PROVIDENCE – A surprising fact emerged from the reporting by ConvergenceRI, looking at the actual data collected by the R.I. Department of Health, to determine the potential impact of the closing of the emergency department at Memorial Hospital on Jan. 1, 2018: the highest number of emergency medical transports in 2017 to the acute care community hospital in Pawtucket in 2017 was 720 for alcohol intoxication, as measured by the top 20 “impressions” recorded by EMT staff. [See link below to ConvergenceRI story, “ED at Memorial closes, setting stage for Care New England to merge with Partners.”]

When added together with impressions for “alcohol use, unspecified” – 77 – and “alcohol dependence with withdrawal” – 33 – the total number of transport impressions related to alcohol intoxication was 830, or nearly 13 percent of all 6,492 EMS transports to Memorial Hospital in 2017.

While “impressions” are not diagnoses, and the data measuring the number of emergency transports do not capture how many were for “repeat” patients, the high total raised a number of questions:

• How did the number of EMS transports for “alcohol intoxication” to Memorial Hospital compare to other hospital emergency rooms in the state?

• How did the numbers in Rhode Island compare to national trends?

• Were the problems of drinking – both binge drinking and chronic alcoholism – being overshadowed by the efforts to address the epidemic of opioid addiction and overdose deaths?

• What were the results of efforts of a pilot diversion program being run by The Providence Center to create an alternative to transporting alcohol intoxicated individuals to the emergency room?

• Was there a good way to calculate the medical costs of emergency transports for intoxicated individuals? How much of the burden fell upon commercial insurance and how much fell on Medicaid?

• What are the politics of alcoholism in Rhode Island? Last week, state Sen. Jamie Doyle from Pawtucket announced his immediate resignation, saying that he was battling alcoholism and he needed to focus on recovery.

The national numbers
The high number of impressions of emergency transports for alcohol intoxication at Memorial Hospital and at other Rhode Island hospital emergency rooms reflects a growing national trend, according to a study published on Jan. 2 in the journal, Alcoholism: Clinical and Experimental Research.

Among the findings of the study, which analyzed data from some 30 million visits to U.S. hospital-based emergency departments, from 945 hospitals in 33 states, were:

• Between 2006 and 2014, the number of ED visits involving alcohol consumption increased 61.6 percent, from 3,080,214 to 4,976,136.

• The total cost of such visits increased 272 percent, from $4.1 billion to $15.3 billion.

• The annual percentage change in rates of all alcohol-related ED visits was larger for females than for males [5.3 percent vs. 4.0 percent].

• Other drug involvement increased the likelihood of admission for inpatient treatment for alcoholism.

What caused the alarming increase in the number of alcohol-related ER visits is not clear, according to one of the authors of the study, Aaron White, a neuroscientist, given just a 2 percent increase in per capita alcohol consumption overall and an 8 percent increase in the number of emergency room visits for any reason during the same nine-year period, according to a report by NPR.

“The lowest hanging fruit in terms of hypotheses is that there must be an increase in risky drinking in some people,” White told NPR.

The increases found in alcohol-related ER visits correlates with the findings by researchers such as Shannon Monnat at Syracuse University, who has found increases in the mortality from alcohol, suicide and drugs, what she has called the “diseases of despair.”

The local numbers
There are many different kinds of “impressions” recorded by EMS transports to emergency rooms at hospitals, such as cardiac arrest, allergic reactions, back pain, acute pain from trauma, anxiety disorders and abdominal pain. The prevalence of alcohol intoxication identified in the data for 2017 for emergency transports to hospitals in Rhode Island points to a serious statewide problem that is occurring under the radar screen.

Besides Memorial Hospital, an analysis of the number of impressions in 2017 for emergency transports for “alcohol intoxication” at other emergency rooms in Rhode Island, using data from the R.I. Department of Health, showed that, for the top 20 categories, alcohol intoxication ranked in the top 10 at nine other hospitals in Rhode Island.

• At Rhode Island Hospital in Providence, alcohol intoxication ranked fourth, with 401 transports.

• At South County Hospital in Wakefield, alcohol intoxication ranked sixth, with 218 transports

• At Fatima Hospital in Providence, alcohol intoxication ranked second, with 173 transports

• At Kent Hospital in Warwick, alcohol intoxication ranked fifth, with 760 transports

• At Miriam Hospital in Providence, alcohol intoxication ranked 14th, with 188 transports

• At Landmark Medical Center in Woonsocket, alcohol intoxication ranked seventh, with 140 transports

• At Roger Williams Hospital in Providence, alcohol intoxication ranked second, with 112 transports [there were also 27 for alcohol use, unspecified, and another 25 for alcohol dependence, for a combined total of 164]

• At Westerly Hospital in Westerly, alcohol intoxication ranked seventh, with 28 transports

• At the VA Hospital in Providence, alcohol intoxication ranked fifth, with 19 transports

Added together with 830 alcohol intoxication impressions for emergency medical transports to Memorial in 2017, the total is approximately 2,921 such transports.

Once again, important caveats with using the data from the R.I. Department of Health for impressions by EMS transports is that they do not capture diagnoses, nor do they necessarily capture the chronic diseases associated with alcohol, including pancreatitis, cirrhosis and other ongoing health problems. Also, the number of repeat “patients” has not been sorted.

