It is not uncommon for weekdays to blur with weekends when working shifts in the emergency department (ED).  However, one of the key distinguishing features is that there are fewer resources available on weekends. This can be an encumbrance when attempting to provide patients with continuity of care for their medical issues. Strikingly, there is nothing remotely comparable for those evaluated in the emergency department when treated for addiction and mental health related concerns. Addiction stands alone to a greater extent, as it is the most challenging of circumstances to offer any reasonable resources with any regularity.  There routinely are few to no options available, any day of the week, in the majority of EDs in the state.  It is that dismal.

In the past 72 hours, four unrelated patient encounters, all active IV heroin users who were looking for some way to get into a rehab program, were essentially left without any reasonable options. Two of them, men in their twenties, lied, stating that they were suicidal.  They later disclosed that it was the only way they had a chance of being admitted to a hospital and to maybe get some help for substance abuse.  One simply did not meet criteria for admission.  The other found it unbearable to spend several days confined to a room within the ED, with no guarantee as to when he would be transferred to a psychiatric facility and knowing that he would not receive addiction counseling or follow up. The other two patients were in the ED after a motor vehicle crash and a family dispute, complicated by heroin use.

They each had very personal histories, varied educational backgrounds, including two college grads.  All had been employed, but none were able to maintain work or sustain personal relationships.  Each had become physically compromised from their substance abuse.  Two patients had ultimately started using heroin as their sole drug of choice other than alcohol, and were introduced to it by friends.  One of the four reported getting hooked after many years of using recreational street drugs from marijuana to LSD, and that the intense high, along with its affordability and accessibility made it the best of its kind.  The fourth patient got turned onto heroin from friends, also, reportedly, because it was cheap.  One woman did admit to using opioids and marijuana that she bought on the street for many years.  All four had been using drugs since they were in their early teens. 

Persistent and wide-reaching socioeconomic devastation is hammering New Hampshire and other states.  It is time to double down with sensible plans attached to a massive advocacy campaign, with clearly identifiable resources to achieve sustainable and reasonable metrics.  What is not likely to be successful are grandiose plans that require unrealistic funding, where results may not occur for years or longer and therefore are likely to fail. “New Hampshire ranks first in the nation for young adult drinking, third for youth drinking and binge drinking, and in the top ten for other drug use.” “Substance use costs the state $1.8 billion annually in lost worker productivity and earnings, health care costs, public safety, and criminal justice expenses.” New Hampshire Tomorrow: Investing In Our Kids, New Hampshire Charitable Foundation, 2015, p.8. 

It is essential to present opportunities and potential solutions in such a manner that people can see and experience accomplishments through tangible step-by-step strategic planning, rather than by offering a panacea to be everything to everyone for years to come. “The Myth of the Change Program: This approach comes with the launch event, the tag line, and the cascading activities.” “Think about it for one minute. Why do most overhyped change programs ultimately fail? Because they lack accountability, they fail to achieve credibility, and they have no authenticity.”  Good to Great  by Jim Collins, 2001.

In order to make necessary strides for our kids, family members, colleagues, patients and citizens, we must support those who are truly interested in making a difference, who are present, passionate, and accountable and who will really remain able to carry on.  We need to empower their passion and grow it.  Rushing to solutions based on not letting a serious crisis go to waste, a la Rahm Emanuel, may offset the work of others who are deeply committed to effectively achieving similar but more sustainable goals, by expanding upon a clear and openly shared multipronged public health campaign.

We should foster partnerships among content experts and influencers, in order to be largely successful.

Lukas Kolm, MD, MPH

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