Advancing patient-centered care for structurally vulnerable drug-using populations: a qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals

How I manage severe bacterial infections in people who inject drugs

BACKGROUND

Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities.

OBJECTIVES

To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection.

SOURCES

The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors.

CONTENT

We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach.

IMPLICATIONS

We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.

Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention

BACKGROUND

There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes.

AIMS

To describe cases of drug use by inpatients requiring an urgent clinical response.

METHODS

We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021.

RESULTS

Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four.

CONCLUSIONS

Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.

Perspectives of patients who inject drugs on a needle and syringe program at a large acute care hospital

BACKGROUND

People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services.

METHODS

We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program.

RESULTS

Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears.

CONCLUSIONS

Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.

The multiple makings of a supervised consumption service in a hospital setting

BACKGROUND

Whereas supervised consumption services (SCSs) are common in many community settings, they are seldomly found in acute care hospitals. As hospitals present unique circumstances that can shape the impacts of an SCS, careful consideration of local implementation contexts and practices is required. We explored the pre-implementation stage of an SCS, to examine how an SCS is made and made differently in relation to the material-discursive context of the hospital.

METHODS

We conducted 11 focus groups with 83 staff and clinicians at an inner-city hospital in Toronto, Canada. Data analysis followed principles of grounded theory and was informed by an 'evidence making interventions' framework.

RESULTS

While most participants indicated they would support the establishment of an SCS at the hospital, multiple enactments of an SCS emerged. An SCS was enacted: as a means to reduce drug-related risks for all people who use drugs, as an opportunity to intervene on patients' drug use, as a means to centralize drug use, and as a transformative intervention for the hospital. In our findings, harm reduction, abstinence, security, and risk mitigation goals existed closely together, yielding overlaying realities.

CONCLUSION

Our findings revealed various enactments of an SCS, some of which are likely to negatively affect people who use drugs and service access. As more hospitals consider the implementation of an SCS, understanding how an SCS is made in practice will be key to building a service that focuses on the needs of people who use drugs.

Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review

BACKGROUND

People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings.

METHODS

A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature.

FINDINGS

The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives.

CONCLUSION

This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.

Emergency department care experiences among people who use substances: a qualitative study

BACKGROUND

People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care.

METHODS

This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis.

RESULTS

Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels.

PATIENT

history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received.

CONCLUSIONS

PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS.

Harm Reduction Principles in a Street Medicine Program: A Qualitative Study

There is ample evidence that homelessness is associated with high rates of morbidity and mortality. Street Medicine seeks to eliminate these disparities by providing healthcare on the streets to people who are unsheltered. While extant research describes health disparities for the unsheltered and programmatic approaches to addressing housing instability, there are few published studies describing how healthcare providers build and maintain relationships with patients on the street. This insight is central to specifying how street medicine differs from traditional forms of care and defining aspects of street medicine that contribute to successful patient engagement. Through a collaboration between Operation Safety Net (OSN), a street medicine provider in Pittsburgh, Pennsylvania, and [name redacted], an exploratory qualitative study was designed and implemented using harm reduction principles as a guiding framework. Qualitative interviews were conducted with eleven OSN street medicine providers and a thematic analysis using a deductive approach was used to analyze the data. Findings identified the ways that relational harm reduction was central to all aspects of patient care provided through this program. Major themes included: (1) individualism, or meeting patients where they are figuratively and literally; (2) humanism, which refers to valuing and holding true regard for patients; and (3) nonjudgmental care, in which providers do not hold negative attitudes toward patients and their decisions. These themes are consistent with relational principles of harm reduction. Challenges that were discussed also aligned with these principles and included frustration with systems providing care that did not meet patients' individualized needs, and pain and trauma experienced by providers upon losing patients for whom they genuinely cared. Understanding these relational principles of harm reduction may help providers operationalize ways to effectively engage and maintain homeless patients in care and subsequently bridge the gap to traditional models of care. This study may provide valuable insights to expand the street medicine field in research and applied clinical and community settings.

'I don't chase drugs as much anymore, and I'm not dead': Client reported outcomes associated with safer opioid supply programs in Ontario, Canada

INTRODUCTION

The ongoing opioid overdose crisis, which has killed over 30,000 people in Canada since 2016, is driven by the volatility of an unregulated opioid drug supply comprised primarily of fentanyl. The Canadian government has recently funded safer opioid supply (SOS) programs, which include off-label prescriptions of pharmaceutical-grade opioids to high risk individuals with the goal of reducing overdose deaths.

METHODS

In 2021, we examined the implementation and adaption of four SOS programs in Ontario. These programs use a primary care model and serve communities experiencing marginalisation. We conducted semi-structured interviews with program clients. We present the results of a thematic analysis with the aim of describing clients' self-reported impact of these programs on their health and well-being.

RESULTS

We interviewed 52 clients between June and October 2021 (mean age 47 years, 56% men, 17% self-identified Indigenous, 14% living with HIV). Our results indicate multifaceted pathways to improved self-reported health and well-being among clients including changes to drug use practices, fewer overdoses, reduced criminalised activity, improved trust and engagement in health care, and increased social stability (e.g., housing).

DISCUSSION AND CONCLUSION

Most clients reported that the intervention saved their life because of the reduced frequency of overdoses. Findings suggest that SOS programs improved clients' health outcomes and increase opportunities for engagement in health services. Our results provide insight into the mechanisms behind some of the emergent evidence on the impact of safer supply prescribing.

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective

BACKGROUND

The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements.

METHODS

Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis.

RESULTS

An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care.

CONCLUSIONS

To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.

[Conflicts between persons with opioid dependency and professionals in an acute hospital: A qualitative document analysis]

Conflicts between persons with opioid dependency and professionals in an acute hospital: A qualitative document analysis Abstract: Background: Opioid dependency is a chronic disease with severe health and social consequences. Patients often suffer from chronic infectious diseases, the consequences of which require treatment in an acute care hospital. On hospital wards, conflicts between patients with opioid dependency and professionals can be observed frequently. Aim: This study explores in which situations and for which reasons conflicts arise. Methods: Entries of professionals in patient charts were analysed qualitatively according to the Thematic Analysis. Results: Entries of 177 cases were analysed and three themes were identified. "Different priorities in the context of an acute hospital" showed that patients and professional teams often had divergent views on what is important during hospitalisation. "Self-medicating" provided evidence that patients suffered from symptoms that were inadequately treated and therefore self-medicated. The basic need "to be perceived as a human being" was not always met in the acute care hospital. Conclusions: Our results show causes and types of conflicts. Divergent values, under-treatment of addiction-specific symptoms and pain, and incomplete expertise among professionals appear to be causal, as does the lack of implementation of harm reduction.

