Language-Based Disparities in Emergency Department Referral to Substance Use Treatment: Lost in Translation

Emergency department (ED)-based substance use navigation programs have expanded access to addiction treatment, yet little is known about whether these programs equitably serve immigrant and refugee patients, particularly those with limited English proficiency. Language barriers are associated with reduced utilization of behavioral health services and lower likelihood of receiving appropriate referrals. We examined whether preferred language was associated with receipt of a substance use consultation with a trained health promotion advocate from Project ASSERT. We conducted a retrospective cross-sectional study of 330,998 ED encounters at two EDs of a large urban academic center (January 2022-February 2024). The primary outcome was receipt of a Project ASSERT consultation. Secondary outcomes among those receiving a consultation included overdose history, referral type (direct vs. indirect) and 30-day treatment enrollment. Language was categorized as English versus non-English. We used logistic regression to estimate unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs), adjusting for age and gender. Complementary analyses were restricted to opioid- and alcohol-related encounters, and a detection pathway analysis examined whether identification of substance-use-related encounters at triage vs. billing diagnosis was associated with language. Most encounters involved English-preferring (89.2%), followed by Spanish-preferring (8.5%) and Other-language-preferring (2.4%) patients. Overall, 2,461 encounters (0.7%) resulted in a Project ASSERT consultation. Consultation rates were significantly lower among non-English-preferring patients (0.3% Spanish, < 0.1% Other) compared to English-preferring patients (0.8%; p < 0.001). After adjusting for age and gender, non-English language preference was associated with significantly lower odds of receiving a consultation (adjusted OR 0.30, 95% CI 0.25-0.37, p < 0.001). Among those receiving a consultation, non-English-preferring patients had significantly lower odds of receiving a direct treatment referral (adjusted OR 0.56, 95% CI 0.33-0.91, p = 0.024). No significant differences were observed in overdose history or 30-day treatment enrollment. Non-English language preference was associated with lower odds of consultation among alcohol-related encounters (adjusted OR 0.37, 95% CI 0.27 to 0.50). The association was attenuated and not statistically significant among opioid-related encounters. Non-English language preference was associated with significantly lower odds of receiving an ED-based substance use consultation and direct treatment referral. Language-based disparities were evident at multiple stages including identification of opioid use and consultation among patients with alcohol-related encounters. These findings highlight persistent language-based disparities in addiction care access that disproportionately affect immigrant and refugee populations. Investment in language-concordant navigation, implementation of interpreter services, and culturally responsive referral pathways are needed to ensure equitable delivery of ED-based substance use treatment.