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Goff A, Lujan-Bear S, Titus H, Englander H. Integrating Hospital-Based Harm Reduction Care-Harnessing the Nursing Model. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:307-313. [PMID: 38258867 DOI: 10.1177/29767342231219577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Hospitals are risk environments for people who use drugs, and most hospitals are unprepared to deliver substance use disorder (SUD) care, including harm reduction (HR) interventions. HR philosophy clashes with traditional hospital hierarchy and norms, and staff may resist HR interventions due to stigma, fear of enabling substance use, legal and safety concerns. Nurses are central to hospital culture and care and could promote and deliver HR care. Our US hospital has an inter-professional addiction consult service (ACS) that includes medical providers, social workers, and peers. We developed and launched a hospital-based registered nurse-(RN) led HR intervention, including distributing safe-use supplies (eg, syringes). We describe model development and early experience, using an Exploration, Preparation, Implementation, and Sustainment framework. ACS experiences and community HR interventions informed our exploration phase. In the preparation phase we secured funding from Medicaid payers for a 2-year pilot, including full-time RN salary and HR supplies. We elicited buy-in from hospital executive leaders, partly by partnering with nurse champions who described unmet patient care and staff education needs. We consulted hospital lawyers and developed an institution-wide media campaign targeting staff, including in-person booths distributing naloxone and materials promoting international overdose awareness day (eg, "#EndOverdose" buttons). We collaborated with local and national experts to develop the intervention, which includes RN bedside HR education and staff trainings. The Implementation was from September 2022 to March 2023. We trained 459 staff (over 15 trainings) and conducted 209 patient encounters. Generally, patients and staff embraced the HR RN role, including previously controversial safe-use supply distribution. Sustainment efforts include engaging stakeholders in continuous improvement and evaluation efforts. A nurse-led hospital-based HR intervention can expand patient services, support staff, and bridge HR and medical models.
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Affiliation(s)
- Amelia Goff
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Susannah Lujan-Bear
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Hope Titus
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Honora Englander
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
- Division of Hospital Medicine, Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR, USA
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Javorski MJ, Rosinski BF, Shah S, Thompson MA, Streem D, Gordon SM, Insler S, Houghtaling PL, Griffin B, Blackstone EH, Unai S, Svensson LG, Pettersson GB, Elgharably H. Infective Endocarditis in Patients Addicted to Injected Opioid Drugs. J Am Coll Cardiol 2024; 83:811-823. [PMID: 38383096 DOI: 10.1016/j.jacc.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death. OBJECTIVES The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors. METHODS From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE). RESULTS Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse. CONCLUSIONS Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.
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Affiliation(s)
- Michael J Javorski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shawn Shah
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew A Thompson
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - David Streem
- Department of Psychiatry, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven M Gordon
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven Insler
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, USA
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Griffin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
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Brothers TD, Bonn M, Lewer D, Comeau E, Kim I, Webster D, Hayward A, Harris M. Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis. Addiction 2023; 118:1853-1877. [PMID: 37170877 DOI: 10.1111/add.16257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/28/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections. METHODS We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes. RESULTS We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission). CONCLUSIONS Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.
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Affiliation(s)
- Thomas D Brothers
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Matthew Bonn
- Canadian Association of People who Use Drugs (CAPUD), Dartmouth, Canada
| | - Dan Lewer
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Emilie Comeau
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Inhwa Kim
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Duncan Webster
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
- Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
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Opioid agonist treatment and risk of death or rehospitalization following injection drug use-associated bacterial and fungal infections: A cohort study in New South Wales, Australia. PLoS Med 2022; 19:e1004049. [PMID: 35853024 PMCID: PMC9295981 DOI: 10.1371/journal.pmed.1004049] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Injecting-related bacterial and fungal infections are associated with significant morbidity and mortality among people who inject drugs (PWID), and they are increasing in incidence. Following hospitalization with an injecting-related infection, use of opioid agonist treatment (OAT; methadone or buprenorphine) may be associated with reduced risk of death or rehospitalization with an injecting-related infection. METHODS AND FINDINGS Data came from the Opioid Agonist Treatment Safety (OATS) study, an administrative linkage cohort including all people in New South Wales, Australia, who accessed OAT between July 1, 2001 and June 28, 2018. Included participants survived a hospitalization with injecting-related infections (i.e., skin and soft-tissue infection, sepsis/bacteremia, endocarditis, osteomyelitis, septic arthritis, or epidural/brain abscess). Outcomes were all-cause death and rehospitalization for injecting-related infections. OAT exposure was classified as time varying by days on or off treatment, following hospital discharge. We used separate Cox proportional hazards models to assess associations between each outcome and OAT exposure. The study included 8,943 participants (mean age 39 years, standard deviation [SD] 11 years; 34% women). The most common infections during participants' index hospitalizations were skin and soft tissue (7,021; 79%), sepsis/bacteremia (1,207; 14%), and endocarditis (431; 5%). During median 6.56 years follow-up, 1,481 (17%) participants died; use of OAT was associated with lower hazard of death (adjusted hazard ratio [aHR] 0.63, 95% confidence interval [CI] 0.57 to 0.70). During median 3.41 years follow-up, 3,653 (41%) were rehospitalized for injecting-related infections; use of OAT was associated with lower hazard of these rehospitalizations (aHR 0.89, 95% CI 0.84 to 0.96). Study limitations include the use of routinely collected administrative data, which lacks information on other risk factors for injecting-related infections including injecting practices, injection stimulant use, housing status, and access to harm reduction services (e.g., needle exchange and supervised injecting sites); we also lacked information on OAT medication dosages. CONCLUSIONS Following hospitalizations with injection drug use-associated bacterial and fungal infections, use of OAT is associated with lower risks of death and recurrent injecting-related infections among people with opioid use disorder.