A qualitative study of professionals' perspectives on the ethics of medically-delivered safer injection education for people who inject drugs

BACKGROUND

In this qualitative analysis we aimed to explore addiction physicians' perspectives on safer injection education for people who inject drugs, especially: (1) on possible means of introducing safer injection education in the medical environment, (2) on the compatibility of safer injection education with each physician's core values and goals, and (3) on possible reasons for the ethical dilemma in safer injection education.

METHODS

We conducted semi-structured interviews with eleven physicians practicing addiction medicine in France in clinical and harm reduction settings.

RESULTS

All participants were in favor of educational interventions for people who inject drugs. Nonetheless, these interventions varied from simple advice to injection supervision and they were seen as less acceptable when they concerned the practical and material aspects of injection. Some participants found that physicians practicing in clinical settings, where patients consult mostly to stop their drug use, should not practice safer injection education. On the contrary, other participants claimed that safer injection education was essential in all settings and was not a choice but rather a duty for addiction physicians. The ethical dilemma of such intervention when delivered by medical staff was viewed as a complex phenomenon, related to the representations of intravenous drug use and to societal expectations from physicians.

CONCLUSION

Physicians' views on safer injection education for people who inject drugs reveal an emotionally charged subject related to the structural organization of addiction management in France. Such education is marked by an arduous history of harm reduction policies in France. IRB REGISTRATION: #00011928.

Prevalence and correlates of experiencing drug-related discrimination among people who use drugs presenting at emergency department at high risk of opioid overdose

Objectives

Our objective is to determine if specific sociodemographic characteristics were associated with perceived drug-related discrimination among people who use drugs (PWUD) presenting for care in the emergency department (ED).

Methods

We conducted a secondary analysis of data from the Navigator trial, a randomized control trial of two behavioral interventions in the ED for people at risk of an opioid overdose. Participants included adult patients presenting to two Rhode Island EDs. Eligible participants included those high risk for an opioid overdose, resided or received most of their healthcare in Rhode Island, and were able to provide consent. The primary outcome of this analysis was self-reported feelings of drug-related discrimination by the medical community. The independent variables of interest included race/ethnicity, gender identity, and sexual orientation. Log-binomial multivariable regression models were constructed with all three independent variables of interest and a selection of sociodemographic covariates.

Results

Of 620 eligible participants, 251 (40.5%) reported ever experiencing drug-related discrimination in their lifetime. In the adjusted model, participants who identified as women and participants who identified as LGBQIA+ were more likely to report experiencing drug-related discrimination from the medical community in EDs. Racial/ethnic minority groups were less likely than White (non-Hispanic) participants to report drug-related discrimination.

Discussion

In this study population, White participants reported more drug-related discrimination than their minority counterparts, although female and LGBQIA+ patients reported more discrimination. Future studies should further assess the significance of these intersecting identities on self-reported discrimination. This knowledge could improve ED-based interventions, policies, and services for PWUD.

Alcohol and other drug use: A qualitative exploration of staff and patient's experiences of language use as a means of stigma communication in hospital and primary care settings

INTRODUCTION

The hospital and primary care settings present opportunities to interact, initiate conversations, and instigate referrals for patients experiencing harm from their alcohol and other drug use. Using a stigma communication model, our qualitative study explored whether stigma communication materialized in staff's language in the hospital and primary care settings, and if so, whether this had any impact on staff's and patients' experiences.

METHOD

The study conducted thematic analysis on 39 semi-structured interviews comprising both male and female adults (n = 20) who had experienced or were currently experiencing problematic alcohol or other drug use; and staff (n = 19) from either alcohol and other drug specialist services, or other broader health care services.

RESULTS

The study identified three themes where language use materialized as a means of stigma communication: (i) language that positioned a patient as undeserving; (ii) language that separated a patient from other patients; and (iii) language that blamed a patient. Where language use materialized as a means of stigma communication, this appeared to influence staff's decision-making, or potential avoidance of staff's obligations related to health care. Where language use materialized as a means of stigma communication for patients, poor experiences occurred for both staff and patients, that potentially influenced health care provision and future treatment-seeking intentions.

CONCLUSIONS

The use of language as a means of stigma communication was present in staff/patient interactions. Although a number of targeted interventions exist that address language and stigma toward people who use alcohol and other drugs, our findings indicate that change may be inhibited if staff do not realize that their own use of language may contribute to the perpetuation of stigma. The findings also suggest that aspects of language that materialize as a means of stigma communication may impact the "no wrong door" approach, which intends that people, regardless of which service they attend, receive appropriate support.

Experiences of patients at high risk of opioid overdose accessing emergency department and behavioral health interventions: a qualitative analysis in an urban emergency department

BACKGROUND

Emergency Departments (EDs) have become critical 'touchpoints' for the identification and early engagement of patients at risk of overdose or who have an opioid use disorder (OUD). Our objectives were to examine patients' ED experiences, identify barriers and facilitators of service uptake in ED settings, and explore patients' experiences with ED staff.

METHODS

This qualitative study was part of a randomized controlled trial that evaluated the effectiveness of clinical social workers and certified peer recovery specialists in increasing treatment uptake and reducing opioid overdose rates for people with OUD. Between September 2019 and March 2020, semi-structured interviews were conducted 19 participants from the trial. Interviews sought to assess participants' ED care experiences across intervention type (i.e., clinical social worker or peer recovery specialist). Participants were purposively sampled across intervention arm (social work, n = 11; peer recovery specialist, n = 7; control, n = 1). Data were analyzed thematically with a focus on participant experiences in the ED and social and structural factors shaping care experiences and service utilization.

RESULTS

Participants reported varied ED experiences, including instances of discrimination and stigma due to their substance use. However, participants underscored the need for increased engagement of people with lived experience in ED settings, including the use of peer recovery specialists. Participants highlighted that ED provider interactions were critical drivers of shaping care and service utilization and needed to be improved across EDs to improve post-overdose care.

CONCLUSIONS

While the ED provides an opportunity to reach patients at risk of overdose, our results demonstrate how ED-based interactions and service provision can impact ED care engagement and service utilization. Modifications to care delivery may improve experiences for patients with OUD or at high risk for overdose.

TRIAL REGISTRATION

Clinical trial registration: NCT03684681.

Community reinforcement approach (CRA) supported with structured recreation therapy: Experiences of people living with HIV in a pilot substance use treatment program at a specialty hospital

INTRODUCTION

Community reinforcement approach (CRA) is a behavioral intervention that has demonstrated favorable treatment outcomes for individuals with substance use disorders across studies. CRA focuses on abstinence; however, abstinence is not a desired goal among all people who use substances. Previous research has called for harm reduction-oriented treatment programs, especially within hospital settings. We examined the feasibility of a pilot CRA program, "Exploring My Substance Use" (EMSU), that integrates a harm-reduction perspective with structured recreation therapy at a specialty HIV hospital in Toronto, Canada.