Diversion
One of the reasons behind the increase in emergency transports to hospitals is a change in liability: before, police stations put intoxicated individuals in what was known as the drunk tank at police stations; now they are required by law to take such individuals to the hospital emergency room.

Often, intoxicated individuals who are transported to emergency rooms may not be admitted, nor do they necessarily receive any recovery or treatment services [in part because they may refuse to participate]. They may be kept warm, fed and rehydrated while they sober up, until they are ready to return back to the outside world.

Recently, following a change in the state law championed by Sen. Josh Miller, The Providence Center began a pilot program called the Recovery Navigation Program, through which intoxicated individuals can be diverted from emergency rooms to the second floor of the Emmanuel House homeless shelter in Providence.

The diversion shelter is open from 12:30 p.m. to 11 p.m., seven days a week, 365 days a year.

To be admitted to the program, individuals must be: inebriated, 18 years of age, not medically compromised, not be experiencing alcohol withdrawal symptoms that require medical treatment, and be cooperative and agreeable to the program’s guidelines. All admissions involve alcohol; the program does accept people with co-occurring substance use disorders.

As Jake Bissaro, spokesman for The Providence Center explained to ConvergenceRI, some of the clients who are participants in what he termed the “traditional diversion” model are dropped off by Providence EMS as well as drop-offs from EMS in Cranston and Central Falls. Others are walk-ins and referrals from community programs such as Anchor Community Recovery Center and Crossroads.

According to Bissaro, the total admission numbers for 2017 for the diversion program were 836, adding that these were not all unique visits. “We have around 20 high utilizers who have been to [the program] more than 10 times each,” he said.

The total number of referrals into medical detox or treatment in 2017 was around 200, according to Bissaro. The numbers appeared to be increasing during the 2017 calendar year, with 26 in January, rising to 141 in December.

The commercial insurance perspective
ConvergenceRI also reached out to Blue Cross & Blue Shield of Rhode Island, to see what the data from the state’s largest health insurer showed in 2017 for alcohol-related diagnosis claims for ambulance transports to emergency rooms.

“Blue Cross had fewer than 350 transportation claims for approximately 250 distinct members in 2017, incurred and paid through December,” Jill Flaxington, Blue Cross spokeswoman, said in an email to ConvergenceRI. The numbers were limited to Blue Cross commercial members, according to Flaxington.

Flaxington continued: “For commercial members, in 2017, Blue Cross had approximately 1,400 distinct members with an alcohol related primary diagnosis attached to a substance abuse claim in any setting [such as professional office, rehab, facility, etc.]”

If Blue Cross had fewer than 350 transportation claims for alcohol-related diagnoses for ambulance transport to emergency rooms in 2017, and there were approximately 3,000 “alcohol intoxication” transports in 2017 statewide, where does the burden for paying for some such transports fall? How many are paid for by Medicaid? How many become charity care at hospitals? How many are “repeat” customers? Without the diversion program in 2017, with its 836 admissions, would the state’s numbers be approaching 4,000?

Hot potato or red herring?
On Tuesday, Jan. 2, WPRO morning talk show host Gene Valicenti had a kidney stone attack while on the air. On apparent orders from his doctor, Valicenti drove himself to the emergency room at Lifespan’s Miriam Hospital. Upon leaving, Valicenti, who had been seen by a physician, treated, and then released, reported that by the late morning the corridors of the hospital’s emergency department were overflowing with patients on gurneys.

What caused the overflow? Was it a case of flu becoming more prevalent in Rhode Island? Was it because it was the day after New Years and the resultant excesses in partying? Was it because of the cold and icy conditions? Was it a result of the closing down of the emergency room at Memorial? Was it the result of diversions from Rhode Island Hospital? Was it all of the above?

Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, appeared twice on Valicenti’s show, the first to answer his questions, the second time at her request to clarify the numbers as related to the closing of the ED at Memorial.

It created, as talk radio is so good at, a lot of buzz. But until the numbers are crunched, the cause-and-effect of the overflow remains unknown and speculative, not evidence-based. One important factor in any analysis conducted would be to calculate the number of transports for impressions of “alcohol intoxication” that arrived at the emergency departments.

Four legs to stand on
On Monday evening, Jan. 15, there will be a public gathering, “Owning Our Own Story: About the Opioid Overdose Epidemic,” featuring a performance of COAAST’s play, “Four Legs To Stand On,” about a family in crisis over an adult child’s drug addiction. In a news release issued on Friday, Jan. 12, by the R.I. Department of Health, the agency said that hundreds were expected to attend the event, billed as a way “to rewrite the end to Rhode Island’s overdose epidemic.”

The play, which skillfully interweaves the stories of four different members of a family and how each coped with the responses to the son’s drug addiction, offers a therapeutic approach, capturing the family dynamic, holding up a mirror to what happened and why.

Still largely left out of the conversation, however, is the role that alcohol use and abuse play as co-morbidities to the drug addiction epidemic. It may be difficult to rewrite the end of the overdose epidemic in Rhode Island without including alcohol – and suicide – as part of the diseases of despair. The evidence provided in the number of emergency transports for alcohol intoxication to emergency rooms in Rhode Island suggests that a more inclusive approach may be needed.