Background/Objectives: The VA Emergency Medicine Addiction Hotline (VEMAH) is a real-time telehealth addiction consult service for Veterans Health Administration (VHA) providers in acute-care settings. VEMAH launched in May 2023 across eight Veterans Integrated Service Network 22 (VISN 22) facilities, expanding to 17 total VHA sites over 3 years. Results: Over 38 months (May 7, 2023 through July 23, 2026), the service completed 2,154 encounters, including real-time e-consults, direct patient tele-care, care coordination, proactive tele-outreach, and provider education. The most common indications for consultation were opioid- and alcohol-related concerns. Pain-related concerns accounted for about 11% of all encounters. VEMAH providers focused on proactive outreach, substance use disorder (SUD) pharmacotherapy interventions, and coordinating care with local SUD services for ongoing treatment. Conclusions: We describe the feasibility of implementing and scaling a real-time telehealth addiction consult service across VHA acute care settings. A descriptive comparison of ED OSI dashboard trends before and after VEMAH implementation showed positive concurrent trends in naloxone and buprenorphine prescribing within VISN 22, though these observations are hypothesis-generating rather than confirmatory. These findings support VEMAH as a scalable model for extending addiction care access across VHA acute-care settings.