(116) Word of Mouth: The Key to Community Connections and HR Among PWUD

Background & Introduction: Post-pandemic, rates of opioid-related deaths remain high with over 100,000 people dying in 2023.1 Growing morbidity among people who use drugs (PWUD) contributes to rising healthcare costs. In 2017, the US spent over $13 billion in healthcare costs driven by emergency department and inpatient visits among PWUD.2 Health systems struggle with how best to respond to the needs of PWUD.
Acute hospitalization for PWUD represents a window of opportunity to offer comprehensive services focused on reducing the risk of morbidity and mortality. Historic approaches to address the opioid epidemic were often limited to increasing access to treatment and required abstinence. In contrast to traditional abstinence-based approaches, harm reduction (HR) is a set of practical, evidence-based strategies focused on reducing the risk of complications associated with substance use. HR embodies both a collection of evidence-based practices and is also a broader philosophy embodying compassion and non-judgement. However, there is limited data on how best to offer harm reduction services to hospitalized PWUD.
In order to better understand how best to make health systems more responsive to the needs of PWUD, we interviewed hospitalized PWUD to understand their experience with HR in both traditional and non-traditional clinical settings.

Methods: This qualitative study was approved by the University of Pittsburgh Institutional Review Board. We conducted 30-60 minute long semi-structured interviews with 20 hospitalized PWUD (mean age 46; ranging in age from 30-77). The majority were White (n=17) and were equal number identified themselves as female (n=10) and male (n=10).
Participants were recruited from an academic medical center with a large rural, suburban, and urban catchment area located in Pittsburgh, PA from February to May 2023. Eligibility criteria included being 18 years or older, reporting illicit opioid use through insufflation, smoking, or injecting, meeting DSM-5 criteria for opioid use disorder (OUD), and being capable of providing informed consent and participating in a telephone interview in English. Participants provided oral informed consent, and received $50 per interview. Recruitment until we reached thematic saturation. All interviews were conducted in English and either in-person or over telephone.
All interviews were audio-recorded and transcribed verbatim. Identifying details were redacted before independent coding using Atlas.ti. Two coders coded 25% of the transcripts and a kappa score was calculated to determine inter-coder reliability. Researchers then conducted thematic analysis to identify key themes, meeting frequently and reconciling all discrepancies by consensus.

Results: We identified three major themes related to patient lived experiences and perspectives: 1) PWUD hold practical knowledge, including both HR practices and treatment opportunities, which they can harness for their own well-being and for the community of PWUD; 2) structural barriers prevent PWUD from access holistic addiction care; and 3) the important roles of community connections and HR services to overcoming these barriers.

Participants described learning practical knowledge related to HR strategies, techniques, and available resources from different sources. Participants frequently cited means such as personally experiencing adverse consequences, observation, and word of mouth. While most participants described knowledge about evidence-based HR practices, some endorsed methods that were either nonfactual or potentially harmful. Participants were motivated to learn more about HR and utilize existing knowledge to improve community well-being.
There are four key structural barriers to PWUD receiving holistic addiction care through both HR services and treatment options. Structural barriers include: health systems failing to address social determinants of health, programmatic policies requiring abstinence to access treatment resources, and hospital policies working in conjunction with the carceral system. Participants described barriers from food insecurity, transportation access, and discriminatory treatment (formal and informal) that limited access to certain kinds of care. Few PWUD received any HR services from traditional clinical settings, with care often explicitly or implicitly requiring abstinence. Hospital policies such as those identifying patients with bench warrants and alerting the police discourage PWUD from seeking timely care, producing treatment delays with serious and/or fatal consequences. For example: "There's more than two people that I'm fully aware of that had endocarditis and died within days of going into the hospital because they put it off for so long, because they were aware of the fact that they had a bench warrant.”
Participants described community-based HR as trusted, accessible, and approachable places to receive holistic services. They reported community-based HR services as crucial to overcome many of the structural barriers preventing access to HR in more traditional clinical sites. Sub-themes included: 1) stigma-free environments and providers, 2) warm-handoffs and longitudinal relationships amongst other HR organizations, 3) patient-centered service delivery approaches, and 4) ease of access for participants with varying levels of need. With these qualities, community-based HR services allow PWUD to overcome the stigma and shame they often experience when accessing more traditional treatment resources.

Conclusion & Discussion: To successfully integrate HR services into health systems, organizations must address structural barriers in multiple domains. Holistic addiction services require policies and procedures that avoid explicitly and implicitly alienating PWUD. Programs that integrate a framework addressing social determinants of health would better enable low-resource participants to access and remain in care. Additionally, PWUD in our study demonstrated care for themselves and others through HR.3 Collectively, these accounts underscore the roles mutual care, peer support, and community serve for survival and well-being among PWUD.4 Health systems could serve as HR service delivery vehicles, improving support for PWUD.
Although study generalizability may be limited due to few participants of color and non-English speakers, our findings show PWUD were motivated to reduce health risks from substance use. While HR was limited in traditional health systems, community-based HR organizations served a crucial role in overcoming the structural barriers to care serving as obstacles to the health and well-being of PWUD.5 Enabling warm handoffs and linkages from health systems to community-based HR organizations could be a pivotal touch-point to promote health equity and accessibility for hospitalized PWUD.

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