this training and program must be expanded to EMTs and departments across the state. The Legislature can make this kind of progress possible by authorizing the secretary of health to issue a statewide standing order to permit this treatment.

Working together, we can implement these timely and proven solutions in our own state. We can reduce the strain on our emergency systems and ensure better care for all. More lives are at stake every day we fail to act. The time for action is now.