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Vervoort D, An KR, Elbatarny M, Tam DY, Quastel A, Verma S, Connelly KA, Yanagawa B, Fremes SE. Dealing with the epidemic of endocarditis in people who inject drugs. Can J Cardiol 2022; 38:1406-1417. [PMID: 35691567 DOI: 10.1016/j.cjca.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/18/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
North America is facing an opioid epidemic and growing illicit drug supply, contributing to growing numbers of injection drug use-related infective endocarditis (IDU-IE). Patients with IDU-IE have high early and late mortality. Patients with IDU-IE more commonly present with right-sided IE compared to those with non-IDU-IE and a majority are a result of S. aureus. While most patients can be successfully managed with intravenous antibiotic treatment, surgery is often required in part related to high relapse rates, potential treatment biases, and more aggressive pathophysiology in some. Multidisciplinary management as endocarditis teams, including not only cardiologists and cardiac surgeons but also infectious disease specialists, drug addiction experts, social workers, neurologists and/or neurosurgeons, is essential to best manage substance use disorder and facilitate safe discharge to home and society. Structural and population-level interventions, such as harm reduction programs, are necessary to reduce IDU-IE relapse rates in the community and other IDU-related health concerns such as overdoses. In this review, we describe the pathophysiological, clinical, surgical, social, and ethical characteristics of IDU-IE and the management thereof. We present the most recent clinical guidelines for this condition and discuss existing gaps in knowledge to guide future research, practice changes, and policy interventions.
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Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Adam Quastel
- Department of Psychiatry, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kim A Connelly
- Division of Cardiology, Department of Medicine, St Michael's Hospital, Keenan Research Centre for Biomedical Research, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Brothers TD, Leaman M, Bonn M, Lewer D, Atkinson J, Fraser J, Gillis A, Gniewek M, Hawker L, Hayman H, Jorna P, Martell D, O'Donnell T, Rivers-Bowerman H, Genge L. Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness. Drug Alcohol Depend 2022; 235:109440. [PMID: 35461084 PMCID: PMC8988445 DOI: 10.1016/j.drugalcdep.2022.109440] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND During a COVID-19 outbreak in the congregate shelter system in Halifax, Nova Scotia, Canada, a healthcare team provided an emergency "safe supply" of medications and alcohol to facilitate isolation in COVID-19 hotel shelters for residents who use drugs and/or alcohol. We aimed to evaluate (a) substances and dosages provided, and (b) outcomes of the program. METHODS We reviewed medical records of all COVID-19 isolation hotel shelter residents during May 2021. The primary outcome was successful completion of 14 days isolation, as directed by public health orders. Adverse events included (a) overdose; (b) intoxication; and (c) diversion, selling, or sharing of medications or alcohol. RESULTS Seventy-seven isolation hotel residents were assessed (mean age 42 ± 14 years; 24% women). Sixty-two (81%) residents were provided medications, alcohol, or cigarettes. Seventeen residents (22%) received opioid agonist treatment (methadone, buprenorphine, or slow-release oral morphine) and 27 (35%) received hydromorphone. Thirty-one (40%) residents received prescriptions stimulants. Six (8%) residents received benzodiazepines and forty-two (55%) received alcohol. Over 14 days, mean daily dosages increased of hydromorphone (45 ± 32 - 57 ± 42 mg), methylphenidate (51 ± 28 - 77 ± 37 mg), and alcohol (12.3 ± 7.6 - 13.0 ± 6.9 standard drinks). Six residents (8%) left isolation prematurely, but four returned. During 1059 person-days, there were zero overdoses. Documented concerns regarding intoxication occurred six times (0.005 events/person-day) and medication diversion/sharing three times (0.003 events/person-day). CONCLUSIONS COVID-19 isolation hotel residents participating in an emergency safe supply and managed alcohol program experienced high rates of successful completion of 14 days isolation and low rates of adverse events.
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Affiliation(s)
- Thomas D Brothers
- Department of Medicine (General Internal Medicine & Clinician-Investigator Program), Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, UK.
| | - Malcolm Leaman
- North End Community Health Centre, Halifax, Nova Scotia, Canada
| | - Matthew Bonn
- Canadian Association of People who Use Drugs, Dartmouth, Nova Scotia, Canada
| | - Dan Lewer
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology & Health Care, University College London, London, UK
| | | | - John Fraser
- North End Community Health Centre, Halifax, Nova Scotia, Canada; Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Anesthesia, Pain Management & Perioperative Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amy Gillis
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Gniewek
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
| | - Leisha Hawker
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
| | - Heather Hayman
- North End Community Health Centre, Halifax, Nova Scotia, Canada
| | | | - David Martell
- Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
| | | | | | - Leah Genge
- North End Community Health Centre, Halifax, Nova Scotia, Canada; Department of Family Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Direction 180, Halifax, Nova Scotia, Canada
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