METHODS

The 12-week EMSU program was delivered alongside a feasibility study that ran for 24 weeks (including an additional 12 weeks after program completion). We recruited hospital in/outpatients with moderate to severe substance use disorder to participate in the program and study. The EMSU program combined weekly substance use groups with weekly recreation therapy sessions. We collected data at five timepoints throughout the study; this article focuses on qualitative data from the final (24-week) interviews, which examine participants' experiences of the program-an under-researched element in CRA literature. We conducted thematic analysis in NVivo12 and descriptive statistics in SPSSv28.

RESULTS

Of the n = 12 participants enrolled in the EMSU program, six completed the 12-week intervention. All participants completed the 24-week study interview. The average age of participants was 41.5 years; eight identified as cis-male; most identified as white, experienced food insecurity, and were unstably housed. All participants valued the program, including opportunities to learn new skills and examine function(s) of their substance use, and would enroll if it were offered again. Participants discussed the benefits of leisure activities introduced through recreation therapy, which fostered social connections and provided inspiration/confidence to try new activities. Participants cited a lack of support for those experiencing health/personal challenges and overly strict program attendance rules. To improve the program, participants suggested more tactile activities and incorporating incentives.

CONCLUSIONS

Our findings support the feasibility of a CRA-based program with an integrated harm reduction and a recreation therapy component within an outpatient setting. Future programs should consider building in more flexibility and increased supports for clients dealing with complexities as well as consider COVID-19 related contingencies.

Barriers to cancer treatment and care for people experiencing structural vulnerability: a secondary analysis of ethnographic data

BACKGROUND

A key pillar of Canada's healthcare system is universal access, yet significant barriers to cancer services remain for people impacted by structural vulnerability (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing structural vulnerability within a Canadian context.

METHODS

We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers.

RESULTS

Our analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) impact of lower health literacy (3) addressing social care needs is a pre-requisite for treatment (4) intersecting and compounding barriers reinforce exclusion from cancer care. These inter-related themes point to how people impacted by health and social inequities are at times 'dropped' out of the cancer system and therefore unable to access cancer treatment.

CONCLUSION

Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publically funded healthcare system. Identifying people who experience structural vulnerability, and approaches to delivering cancer services that are explicitly equity-oriented are urgently needed.

Hospital adoption of harm reduction and risk education strategies to address substance use disorders

Background: Hospitals are well-positioned to integrate harm reduction into their workflow. However, the extent to which hospitals across the United States are adopting these strategies remains unknown.Objectives: To assess what factors are associated with hospital adoption of harm reduction/risk education strategies, and trends of adoption across time.Methods: We constructed a dataset marking implementation of harm reduction/risk education strategies for a 20% random sample of nonprofit hospitals in the U.S (n = 489) using 2019-2021 community health needs assessments (CHNAs) and implementation strategies obtained from hospital websites. We used two-level mixed effects logistic regression to test the association between adoption of these activities and organizational and community-level variables. We also compared the proportion of hospitals that adopted these strategies in the 2019-2021 CHNAs to an earlier cohort (2015-2018.)Results: In the 2019-2021 CHNAs, 44.7% (n = 219) of hospitals implemented harm reduction/risk education programs, compared with 34.1% (n = 156) in the 2015-2018 cycle. In our multivariate model, hospitals that implemented harm reduction/risk education programs had higher odds of having adopted three or more additional substance use disorder (SUD) programs (OR: 10.5: 95% CI: 5.35-20.62), writing the CHNA with a community organization (OR: 2.14; 95% CI: 1.15-3.97), and prioritizing SUD as a top three need in the CHNA (OR: 2.63; 95% CI: 1.54-4.47.)Conclusions: Our results suggest that hospitals with an existing SUD infrastructure and with connections to community are more likely to implement harm reduction/risk education programs. Policymakers should consider these findings when developing strategies to encourage hospital implementation of harm reduction activities.

Individuals Reporting Past 3-month Smoked Stimulant Use Are Placed at Risk for Infection and Injury Amid COVID-19

OBJECTIVES

Smoking stimulants, such as methamphetamine and "crack" cocaine, can spread infections, including hepatitis C and COVID-19, and lead to injuries, particularly when individuals share or use makeshift pipes. The purpose of the study was to assess the practices of people who inhale ("smoke") stimulants to guide future clinical harm reduction efforts.

METHODS

Anonymous surveys were administered to participants reporting inhalation of crack cocaine and/or methamphetamine in the past 3 months. Participants were eligible if they sought services from an outreach team staffed by a municipal syringe service program (SSP) or if they were patients at a low-threshold substance use disorder treatment program, the Massachusetts General Hospital Bridge Clinic.

RESULTS

The survey was administered to 68 total participants, 30% of whom were recruited in the Massachusetts General Hospital Bridge Clinic and 70% through SSP outreach. Unsafe smoking practices were reported by 93% of participants. Among the 46% of participants surveyed who both smoked and injected stimulants, 61% of those participants stated that they injected instead of smoked stimulants because of lack of access to pipes. Amid COVID-19, 35% of participants adopted safer smoking practices. Most participants reported that they would be more likely to attend an SSP or health center if pipes were provided.

CONCLUSIONS

Inhalational practices that place participants at risk of injury and illness are common. Providing safer smoking equipment may promote health and engage individuals in care.

Emergency department experiences of people who use drugs who left or were discharged from hospital against medical advice

BACKGROUND

People who use drugs (PWUD) frequent emergency departments at a higher rate than the general population, and experience a greater frequency of soft tissue infections, pneumonia, and chronic conditions such as, HIV/AIDs and hepatitis C. This population has distinct health care considerations (e.g. withdrawal management) and are also more likely to leave or be discharged from hospital against medical advice.

METHODS

This study examines the experiences of PWUD who have left or been discharged from hospital against medical advice to understand the structural vulnerabilities that shape experiences with emergency departments. Semi-structured qualitative interviews were conducted with 30 PWUD who have left or been discharged from hospital against medical advice within the past two years as part of a larger study on hospital care and drug use in Vancouver, Canada.

RESULTS

Findings characterize the experiences and perceptions of PWUD in emergency department settings, and include: (1) stigmatization of PWUD and compounding experiences of discrimination; (2) perceptions of overall neglect; (3) inadequate pain and withdrawal management; and (4) leaving ED against medical advice and a lack of willingness to engage in future care.

CONCLUSIONS

Structural vulnerabilities in ED can negatively impact the care received among PWUD. Findings demonstrate the need to consider how structural factors impact care for PWUD and to leverage existing infrastructure to incorporate harm reduction and a structural competency focused care. Findings also point to the need to consider how withdrawal and pain are managed in emergency department settings.

