Cardiac surgeons' perspectives and practices regarding people who use drugs: A scoping review

Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians

Background: Caring for patients with substance use disorders (SUD) is held in low regard and many clinicians resist treating them. To address this situation, numerous research projects assessed training program gaps and professional attitudes. In contrast, this study explored the actual clinical difficulties that a variety of hospital-based professionals encounter when treating patients with SUD. Methods: Qualitative multiple method design including: (1) individual semi-structured interviews with SUD experts and educators; (2) video-elicited, cross self-confrontation interviews with clinicians working in a specialist addiction unit; (3) paired semi-structured interviews with clinicians working in non-specialist units. Participants were recruited within one university hospital. Data collected at stages (1) and (3) relied on an interview guide and were analyzed using conventional content analyses. Data collected at stage (2) consisted of discussions of video recorded clinical interviews and were analyzed based on a participatory approach. Results: Twenty-three clinicians from seven hospital units participated. Forty-four difficulties were reported that we classified into six categories: knowledge-based; moral; technical; relational; identity-related; institutional. We identified seven cross-category themes as key features of SUD clinical complexity: exacerbation of patient characteristics; multiplication of medical issues; hybridity and specificity of medical discipline; experiences of stalemate, adversity, and role reversal. Conclusions: Our study, providing a comprehensive analysis of the difficulties of caring for patients with SUD, reveals a highly challenging clinical practice for a diversity of healthcare providers. They represent a complementary approach to addressing resistance as an important feature of a complex clinical system, and valuable material to discussing professional preparedness.

Drug use practices and wound care experiences in the age of xylazine adulteration

INTRODUCTION

Exposure to xylazine has been associated with wounds distinct from typical injection-related skin and soft tissue infections. We sought to understand drug use and wound care practices, and treatment experiences of people who use drugs (PWUD) in a high-prevalence area of xylazine adulteration.

METHODS

In August 2023, we surveyed adult PWUD reporting at least one past-year drug use-related wound across three Massachusetts syringe service programs. Using a representative illustration, participants indicated if they had experienced a xylazine wound in the past 90 days. We compared demographic, drug use factors, wound care, and medical treatment experiences among those with and without xylazine wounds. We also conducted additional content analysis of open-ended responses.

RESULTS

Of the 171 respondents, 87 % (n=148) had a xylazine wound in the past 90 days. There were no statistically significant demographic differences between those with and without xylazine wounds. Among those primarily injecting (n=155), subcutaneous injection was nearly ten times more likely among people with xylazine wounds. For those with xylazine wounds (n=148), many engaged in heterogeneous wound self-treatment practices, and when seeking medical care, 74 % experienced healthcare stigma and 58 % had inadequate pain and withdrawal management.

CONCLUSION

People with self-identified xylazine wounds were more likely to engage in subcutaneous injection and faced several barriers seeking medical wound treatment. Programs serving people exposed to xylazine should work to support safer injection practices, including alternatives to injecting and improving access to high-quality, effective wound care. Further study is warranted to understand the causes, promoters, and prevention of xylazine-related wounds.

"Even Though the System Had Failed Him His Entire Life, We Were Failing Him Yet Again": How Clinical, Welfare, and Penal Medicine Interact to Drive Health Inequities and Medical Moral Injury

Adam, a justice-involved young man, was brought into the emergency department at the county hospital in cardiogenic shock due to a recurring episode of injection-drug-use-related infective endocarditis (IDU-IE). Adam had initiated injection opioid use in prison. He was surgically treated for the previous episodes of IDU-IE but was unable to fully recover due to limitations in care within penal medicine. This case report explores the prison as a determinant of health, interactions between clinical, welfare, and penal medicine, to produce and maintain health inequities, and structural drivers of physician moral injury through an interview with Adam and reflexive writings from emergency medicine physicians. This case demonstrates the need for three types of structural health interventions: (1) restorative justice, community-based reentry programs, and housing as welfare medicine, (2) increased harm reduction services across healthcare, especially penal medicine, and (3) equitable institutional protocols (contrary to ambiguous guidelines) to treat clinical conditions like IDU-IE that disproportionately impact structurally vulnerable patients.

Xylazine-Associated Wounds and Related Health Concerns Among People Who Use Drugs: Reports From Front-Line Health Workers in 7 US States

BACKGROUND

Xylazine, an adrenergic alpha-2 agonist increasingly present in the US drug supply, is associated with severe skin ulcers and other harms. Expert knowledge from front-line harm reduction and healthcare professionals is an essential component of evidence-based practice. The purpose of this study is to describe the progression and treatment of xylazine-associated wounds, other xylazine-related health concerns, and the most urgent research priorities as reported by front-line harm reduction and healthcare professionals serving people who use drugs.

METHODS

A convenience sample of 17 healthcare and harm reduction professionals who serve people who use drugs in the US states of Maryland, Massachusetts, Michigan, Minnesota, North Carolina, Pennsylvania, and Texas participated in semi-structured interviews. Participants were asked about the appearance and progression of xylazine-associated wounds; preferred treatment strategies; other xylazine-related harms experienced by people who use drugs; and the most urgent priorities for xylazine-related research.

FINDINGS

Xylazine-associated wounds were broadly described as small lesions appearing mostly on extremities both at and away from injection sites, often within hours or days of exposure, that quickly developed into large, complex, chronic wounds. Reported risk of secondary infection was generally low but appeared more common among unhoused populations. Most participants preferred conservative treatment strategies that included regular wound care, enzymatic debridement, and hygiene. Xylazine-associated wounds and xylazine withdrawal reportedly act as significant barriers to care, including addiction treatment. Participants reported urgent need for scientific research and evidence-based guidance on the management of xylazine-associated wounds and withdrawal.

CONCLUSIONS

High-quality scientific evidence on risk factors for xylazine-associated wounds and on their biologic mechanisms is needed. Such studies could inform new strategies for the prevention and treatment of these wounds. Efforts to improve the management of xylazine withdrawal and to reduce stigma by incorporating harm reduction professionals into healthcare settings may improve access to and retention in care.

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.

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.