(17) Attitudes of Patients Who Use Drugs Towards Policies Regarding In-Hospital Use

Background & Introduction: In-hospital illicit substance use is common, with as many as 40% of patients with substance use disorders (SUD) reporting doing so at least once in their life (1,2). Overdose events from such episodes result in care complications, prolonged stays, and discordance in the treatment team-patient relationship. Guidelines for standard of care around prevention and responses to in-hospital use are limited. Previous efforts have sought to characterize reasons for in-hospital use and patient directed discharges, but not as much on patient perspectives for strategies to prevent in-hospital use (3). The Joint Commission leaves policy to the individual hospital (4). As such, hospitals utilize different techniques, from limiting access to substances, stepwise responses to patient behaviors (i.e. paraphernalia found), or legal involvement. Given the four principles of medical ethics and the vulnerability of the addiction medicine population, it is paramount that patient voices are included in policy generation. However, this information is limited in the literature. This project’s purpose was to engage directly with patients on the addiction medicine consult service about potential policies and procedures for illicit substance use in the hospital. This is part of a system-wide quality improvement initiative to reduce overdose risk in the hospital by self-administered substances.

Methods: Semi-structured interviews were conducted with patients admitted to a large, tertiary medical center in the Midwest with these inclusion criteria: ≥18 years old, ICD10 diagnosis of current/past misuse of illicit substances which must include opioids (with or without associated SUD diagnosis), addiction medicine consultation. Exclusion criteria were those without a history of opioid misuse, medical instability precluding interview, patient lacking capacity for consent, and non-English speaking. Interviewers were clinicians briefly trained in qualitative techniques. Interviews consisted of demographic data, reflections to proposed policies, and open-ended questions from a code book generated by a member of the team (e.g. What do you think is the best way for the hospital to help people not use substances while they are admitted?). Interviewers were not a member of the patient's medical care during that admission and another member transcribed. Transcriptions were de-identified prior to storage and analysis. The sample was collected by convenience sampling. Interviewees were provided a 10 dollar gift card for participation. Atlas ti was utilized for thematic analysis, and interviews continued until saturation was reached. Intercoder reliability was calculated with Krippendorff’s Cu-α: 0.735. The project was IRB exempt.

Results: A total of 25 interviews were included for analysis based on selection criteria. Of these 25 respondents, 16 identified as male and 9 identified as female. Respondents ranged from 25 to 67 years old. Four main themes were identified in our interviews. Non-invasive versus invasive strategies: most respondents endorsed measures that did not necessitate physical interaction with a patient's person or room to avoid episodes of inpatient use, such as explaining goals for the hospital stay at the time of admission: “Be understanding and upfront with them right away that using in the hospital is not acceptable, but that you are there to help them.” However, there was more than expected heterogeneity of endorsed strategies: “[On inspection at admission] I wouldn’t be opposed, but people are going to catch on. So they are going to find another way.” Treatment as prevention: a patient’s symptoms of withdrawal and pain are taken seriously and addressed by all members of a care team. This was an approach endorsed or at least alluded to across a large majority of respondents: “If someone is in pain, treat the pain.” Awareness: emphasizing the value of having care team members knowledgeable in the treatment of substance use and the underlying challenges those with SUD face: “…there should be some sort of training or some type of introduction into how people become addicts and that it is a disease.” Lastly, compassion in care: sometimes within the context of treatment as primary prevention but also in response to episodes of use: “They [the patient] should be asked ‘why’ in order to understand.”

Conclusion & Discussion: This single center qualitative project demonstrates an interesting heterogeneity in proposed measures of avoidance of in-hospital substance use and medical system response. The greater than expected heterogeneity in respondents’ endorsed prevention strategies could be explained by conflation of prevention answers with proposed responses to episodes of use. Compassion from members of the care team was a consistent element throughout proposed prevention and response strategies. An emphasis was placed for many on the importance of team understanding that in-hospital use represents an opportunity to improve treatment plans more rigorously, trauma-informed way. This project is helping to inform the formulation and implementation of policy for our health system with respect to prevention of- and responses to use in the hospital. It demonstrates the importance of emphasizing patient collaboration and awareness around prevention and non-punitive responses to episodes of illicit use while admitted.

References: 1. Danovitch I, Vanle B, Van Groningen N, Ishak W, Nuckols T. Opioid Overdose in the Hospital Setting: A Systematic Review. J Addict Med. Jan/Feb 2020;14(1):39-47. doi:10.1097/adm.0000000000000536
2. Fanucchi LC, Lofwall MR, Nuzzo PA, Walsh SL. In-hospital illicit drug use, substance use disorders, and acceptance of residential treatment in a prospective pilot needs assessment of hospitalized adults with severe infections from injecting drugs. J Subst Abuse Treat. Sep 2018;92:64-69. doi:10.1016/j.jsat.2018.06.011
3. McNeil R, Small W, Wood E, Kerr T. Hospitals as a 'risk environment': an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med. 2014 Mar;105:59-66. doi: 10.1016/j.socscimed.2014.01.010. Epub 2014 Jan 19. PMID: 24508718; PMCID: PMC3951660.
4. Martin M, Snyder HR, Otway G, Holpit L, Day LW, Seidman D. In-hospital Substance Use Policies: An Opportunity to Advance Equity, Reduce Stigma, and Offer Evidence-based Addiction Care. J Addict Med. Jan-Feb 01 2023;17(1):10-12. doi:10.1097/adm.0000000000001046.