"There's a big tag on my head": exploring barriers to treatment seeking with women who use methamphetamine in Sydney, Australia

BACKGROUND

Australia has a high prevalence of regular use of methamphetamine. While half of people who use methamphetamine regularly are women, they make up only one third of people seeking treatment for methamphetamine use disorder. There is a lack of qualitative research into the facilitators and barriers to treatment for women who use methamphetamine regularly. The study seeks a better understanding of the experiences and treatment preferences of women who use methamphetamine, to inform person-centred changes in practice and policy that break down barriers to treatment.

METHODS

We conducted semi-structured interviews with 11 women who frequently use methamphetamine (at least once a week), and who are not engaged in treatment. Women were recruited from health services surrounding a stimulant treatment centre at an inner-city hospital. Participants were asked about their methapmhetamine use and health service needs and preferences. Thematic analysis was completed using Nvivo® software.

RESULTS

Three themes were developed from participants' responses around experiences of regular methamphetamine use and treatment needs: 1. Resistance of stigmatised identity including dependence; 2. Interpersonal violence; 3. Institutionalised stigma. A fourth set of themes on service delivery preferences were also elicited, including continuity of care, integrated health care, and provision of non-judgmental services.

CONCLUSION

Gender-inclusive health care services for people who use methamphetamine should actively work to address stigma, support a relational approach to assessment and treatment, and seek to provide structurally competent health care that is trauma and violence informed, and integrated with other services. Findings may also have application for substance use disorders other than methamphetamine.

Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study

BACKGROUND

Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention.

METHODS

Participants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs.

RESULTS

Implementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team's advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing.

CONCLUSION

Integration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.

Factors related to substance use treatment attendance after peer recovery coach intervention in the emergency department

Introduction

Brief intervention with peer recovery coach support has been used to generate referrals to substance use disorder treatment from the emergency department (ED). This retrospective study evaluated factors associated with successful linkage to treatment following brief intervention in the ED.

Methods

Data were extracted from the electronic health record for patients who were referred to substance use treatment from the ED and for whom follow-up data regarding treatment attendance was available (n=666). We examined associations between demographic and insurance variables, substance use, mental health diagnosis, prior abstinence, and stage of change with successful linkage to substance use treatment after ED referral.

Results

The sample was majority male (68%), White (62%), and had a mean age of 43 years (SD=12). Medicaid was the most common insurance (49%) followed by employer/private (34%). Multivariable logistic regression determined patients with Medicaid (OR=2.94, 95% CI:2.09-4.13, p=<.001), those who had a documented alcohol use disorder diagnosis (OR=1.59, 95% CI:1.074-2.342, p=.02), and those in the "Action" stage of change (OR=2.33, 95% CI:1.47-3.69, p=<.001) had greater odds of being successfully linked to treatment.

Conclusions

These results identify characteristics of patients available in the health record to determine who is more likely or less likely to attend substance use treatment following ED referral. Given appropriate screening, this information could be used to direct standard care resources to those with high likelihood of treatment attendance and strengthen follow-up interventions with peer recovery coaches for those with lower likelihood of treatment attendance.

Philanthropic donor perspectives about providing harm reduction services for people living with HIV/AIDS in a hospital setting

BACKGROUND

Hospital-based harm reduction services are needed to reduce drug-related harms, facilitate retention in care, and increase medical treatment adherence for people who use drugs. Philanthropic donor support plays a key role in delivering such innovative services which might fall outside current funding streams. However, little is known about how the principles, implementation, and practice of harm reduction services, which are often highly stigmatized, may impact donor behaviours. We explored this issue within Casey House, a speciality hospital in Toronto, Canada.

METHODS

Our mixed methods study utilized an explanatory sequential design. A convenience sample of n = 106 philanthropic individual donors, recruited via email, completed an anonymous web-based survey, between July and October 2020, which assessed their knowledge of harm reduction services and the potential impact of implementing new hospital-based harm reduction services on donors' future support. Following this, we conducted semi-structured qualitative interviews with n = 12 of the donors who completed a survey and volunteered to be interviewed. Interviews examined donors' perspectives about harm reduction and their hopes/concerns for such programming at Casey House. Data were analysed using descriptive statistics and participatory-based thematic analysis.

RESULTS

Survey data show a high level of support for hospital-based harm reduction services, with participants reporting that they "strongly agree/agree" with providing harm reduction equipment (85%), supervised consumption services (82%), and prescription opioid treatment (76%) at Casey House. A majority of participants (66%) claimed that implementing new harm reduction services at the hospital would not impact their future donation, while 6% said they would be less inclined to donate. Interview participants were supportive of harm reduction services at Casey House, recognizing the benefits of providing such services for hospital clients and the wider community. However, some spoke of the potential impact that implementing hospital-based harm reduction services may have on "other" donors who might be opposed. Although some believed harm reduction services should be fully funded by the government, most saw a role for donors in supporting such services.

CONCLUSIONS

Our findings show support of hospital-based harm reduction services among philanthropic donors and provide insight into how donor support may be affected when such services are introduced.

Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections

Background:

Patients with injection drug use (IDU)-associated infections traditionally experience prolonged hospitalizations, which often result in negative experiences and bad outcomes. Harm reduction approaches that value patient autonomy and shared decision-making regarding outpatient treatment options may improve outcomes. We sought to identify health care professionals (HCPs) perspectives on the barriers to offering four different options to hospitalized people who use drugs (PWUD): long-term hospitalization, oral antibiotics, long-acting antibiotics at an infusion center, and outpatient parenteral antibiotics.

Methods:

We recruited HCPs (n = 19) from a single tertiary care center in Portland, Maine. We interviewed HCPs involved with discharge decision-making and other HCPs involved in the specialized care of PWUD. Semi-structured interviews elicited lead HCP values, preferences, and concerns about presenting outpatient antimicrobial treatment options to PWUD, while support HCPs provided contextual information. We used the iterative categorization approach to code and thematically analyze transcripts.

Results:

HCPs were willing to present outpatient treatment options for patients with IDU-associated infections, yet several factors contributed to reluctance. First, insufficient resources, such as transportation, may make these options impractical. However, HCPs may be unaware of existing community resources or viable treatment options. They also may believe the hospital protects patients, and that discharging patients into the community exposes them to structural harms. Some HCPs are concerned that patients with substance use disorder will not make ‘good’ decisions regarding outpatient antimicrobial options. Finally, there is uncertainty about how responsibility for offering outpatient treatment is shared across changing care teams.

Conclusion:

HCPs perceive many barriers to offering outpatient care for people with IDU-associated infections, but with appropriate interventions to address their concerns, may be open to considering more options. This study provides important insights and contextual information that can help inform specific harm reduction interventions aimed at improving care of people with IDU-associated infections.

