The ED Catches Teens at the Worst Moment

A 16-year-old comes into the emergency department after a night that went sideways. Maybe it’s a car crash. Maybe it’s a panic attack that won’t stop, or a friend who called 911 because someone wasn’t breathing right. The chief complaint rarely says “substance use.” It says something else. Somewhere in that visit, a screening question gets asked, and the answer changes what should happen next.

At our ED, that question has been asked of adolescent patients for over twelve years, with completion above 92%. Screening was never where things fell apart.

Where Things Fall Apart

A positive screen gets written into a provider note 57% of the time. It shows up in the assessment and plan, the section that actually drives discharge decisions, in just 9% of encounters. A referral to treatment gets documented in fewer than 1%. In one review of 743 adolescents who screened positive at our ED, 3 encounters had a documented referral, and none of those three had documented follow-up care. Zero.

Nationally the pattern repeats. Fewer than one in five adolescents with a substance use disorder gets any treatment. Fewer than a third get follow-up care within 60 days of an ED visit where substance use came up. One in five returns to the ED within a year for a substance-related visit. The door keeps swinging, and almost nobody walks through the other one, into care.

The ED is often the only point of contact these teens have with the health system for this issue. They don’t seek out primary care for substance use on their own, and parents don’t always know what to ask a pediatrician. The ED sees adolescents at 2am, in crisis, when the walls are down and honesty comes easier than it does at a scheduled 15-minute well visit. That window closes fast.

Prehospital data tell a related story. In a statewide analysis of pediatric opioid EMS encounters, higher-income zip codes generated more calls than lower-income ones, but in lower-income areas, when EMS did respond, naloxone got administered at a higher rate. It says something about who gets noticed and who gets treated once someone finally shows up.

We started a peer recovery navigator program at our ED two years ago. It’s still small. The adolescents enrolled in it are the first cohort in our system’s history to get anyone checking in on them after that ED door swings shut behind them.

Key Points

• Our emergency department has screened over 92% of adolescent patients for substance use for more than a decade, yet a documented referral to treatment occurred in fewer than 1% of those encounters.
• In a review of 743 adolescent encounters with a positive substance use screen, only 3 had a documented referral to care, and none of those three had documented follow-up.
• One in five adolescents returns to the ED within a year for a substance-related visit (Kim et al., PLOS ONE, 2023).
• Prehospital data show lower-income zip codes generate fewer pediatric opioid EMS calls but higher rates of naloxone administration once EMS responds, a pattern that points to delayed help-seeking rather than lower risk.