Massachusetts ACEP, ENA, Nurse Practitioners, Medical Interpreters Association, Boston EMS, and the Massachusetts Hospital Association
Massachusetts Organization for Addiction Recovery (MOAR)

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Evolution of an ED-based collaborative model
for improving the care of patients with substance abuse problems:
From one institution to nationwide dissemination, 1991-2006

Mixed Blessings: Opportunity and challenge in the nation’s EDs
 ED patients are 1.5-3.0 times more likely to report heavy drinking or consequences than primary care patients (Cherpitel, 1999).  More than 10% meet formal criteria for dependence (Lowenstein, 1998), and 25% are AUDIT test positive using a probability sample (Cherpitel, 1995).   In a five year follow-up, alcohol-intoxicated ED patients had twice the mortality rate as a non-intoxicated comparison group (Davidson, 1997).  However, providers identified less than a third of the 31% of dependent drinkers as having a current problem, and less than a fourth of those identified received treatment referrals, despite the location of an assessment and placement facility adjacent to the ED (Bernstein et al., 1996).

While there is ample opportunity to encounter ED patients at risk for injury and other alcohol-related consequences, both preventive and chronic care  are generally seen as outside the mission of emergency medicine. Although dependence on alcohol and other substances is at the root of many presenting problems, injured patients are often stitched up and discharged without addressing either current or chronic substance use, and the high risk drinker who lacks the stigmata of ‘alcohol on breath’ is very likely to leave undetected.

The rationale for action
Project ASSERT was derived from evidence supporting the role of community health workers as casefinders, culture-brokers, educators and access facilitators in underserved areas (Swider 2002, Brownstein et al., 2006), and motivational interviewing as a strategy for behavior change (Miller & Rollnick, 1991). A landmark study at Massachusetts General Hospital 50 years ago provided inspiration for change. In a controlled trial, Dr. Chafetz enrolled 200 middle-aged, homeless, dependent drinkers to test a non-confrontational brief intervention delivered by trained residents and social workers.  As a result, 40% of the intervention group but none of the controls kept five alcohol treatment appointments (Chafetz, 1962). If the intervention worked so well with alcoholics from Boston ’s notorious Scollay Square, why not give it a try in a comparable ED?  Project ASSERT was established in 1994 at Boston City Hospital with a demonstration grant from the national Center for Substance Abuse Treatment (CSAT) (Bernstein et al., 1997). Since then it has served more than 50,000 patients at the Boston Medical Center ED,  where Health Promotion Advocates (HPAs) screen for substance abuse and offer brief intervention and access to primary care, preventive services and substance abuse treatment. This model has been disseminated EDs across the nation, and now, with the help of the Massachusetts Bureau of Substance Abuse Services, there is capacity to establish programs in six Massachusetts EDs and funds for hiring Health Promotion Advocates at each site to improve the care of patients with substance abuse problems.