Impact of harm reduction care in HIV clinical settings on stigma and health outcomes for people with HIV who use drugs: study protocol for a mixed-methods, multisite, observational study

INTRODUCTION

Our previous pilot work suggests relational harm reduction strengthens relationships between people with HIV (PWH) who use drugs and their healthcare providers and improves HIV health outcomes. However, there is limited research examining ways that structural (eg, strategies like syringe service programmes) and/or relational (patient-provider relationship) harm reduction approaches in HIV clinical settings can mitigate experiences of stigma, affect patient-provider relationships and improve outcomes for PWH who use drugs. Our mixed methods, multisite, observational study aims to fill this knowledge gap and develop an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings.

METHODS AND ANALYSIS

Aim 1 will explore the relationship between healthcare providers' stigmatising attitudes towards working with PWH who use drugs and providers' acceptance and practice of structural and relational harm reduction through surveys (n=125) and interviews (n=20) with providers. Aim 2 will explore the interplay between patient-perceived harm reduction, intersectional stigma and clinical outcomes related to HIV, hepatitis C (if applicable) and substance use-related outcomes through surveys (n=500) and focus groups (k=6, total n=36) with PWH who use drugs. We will also psychometrically evaluate a 25-item scale we previously developed to assess relational harm reduction, the Patient Assessment of Provider Harm Reduction Scale. Aim 3 will use human-centred design approaches to develop and pretest an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings.

ETHICS AND DISSEMINATION

This study was approved via expedited review by the University of Pittsburgh Institutional Review Board (STUDY21090002). Study findings will be presented in peer-reviewed journals and public health conferences as well as shared with patient participants, community advisory boards and harm reduction organisations.

TRIAL REGISTRATION NUMBER

NCT05404750.

"I have such a hard time hitting myself, I thought it'd be easier": perspectives of hospitalized patients on injecting drugs into vascular access devices

Background

Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians’ concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms.

Methods

Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually.

Results

A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms.

Conclusions

VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.

A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study

BACKGROUND

For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues.

OBJECTIVES

The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial.

DESIGN

A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures.

SETTING

The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England.

PARTICIPANTS

Participants were people experiencing homelessness and problem substance use (n = 68) (intervention).

INTERVENTION

This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support.

MAIN OUTCOME MEASURES

Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure.

RESULTS

The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies.

LIMITATIONS

Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited.

CONCLUSIONS

A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention.

FUTURE WORK

A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments.

TRIAL REGISTRATION

This trial is registered as ISRCTN15900054.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis

BACKGROUND

Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs.

METHODS

Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months.

RESULTS

We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice.

CONCLUSIONS

Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.

Characteristics associated with motivation to stop substance use and improve skin and needle hygiene among hospitalized patients who inject drugs

Background: Hospitalizations for people who inject drugs (PWID) are opportunities to address substance use. However, little is known about hospitalized PWIDs' motivation to stop substance use or improve skin and needle hygiene, common means for reducing injection sequelae. Methods: We used baseline data from a randomized controlled trial of a behavioral intervention to improve skin and needle hygiene among 252 hospitalized PWID between January 2014 and June 2018. We examined motivation (scale 1-10) to stop substance use, use new needles, and clean skin and used multiple linear regression models to evaluate characteristics associated with these outcomes. Results: PWID were recruited during injection-related (154, 61.1%) and non-injection-related hospitalizations (98, 38.9%). Motivation to stop substance use was 7.11 (SD = 2.67), use new needles was 7.8 (SD = 1.9), and clean skin was 6.7 (SD = 2.3). In adjusted models, experiencing an injection-related hospitalization was not significantly associated (p > 0.05) with motivation to stop substance use (β = -0.76, SE = 0.299), use new needles (β = 0.301, SE = 0.255), or clean skin (β = 0.476, SE = 0.323). Number of past-year skin and soft tissue infections was negatively associated with motivation to use new needles (β = -0.109, SE = 0.049, p < 0.05) and clean skin (β = -0.131, SE = 0.062, p < 0.05). Greater opioid withdrawal was associated with lower motivation to use new needles (β = -0.275, SE = 0.92, p < 0.01). Conclusions: Among hospitalized PWID, motivation to stop substance use and improve skin and needle hygiene was moderately high, but injection-related hospitalizations were not associated with greater motivation. Efforts to reduce injection sequelae for all hospitalized PWID are needed.

Harm Reduction in Health Care Settings

Harm reduction is an approach to reduce the risk of harms to an individual using substances without requiring abstinence. This review discusses substance-specific interventions for opioids, alcohol, and stimulants that can minimize harms for individuals who use these substances. Topics discussed include overdose prevention, infection prevention, and low-barrier substance use disorder treatment.

A qualitative examination of substance use service needs among people who use drugs (PWUD) with treatment and service experience in Ontario, Canada

BACKGROUND

People who use drugs (PWUD) often have complex health and social support needs related to substance use, yet face numerous barriers to service access, resulting in unmet treatment needs and a corresponding gap in treatment. While initiatives to scale up substance use services for PWUD in Canada - and Ontario - have been undertaken, these have excluded PWUD' perspectives, and their needs have largely been defined by other actors. As end-users of services, PWUD' perspectives are vital to understanding what services are required, and whether existent services are adequate, appropriate and effective. Thus, the present study aimed to elicit in-depth knowledge from PWUD with lived experience of accessing services to better understand their unmet treatment and service needs, towards closing the service and treatment gap in Ontario.

METHODS

This qualitative study included one-on-one interviews conducted with a cohort of n = 45 adult PWUD with substance use and treatment experience in Ontario, Canada. Participants were recruited from substance use services based on ConnexOntario's directory of all provincial addiction services, as well as by word-of-mouth. Questions focused on participants' experiences and perspectives on substance use services towards understanding their service needs. Data underwent an inductive thematic analysis based on key themes that emerged.

RESULTS

Participants commonly engaged in polysubstance use, and identified a number of unmet substance use service needs including complex factors within the current service system that influenced access to available programs. Specifically, participants suggested the need to address stigmatization and system fragmentation, increase service provision and capacity, and scale up specific services and related supports such as harm reduction, counseling, treatment, and housing.

CONCLUSIONS

This study identified PWUD' needs in relation to substance use service provision in Ontario, Canada, and highlighted important areas for policy change and program planning and implementation. Concrete recommendations include the development of a government-funded, low-barrier, comprehensive and integrated service delivery and referral models that include PWUD as collaborators and program facilitators to ensure that services are as accessible, effective, and cohesive as possible. Results from this study can be used to enhance provincial substance use treatment and service provision.

Identifying harm reduction strategies for alcohol and drug-use in inpatient care settings and emergency departments: a scoping review protocol

INTRODUCTION

People who use alcohol and/or drugs (PWUAD) are at high risk of medical complications, frequent hospitalisation and drug-related death following discharge from inpatient settings and emergency departments (EDs). Harm reduction strategies implemented in these settings may mitigate negative health outcomes for PWUAD. However, the scope of harm reduction strategies used globally within inpatient settings and EDs is unknown. The objective of this review is to identify and synthesise reported harm reduction strategies that have been implemented across inpatient settings and EDs for PWUAD.

