Inside the Hospital Programs Trying to Fix How America Treats Addiction

Picture a hospital bed as a door that opens only once. Someone arrives in crisis, an infection from injection drug use, an overdose, a broken bone from a fall during withdrawal, and for a few days they are physically present in a system built to treat their bodies but not necessarily their addiction. Then they go home, back into the same conditions that brought them there. For decades, that door has closed on millions of people without anyone walking through it with them.

Honora Englander, M.D., saw that pattern up close in the early 2010s as a hospitalist at Oregon Health & Science University. Hospitalizations tied to substance use disorder complications were climbing, but the system around her wasn't built to respond. "Despite having a really committed staff and well-intended clinicians across disciplines, we really didn't have systems or structures in place to care for people with substance use disorder in the hospital," she said.

A needs assessment OHSU conducted around that time confirmed just how important that hospital window really was. Up to two-thirds of patients with active drug use said they wanted to cut back or quit. Many wanted to start medications for opioid use disorder, known as MOUD, right there in the hospital. What was missing wasn't willingness. It was a bridge to care after discharge.

In 2015, Englander built that bridge. She formed IMPACT, the Improving Addiction Care Team, a multidisciplinary consult group of addiction medicine doctors, advanced practice providers, social workers and others. It was one of the first programs of its kind in the country. It has since grown to three dozen staff working across multiple hospitals.

The numbers back up the model. OHSU research found that patients who met with IMPACT while hospitalized were twice as likely to enter SUD treatment after going home. Other findings point to reduced substance use post-discharge, lower costs from shorter hospital stays, higher patient trust and better-informed hospital staff. Think of it like a cardiology consult for a heart attack patient: someone with specific expertise steps in, evaluates, and hands off a clear plan, except here the diagnosis is addiction and the treatment plan often continues long after discharge.

The scale of the need is hard to overstate. More than 48 million Americans live with substance use disorder, according to 2023 federal data. Overdose deaths have eased from the brutal peaks of 2022 and 2023, but remain what Itai Danovitch, M.D., an addiction psychiatrist and chair of the American Society of Addiction Medicine's Quality Improvement Council, calls "unacceptably and tragically high." Black and Native Americans die from overdose at 1.4 and 1.8 times the rate of white Americans, respectively. Most people with SUD never receive treatment at all, often because existing programs demand abstinence as a condition of entry, a barrier that shuts out people who aren't ready or able to stop using immediately.

Building the Infrastructure

What's shifting now is momentum. Stigma is softening as more people in recovery speak publicly about their experiences, which is also driving demand for services. Younger physicians are pushing harder for SUD protocols in emergency and inpatient settings than their predecessors did. Danovitch remembers a very different reception two decades ago. "They would kind of tolerate the discussion with me," he said of colleagues back then. "Now, I have a hard time getting off the phone with them."

Government has taken notice too. The Department of Health and Human Services announced a $100 million investment earlier this year aimed at homelessness, opioid addiction and public safety, with Health Secretary Robert F. Kennedy Jr. describing plans to build integrated systems that move people smoothly between crisis response, treatment and social support.

In 2023, ASAM laid out the core capabilities every hospital should have to properly care for SUD patients. This year it followed that up with a practical implementation guide, developed by a task force that included both Danovitch and Englander. The guide describes three main care models: addiction consultation services, bridging services, and hospital-based opioid treatment. Hospitals don't need to build from scratch, either. "Hospitals already have many of the components needed to standardize SUD care," Danovitch noted, pointing to social workers, nurses and pharmacists already on staff. "The problem is those ingredients haven't been organized to prioritize and focus on substance use disorder to the degree that is warranted." As he put it, "the model is less important than the commitment to the result."

At Yale New Haven Hospital, Melissa Weimer, D.O., who had earlier helped Englander get IMPACT off the ground, founded the Yale Addiction Medicine Consult Service in 2018. The hospital's more than 1,500 beds serve a diverse city with a high prevalence of substance use disorder, and Weimer found a system where MOUD was underused, partly because clinicians weren't sure about the legal rules around prescribing methadone, a tightly regulated medication.

Today her team, made up of addiction medicine doctors, advanced practice providers, fellows, residents, care coordinators and social workers, takes consult requests every day of the year during business hours. Metrics the hospital tracks, including emergency department admissions, length of stay and 30-day readmissions, have all improved since the service launched. A 2022 federal rule allowing hospitals to dispense up to three days of methadone at once, rather than requiring daily return visits, saved Yale more than $300,000 in the past year alone.

Back at OHSU, IMPACT has developed its own protocols, including low-dose buprenorphine and rapid methadone approaches, and does much of its work at the bedside alongside social workers and nurses. Englander described treating a patient who recently needed higher-than-usual methadone doses to interrupt their drug use. In the past, she said, that patient might have been discharged still in withdrawal. Now, the approach is more trauma-informed. IMPACT also runs a statewide physician advice line, a program focused on SUD in pregnancy, and a telementoring initiative called ECHO that has reached more than 700 participants.

Why It Matters

None of this works in isolation, and both program leaders are emphatic about that. Weimer stressed that "the majority of the care and the recovery is going to happen outside of the hospital setting," which is why her team partners with outpatient providers, a street medicine team, and a federally qualified health center, and why she sits on a state committee working to expand SUD care into skilled nursing facilities. Englander echoed the same philosophy, noting that IMPACT was built from the start to work with housing organizations, coordinated care groups and the Mental Health & Addiction Association of Oregon. "We really set out in our development to get past the traditional silos," she said. "That's a critical piece of what we do."

Danovitch believes broader change will require hospitals to report more on SUD-specific quality measures, since addiction services rarely drive revenue on their own. "What drives them to address these things is quality reporting and wanting to perform well," he said, arguing that pressure, not profit, is what will push more hospitals to adopt these models. Weimer agrees the business case alone won't cut it. "The argument at Yale really was about quality of care," she said. "If you only try to make the business case, it probably will fall flat." What's needed, in her view, is at least one physician champion with real addiction medicine training and the stamina for what she calls hard work: rebuilding, patient by patient, the trust a healthcare system spent decades losing.