Implementing syringe services programs within the Veterans Health Administration: facility experiences and next steps

Integrating Hospital-Based Harm Reduction Care-Harnessing the Nursing Model

Hospitals are risk environments for people who use drugs, and most hospitals are unprepared to deliver substance use disorder (SUD) care, including harm reduction (HR) interventions. HR philosophy clashes with traditional hospital hierarchy and norms, and staff may resist HR interventions due to stigma, fear of enabling substance use, legal and safety concerns. Nurses are central to hospital culture and care and could promote and deliver HR care. Our US hospital has an inter-professional addiction consult service (ACS) that includes medical providers, social workers, and peers. We developed and launched a hospital-based registered nurse-(RN) led HR intervention, including distributing safe-use supplies (eg, syringes). We describe model development and early experience, using an Exploration, Preparation, Implementation, and Sustainment framework. ACS experiences and community HR interventions informed our exploration phase. In the preparation phase we secured funding from Medicaid payers for a 2-year pilot, including full-time RN salary and HR supplies. We elicited buy-in from hospital executive leaders, partly by partnering with nurse champions who described unmet patient care and staff education needs. We consulted hospital lawyers and developed an institution-wide media campaign targeting staff, including in-person booths distributing naloxone and materials promoting international overdose awareness day (eg, "#EndOverdose" buttons). We collaborated with local and national experts to develop the intervention, which includes RN bedside HR education and staff trainings. The Implementation was from September 2022 to March 2023. We trained 459 staff (over 15 trainings) and conducted 209 patient encounters. Generally, patients and staff embraced the HR RN role, including previously controversial safe-use supply distribution. Sustainment efforts include engaging stakeholders in continuous improvement and evaluation efforts. A nurse-led hospital-based HR intervention can expand patient services, support staff, and bridge HR and medical models.

Assessment of an education tool to improve knowledge and reduce stigma of a syringe service program (SSP) at a VA Medical Center

BACKGROUND

Drug overdose deaths are a growing epidemic in the United States owing in part to inadequate support from health care systems. In response, the Veterans Health Administration (VHA) plans to implement syringe service programs (SSPs) across VHA medical centers. This SSP education project aims to positively affect health care staff perceptions regarding SSPs and reduce the stigma surrounding substance use.

OBJECTIVES

The purpose of this research was to allow Advanced Pharmacy Practice Experience (APPE) students to implement and assess an educational program regarding SSP enactment at this institution. Furthermore, the objectives of the educational program were to address the stigma associated with substance use and provide knowledge to staff about SSPs.

PRACTICE DESCRIPTION

Eleven complete and one abbreviated (no questionnaire) presentations were delivered by APPE students throughout the main facility and outpatient clinics, with presentations being delivered to physicians, nurses, and a range of other professions.

PRACTICE INNOVATION

APPE students developed educational content and pre- and postsurveys that were used to assess for changes in knowledge and perception surrounding substance use and SSPs.

EVALUATION METHODS

The primary outcome was to assess individual pre- and postprogram survey responses using mean, SD, and mean change to measure the impact that the presentation had on individualized stigma.

RESULTS

A total of 104 completed surveys were analyzed in Microsoft Excel and subcategorized by profession; 10 of the 15 questions asked in the questionnaire yielded statistical significance when comparing pre- and postpresentation results (P < 0.05).

CONCLUSIONS

A presentation method developed and delivered by APPE students resulted in a statistically significant change in perception and knowledge, proving to be an effective method for educating health care staff on SSPs.

Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction

Importance

Harm reduction is associated with improved health outcomes among people who use substances. As overdose deaths persist, hospitals are recognizing the need for harm reduction services; however, little is known about the outcomes of hospital-based harm reduction for patients and staff.

Objective

To evaluate patient and staff perspectives on the impact and challenges of a hospital-based harm reduction program offering safer use education and supplies at discharge.

Design, Setting, and Participants

This qualitative study consisted of 40-minute semistructured interviews with hospitalized patients receiving harm reduction services and hospital staff at an urban, safety-net hospital in California from October 2022 to March 2023. Purposive sampling allowed inclusion of diverse patient racial and ethnic identities, substance use disorders (SUDs), and staff roles.

Exposure

Receipt of harm reduction education and/or supplies (eg, syringes, pipes, naloxone, and test strips) from an addiction consult team, or providing care for patients receiving these services.

Main Outcomes and Measures

Interviews were analyzed using thematic analysis to identify key themes.

Results

A total of 40 participants completed interviews, including 20 patients (mean [SD] age, 43 [13] years; 1 American Indian or Alaska Native [5%], 1 Asian and Pacific Islander [5%], 6 Black [30%]; 6 Latine [30%]; and 6 White [30%]) and 20 staff (mean [SD] age 37 [8] years). Patients were diagnosed with a variety of SUDs (7 patients with opioid and stimulant use disorder [35%]; 7 patients with stimulant use disorder [35%]; 3 patients with opioid use disorder [15%]; and 3 patients with alcohol use disorder [15%]). A total of 3 themes were identified; respondents reported that harm reduction programs (1) expanded access to harm reduction education and supplies, particularly for ethnically and racially minoritized populations; (2) built trust by improving the patient care experience and increasing engagement; and (3) catalyzed culture change by helping destigmatize care for individuals who planned to continue using substances and increasing staff fulfillment. Black and Latine patients, those who primarily used stimulants, and those with limited English proficiency (LEP) reported learning new harm reduction strategies. Program challenges included hesitancy regarding regulations, limited SUD education among staff, remaining stigma, and the need for careful assessment of patient goals.

Conclusions and Relevance

In this qualitative study, patients and staff believed that integrating harm reduction services into hospital care increased access for populations unfamiliar with harm reduction, improved trust, and reduced stigma. These findings suggest that efforts to increase access to harm reduction services for Black, Latine, and LEP populations, including those who use stimulants, are especially needed.