METHODS AND ANALYSIS

This review will include studies from any country and health service reporting on harm reduction strategies implemented in inpatient settings or EDs. The population of interest includes people of any race, gender and age identifying as PWUAD, or individuals who provided care to PWUAD. Studies which describe implementation strategies and barriers and enablers to implementation will be included. Studies published in English, or those available for English translation will be included. The following databases will be searched: MEDLINE All (Ovid), Embase (Elsevier Embase.com), CINAHL with Full Text (EBSCOhost), PsycINFO (EBSCOhost) and SCOPUS (Elsevier Scopus.com). A grey literature search will be conducted. There will be no date restrictions on the search. Titles, abstracts and full texts will be screened in duplicate. Data will be extracted using a standardised form. The results will be reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews.

ETHICS AND DISSEMINATION

Scoping reviews do not require ethical approval. Patient partners with lived experience and relevant knowledge users will be engaged as research team members throughout all phases of the research process. A report detailing context, methodology and findings from this review will be disseminated to knowledge users and relevant community stakeholders. This review will be submitted for publication to a relevant peer-reviewed journal.

"With a PICC line, you never miss": The role of peripherally inserted central catheters in hospital care for people living with HIV/HCV who use drugs

BACKGROUND

People who use drugs (PWUD), and especially those who inject drugs, are at increased risk of acquiring bloodborne infections (e.g., HIV and HCV), experiencing drug-related harms (e.g., abscesses and overdose), and being hospitalized and requiring inpatient parenteral antibiotic therapy delivered through a peripherally inserted central catheter (PICC). The use of PICC lines with PWUD is understood to be a source of tension in hospital settings but has not been well researched. Drawing on theoretical and analytic insights from "new materialism," we consider the assemblage of sociomaterial elements that inform the use of PICCs.

METHODS

This paper draws on n = 50 interviews conducted across two related qualitative research projects within a program of research about the impact of substance use on hospital admissions from the perspective of healthcare providers (HCPs) and people living with HIV/HCV who use drugs. This paper focuses on data about PICC lines collected in both studies.

RESULTS

The decision to provide, maintain, or remove a PICC is based on a complex assemblage of factors (e.g., infections, bodies, drugs, memories, relations, spaces, temporalities, and contingencies) beyond whether parenteral intravenous antibiotic therapy is clinically indicated. HCPs expressed concerns about the risk posed by past, current, and future drug use, and contact with non-clinical spaces (e.g., patient's homes and the surrounding community), with some opting for second-line treatments and removing PICCs. The majority of PWUD described being subjected to threats of discharge and increased monitoring despite being too ill to use their PICC lines during past hospital admissions. A subset of PWUD reported using their PICC lines to inject drugs as a harm reduction strategy, and a subset of HCPs reported providing harm reduction-centred care.

CONCLUSION

Our analysis has implications for theorizing the role of PICC lines in the care of PWUD and identifies practical guidance for engaging them in productive and non-judgemental discussions about the risks of injecting into a PICC line, how to do it safely, and about medically supported alternatives.

Utilising an access to care integrated framework to explore the perceptions of hepatitis C treatment of hospital-based interventions among people who use drugs

BACKGROUND

Gaps remain in the hepatitis C virus (HCV) care cascade for people who use drugs (PWUD). Acute medical or surgical illnesses requiring hospitalisation are an opportunity to address addiction, but how inpatient strategies could affect HCV care accessibility for PWUD remains unknown. We explored patient perspectives of hospital-based interventions using an integrated framework of access to HCV care.

METHODS

We conducted a qualitative study of hospitalised adults (n=27) with HCV and addiction admitted to an urban academic medical centre in the United States between June and November 2019. Individual interviews were audio-recorded, transcribed, and dual-coded. We analysed data with coding specific for hospital-based interventions including screening, conducting HCV-related laboratory work-up, starting treatment, connecting with peers, and coordinating outpatient care. We analysed coded data at the semantic level for emergent themes using a framework approach based off an integrated framework of access to HCV care.

RESULTS

The majority of participants primarily used opioids (78%), were white (85%) and men (67%). Participants frequently reported HCV screening during previous hospitalisation with rare inpatient connection to HCV-related services. Participants expressed willingness to discuss HCV treatment candidacy during hospitalisation; however, lack of inpatient conversations led to perception that "nothing could be done" during admission. Participants expressed interest in completing inpatient HCV work-up to "get the ball rollin'" - consolidating care would enhance outpatient service permeability by reducing barriers. Others resisted HCV care coordination, preferring to focus on "immediate" issues including health conditions and addiction treatment. Participants also expressed openness to engaging with peers about HCV, noting shared drug use experience as critical to a peer relationship when discussing HCV.

CONCLUSION

Hospitalised PWUD have varied priorities, necessitating adaptable interventions for addressing HCV. Hospitalisation can be an opportunity to address HCV access to care including identification of treatment eligibility, consolidation of care, and facilitation of HCV-related referrals.

Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review

OBJECTIVE

The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.

INCLUSION CRITERIA

To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts.

METHODS

An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives.

RESULTS

A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed.

CONCLUSIONS

We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.

Feasibility, acceptability, concerns, and challenges of implementing supervised injection services at a specialty HIV hospital in Toronto, Canada: perspectives of people living with HIV

BACKGROUND

Substance use significantly impacts health and healthcare of people living with HIV/AIDS (PLHIV), especially their ability to remain in hospital following admission. Supervised injection services (SIS) reduce overdoses and drug-related harms, but are not often provided within hospitals/outpatient programs. Leading us to question, what are PLHIV's perceptions of hospital-based SIS?

METHODS

This mixed-methods study explored feasibility and acceptability of implementing SIS at Casey House, a Toronto-based specialty HIV hospital, from the perspective of its in/outpatient clients. We conducted a survey, examining clients' (n = 92) demand for, and acceptability of, hospital-based SIS. Following this, we hosted two focus groups (n = 14) and one-on-one interviews (n = 8) with clients which explored benefits/drawbacks of in-hospital SIS, wherein participants experienced guided tours of a demonstration SIS space and/or presentations of evidence about impacts of SIS. Data were analysed using descriptive statistics and thematic analysis.

RESULTS

Among survey participants, 76.1% (n = 70) identified as cis-male and over half (n = 49;54.4%) had been a hospital client for 2 years or less. Nearly half (48.8%) knew about clients injecting in/near Casey House, while 23.6% witnessed it. Survey participants were more supportive of SIS for inpatients (76.1%) than for outpatients (68.5%); most (74.7%) reported SIS implementation would not impact their level of service use at Casey House, while some predicted coming more often (16.1%) and others less often (9.2%). Most focus group/interview participants, believed SIS would enhance safety by reducing health harms (e.g. overdose), increasing transparency between clients and clinicians about substance use, and helping retain clients in care. Debate arose about who (e.g., in/outpatients vs. non-clients) should have access to hospital-based SIS and how implementation may shift organizational priorities/resources away from services not specific to drug use.

CONCLUSIONS

Our data showed widespread support of, and need for, hospital-based SIS among client stakeholders; however, attempts to reduce negative impacts on non-drug using clients need to be considered in the balance of implementation plans. Given the increased risks of morbidity and mortality for PLHIV who inject drugs as well as the problems in retaining them in care in a hospital setting, SIS is a key component of improving care for this marginalized group.

Hospital policy as a harm reduction intervention for people who use drugs

Hospitals are a critical touchpoint for people who use drugs (PWUD). However, hospital policies, both formal and informal, can have a detrimental impact on PWUD in acute care settings. Introducing new policies, or revising existing policies that inadvertently harm or stigmatize PWUD while hospitalized, could be an effective harm reduction intervention for this high-risk population. This paper explores seven areas where institutional policy change could improve the hospital experience of PWUD: (1) use of nonprescribed substances in hospital, (2) supporting inpatient addiction consultation services (3) in-hospital supervised consumption spaces (4) supply and distribution of safe drug use equipment and naloxone, (5) role of security services and personal searches, (6) use of hospital restrictions, and (7) involvement of PWUD in policy development.

Exploring care of hospital inpatients with substance involvement

INTRODUCTION

This article presents demographic and care factors related to persons who are substance-involved and require inpatient administration of intravenous antibiotics.

PURPOSE

This study was conducted to explore healthcare responses to support substance-involved inpatients, through exploration of documented client outcomes, healthcare provider accounts, and representation of clients through documentation.

METHOD(S)

A patient-oriented research team undertook this multiple methods, exploratory study. A health record review included people admitted to a complex continuing care hospital, within a 2-year period, for long-term antibiotic treatment and concurrent illicit substance use. Correlations were examined between whether or not clients were discharged against medical advice (AMA) in comparison to demographic, medical, and care-related factors. Qualitative analysis of narrative health record data was undertaken. Semi-structured interviews of healthcare providers and decision makers were conducted.

RESULTS

Twenty-five people met recruitment criteria for health record review; three people were admitted twice, resulting in 28 admissions. Interviews with seven healthcare providers and decision makers uncovered themes of client autonomy, professional liability, client responsibility, the "right" service, and burnout, hopelessness, and helplessness.

CONCLUSION

Recommended strategies to effectively respond to substance use among clients admitted for general medical concerns are: i) support inpatients with complex health needs, including substance use, ii) ensure substance use and addiction services are integrated into all inpatient practice areas, iii) support effective harm reduction practices for hospital-admitted clients, and iv) develop robust policies and protocols to support healthcare providers and inpatients.

"You don't have to squirrel away in a staircase": Patient motivations for attending a novel supervised drug consumption service in acute care

BACKGROUND

Acute care hospitals have been described as a high risk environment for people who use drugs (PWUD). Formal and informal bans on drug use can lead patients to conceal their use and consume under unsafe circumstances. Provision of hospital-based supervised consumption services (SCS) could help reduce drug-related harms and improve patient care. However, no peer-reviewed research documents patient experiences with attending SCS in this setting. To address this gap, the present study examines key factors that shape patients' decisions to attend or not attend a novel SCS embedded within a large, urban acute care hospital in Western Canada.

METHODS

We adopted a focused ethnographic design and conducted 28 semi-structured interviews with SCS-eligible patients. We examined participant accounts thematically, and Rhodes' "Risk Environment" framework helped guide our analysis.

RESULTS

Most participants perceived the SCS as a safer environment that made it possible to reduce drug-related risks and avoid using in unsafe areas of the hospital where they could be caught by staff, security, or police. However, some participants did not trust that the SCS would provide adequate protection from criminalization, which motivated them to avoid the site. Several participants also worried about the potential for unwanted changes to their patient care following SCS use. Physical site and policy limitations, such as eligibility requirements and a lack of infrastructure to support supervised inhalation, were additional reasons for not attending the SCS.

CONCLUSION

PWUD in this study attended the hospital-based SCS in an attempt to reduce risks associated with their hospital stay. However, we note a number of access barriers that should be addressed to ensure optimal uptake. Wider provision of SCS in acute care requires both changes to the hospital environment and broader drug policy reform.

Association between discharges against medical advice and readmission in patients treated for drug injection-related skin and soft tissue infections

BACKGROUND

The prevalence of injection drug use (IDU)-related skin and soft tissue infections (SSTI) in Philadelphia has been steadily increasing since 2013. Patients seeking treatment for these infections are more likely to be discharged against medical advice (AMA), increasing the likelihood that they will end antibiotic treatment prematurely and require additional medical interventions.

METHODS

The research team performed a nested case-control study using the Pennsylvania Health Care Cost Containment Council database for Philadelphia residents hospitalized for SSTI and substance use-related diagnoses between 2013 and 2018. The primary outcome was readmission in the same or following quarter. The study examined the impact of discharge AMA on readmission along with clinical characteristics including diagnoses for anxiety, bipolar disorder, depression, schizophrenia, diabetes, and polydrug use.

RESULTS

There were 8265 hospitalizations for IDU-related SSTI and 316 (6%) were readmitted to the hospital at least once in the same or following quarter. In total, 23.4% of cases and 13% of controls left AMA. In the final multivariable regression model, AMA discharge (AOR 2.04, 95% CI 1.46-2.86), anxiety (AOR 1.44, 95% CI 1.01-2.05), diabetes (AOR 2.02, 95% CI 1.46-2.81), and polydrug use (AOR 2.11, 95% CI 1.52-2.92) were associated with higher odds of readmission.

CONCLUSIONS

Our study demonstrates that readmissions for IDU-related SSTI are associated with recent discharge AMA. As IDU-related SSTI and polydrug use continue to rise, premature antibiotic treatment completion will impact more people, leading to worse health outcomes and additional strain on the health care system.

A qualitative assessment of discharge against medical advice among patients hospitalized for injection-related bacterial infections in West Virginia

BACKGROUND

The incidence of infective endocarditis (IE) and other systemic bacterial infections is increasing, and people who inject drugs (PWID) have higher rates of discharge against medical advice (AMA) for these infections than patients whose infections are not injection-related. In this study, we characterize factors that contribute to AMA hospital discharge among PWID.

METHODS

We conducted qualitative interviews with twenty PWID hospitalized with serious injection-related bacterial infections in West Virginia. Participants completed a brief survey and in-depth qualitative interview. Interviews were recorded and transcribed verbatim and analyzed using a codebook developed based on deductive and inductive thematic analysis. We also conducted medical records abstraction and used descriptive statistics to summarize medical and survey data.

RESULTS

Average age was 34 years, 55% were female, 95% identified as white, and 75% had a primary diagnosis of IE. Drugs injected prior to hospitalization were methamphetamine (60%), prescription opioids (38%), and/or heroin/fentanyl (25%). Participants cited multiple contributors to AMA discharge including negative interactions with hospital staff that they perceived as stigmatizing, including being searched or monitored for illicit drug use; inadequate management of pain and withdrawal; boredom and confinement during lengthy hospitalizations; and isolation from family and other social supports.

CONCLUSION

We identified multiple factors contributing to AMA discharge that are amenable to intervention. Given the significant morbidity, mortality, and financial costs associated with hospitalizing PWID for serious injection-related bacterial infections, hospitals should be highly motivated to develop and test interventions designed to improve outcomes among these patients.

A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs

Antiretroviral therapy (ART) dispensing is strongly associated with treatment adherence. Among illicit drug-using populations, whom experience greater structural barriers to adherence, directly administered antiretroviral therapy (DAAT) is often regarded as a stronger predictor of optimal adherence over self-administered medications. In Vancouver, Canada, people living with HIV (PLHIV) who use drugs and live in low-income housing are a critical population for treatment support. This group is typically able to access two key DAAT models, daily delivery and daily pickup, in addition to ART self-administration. This ethno-epidemiological qualitative study explores how key dispensing models impact ART adherence among PLHIV who use drugs living in low-income housing, and how this is framed by structural vulnerability. Semi-structured interviews lasting 30-45 minutes were conducted between February and May 2018 with 31 PLHIV who use drugs recruited from an ongoing prospective cohort of PLHIV who use drugs. Interviews were audio-recorded, transcribed verbatim, and analyzed using QSR International's NVivo 12 software. Interviews focused on housing, drug use, and HIV management. Models that constrained agency were found to have negative impacts on adherence and quality of life. Treatment interruptions were framed by structural vulnerabilities (e.g., housing vulnerability) that impacted ability to maintain adherence under certain dispensing models, and led participants to consider other models. Participants using DAAT models which accounted for their structural vulnerabilities (e.g., mobility issues, housing instability), credited these models for their treatment adherence, but also acknowledged factors that constrained agency, and the negative impacts this could have on both adherence, and quality of life. Being able to integrate ART into an established routine is key to supporting ART adherence. ART models that account for the structural vulnerability of PLHIV who use drugs and live in low-income housing are necessary and housing-based supports could be critical, but the impacts of such models on agency must be considered to ensure optimal adherence.

Towards health equity for people experiencing chronic pain and social marginalization

Objective

For people who experience social inequities and structural violence, pain and related care are inexorably linked to experiences of injustice and stigma. The purpose of this study was to examine in greater depth the experiences of pain and discrimination and stigma across diverse marginalized communities in order to recommend equity-oriented healthcare approaches.

Methods

This community-based qualitative study reports on four focus groups that included 36 people living with pain. All participants identified with one of three groups known to experience high levels of inequities and structural violence including an Indigenous group, a LGBTQ2S group, and two newcomer and refugee groups.

Results

Pain was entangled with and shaped by: social locations and identities, experiences of violence, trauma and related mental health issues, experiences of discrimination, stigma and dismissal, experiences of inadequate and ineffective health care, and the impacts of these intersecting experiences.

Conclusions

Equity-oriented responses to chronic pain would recognize pain not only as a biomedical issue but as a social justice issue. The EQUIP Framework is an approach to integrating trauma- and violence-informed care; culturally-safe care; and harm reduction in health care that may hold promise for being tailored to people experiencing pain and social marginalization.

Implementation and evaluation of a novel, unofficial, trainee-organized hospital addiction medicine consultation service

BACKGROUND

To evaluate a novel, unofficial, trainee-organized, hospital addiction medicine consultation service (AMCS), we aimed to assess whether it was (1) acceptable to hospital providers and patients, (2) feasible to organize and deliver, and (3) impacted patient care. Methods: We performed a retrospective descriptive study of all AMCS consultations over the first 16 months. We determined acceptability via the number of referrals received from admitting services, and the proportion of referred patients who consented to consultation. We evaluated feasibility via continuation/growth of the service over time, and the proportion of referrals successfully completed before hospital discharge. As most referrals related to opioid use disorder, we determined impact through the proportion of eligible patients offered and initiated on opioid agonist therapy (OAT) in hospital, and the proportion of patients who filled their outpatient prescription or attended their first visit with their outpatient OAT prescriber. Results: The unofficial AMCS grew to involve six hospital-based residents and five supervising community-based addiction physicians. The service received 59 referrals, primarily related to injection opioid use, for 50 unique patients from 12 different admitting services. 90% of patients were seen before discharge, and 98% agreed to addiction medicine consultation. Among 34 patients with active moderate-severe opioid use disorder who were not already on OAT, 82% initiated OAT in hospital and 89% of these patients continued after discharge. Conclusions: Established in response to identified gaps in patient care and learning opportunities, a novel, unofficial, trainee-organized AMCS was acceptable, feasible, and positively impacted patient care over the first 16 months. This trainee-organized, unofficial AMCS could be used as a model for other hospitals that do not yet have an official AMCS.

Motivations to initiate injectable hydromorphone and diacetylmorphine treatment: A qualitative study of patient experiences in Vancouver, Canada

BACKGROUND

Within the context of the ongoing overdose crisis and limitations of conventional opioid treatments, the scale-up of injectable hydromorphone (HDM) and diacetylmorphine (DAM) as evidenced-based treatments is currently underway in some settings in Canada. Past research has underscored the importance of treatment initiation in shaping onward treatment trajectories, however structural factors that influence participants' motivations to access injectable HDM or DAM have not been fully characterized. This study examines peoples' motivations for accessing HDM/DAM treatment and situates these within the social and structural context that shapes treatment delivery by employing the concept of structural vulnerability.

METHODS

Fifty-two individuals enrolled in injectable HDM/DAM programs were recruited from four community-based clinical programs in Vancouver, Canada to participate in qualitative semi-structured interviews. Approximately 50 h of ethnographic fieldwork was also completed in one clinical setting, and one-on-one with participants public spaces. Interview transcripts and ethnographic fieldnotes were analyzed through a structural vulnerability lens with a focus on treatment initiation.

RESULTS

Participants' previous experiences and perceptions of other drug treatments (e.g. methadone) foregrounded their initiation of injectable HDM/DAM. Social and structural factors (e.g. fentanyl-adulterated drug supply, poverty, drug criminalization) influenced participants' motivations to address immediate physical risks and their initial perception of this treatment's ability to align with their opioid use experiences. Similar social and structural factors that drive immediate physical risks, were also evidenced in participants' motivations to make changes in their daily lives and to address broader opioid use goals.

CONCLUSION

Participants descriptions of their motivations to initiate HDM/DAM highlight how structural vulnerabilities shaped participants' experiences initiating injectable HDM/DAM.