Patients using nonprescribed drugs in the hospital is a common issue, and raises dilemmas. Health care workers have genuine concerns about medical and safety impacts, but also reactions rooted in stigma—which can often result in people who use drugs being mistreated, leaving care or choosing not to return if future care is needed.
So what’s the best approach? A recent study, published in JAMA Network Open, sought answers—and in doing so, underlined the importance of involving people with lived experience in policy decisions.
To come up with recommendations, the study consulted 38 experts: seven clinicians with personal lived or living experience of substance use disorder (SUD); 21 clinicians without experience of SUD; and 10 nonclinicians with experience of SUD.
Eligible clinician experts were physicians, advanced practice clinicians, nurses, and social workers who had worked on a hospital-based addiction consultation team for at least four weeks in the past year. Personal experience of SUD was self-identified by experience of a hospitalization in the past 10 years, and meeting diagnostic criteria.
It was important that everyone was considered equally “expert,” according to lead author Joseph H. Donroe, MD, associate professor at Yale School of Medicine and a member of the Yale Addiction Medicine Consult Service.
“Every expert opinion was equally powerful, no matter what their background was,” he told Filter.
While the experts broadly agreed in most cases, there were significant differences between those with experience of SUD and those without on 10 of the recommendations.
The researchers used the Delphi process, which involves asking a group of experts questions anonymously to arrive at a consensus. The participants reached consensus on 84 recommendations.
There were three rounds of online surveys, the last of which included eight categories of recommendations, ranging from what should happen at the time of hospital admission to what should happen if substance use is suspected, the nature of the response and expected outcomes.
Looking at different potential approaches, participants recommended to always implement, sometimes implement, rarely implement, or never implement.
Recommendations on which consensus was reached included providing evidence-based SUD treatment, assessing and reassessing pain management, and treatment of withdrawal.
While the experts broadly agreed in most cases, there were significant differences between those with experience of SUD (whether or not they were clinicians) and those without on 10 of the recommendations.
For instance, none of the participants with experience of SUD (clinicians or nonclinicians) agreed that nonprescribed substances, if found on a patient, should always be stored in a locked place during hospitalization. But 70 percent of the clinicians without SUD experience recommended this.
Meanwhile, all but one of the clinicians without SUD experience said staff should always assess patients for SUD at the time of admission. But fewer than half (42 percent) of the clinicians and nonclinicians with SUD experience said the same.
In both cases, most participants with SUD experience said the policies should sometimes be implemented, depending on circumstances, and so “sometimes” was the consensus reached.
The caution of the SUD cohort is well-founded.
“The partnership breaks down, people get frustrated on both sides, and at its worst, patients leave the hospital. I’ve seen it go wrong so many times.”
“We frequently hear from people who use drugs that a primary reason they delay or avoid hospital care is knowing they will not receive withdrawal management,” Rebekah Joab, deputy director of litigation and legal services at the Legal Action Center, which advocates for health care access and harm reduction, told Filter.
“When hospitals fail to provide withdrawal management and police and punish in-hospital use, too often the outcome is that people who use drugs don’t get health care,” she added. “Harm reduction belongs in hospitals as well as in the community: The goal should not be to stop a person’s drug use, but to ensure that they receive appropriate medical treatment.”
What happens in the hospital is “distrust,” Donroe acknowledged. “The partnership breaks down, people get frustrated on both sides, and at its worst, patients leave the hospital. I’ve seen it go wrong so many times.”
Many studies point to the link between a patient having SUD history and “discharge against medical advice,” now termed patient-directed discharge.
The new study focused on the consensus recommendations more than the differences. However, Donroe said, “It seemed from our data that people with lived experience were safeguarding their autonomy, their ability to participate in decision-making.”
While the clinicians all recognized the importance of patient safety, he continued, those without lived experience placed more weight on their perceptions of the safety of other patients, as well as patients with SUD. “There was a bit of tension there.”
Another example of an area with less consensus concerned involving the floor nurse in hospital substance use. For some of the physicians and advanced practice providers, it made sense to have the nurse involved, Donroe said. “But people with lived experience have been at the other end of it, and thought that maybe the nurse shouldn’t be involved.”
What about the anesthesiologist, who would surely want to know about what drugs the patient has been using, is tolerant to, or is withdrawing from?
“This is part of what makes this a nuanced and complicated issue,” Donroe said. “Every person you bring into the conversation should approach it with compassion. The situation can improve, or it can get a lot worse.”
Once there is a relationship with the patient, information about their drug use can be sought in a non-stigmatizing way, he continued. “It can be useful for the anesthesiologist to know what the tolerance will be. But don’t follow it up with anything punitive.”
To this end, he recommended that if use is established, providers ask the person about why they use drugs. “There are often reasons—pain, anxiety, withdrawal. The idea behind this paper is not to say anybody is condoning inpatient substance use, but that when it is identified or suspected, is there a way we can approach it that is compassionate?”
“Health records can turn into a rap sheet for people with a history of drug use, and hospital protocol for suspected inpatient use should include strict confidentiality.”
Jacqueline Seitz, the Legal Action Center’s deputy director of health privacy, also had takeaways from the study. “Among the consensus recommendations, it caught my eye that 89 percent of the experts agreed: When substances or supplies are found, patient confidentiality should be maintained, and providers should avoid linking evidence to the patient,” she told Filter.
“But in practice, we frequently see hospitals recording the events surrounding suspected or actual in-hospital substance use,” she continued. “These notes can end up following a patient for the rest of their life, leading to future stigma and discrimination among providers with access to the electronic health record.”
“Under current law, it can be challenging or impossible to amend erroneous information or restrict disclosures of stigmatizing or harmful information,” Seitz said. “Health records can turn into a rap sheet for people with a history of drug use, and hospital protocol for suspected inpatient use should include strict confidentiality protocols to avoid this criminalization of health information.”
The American Hospital Association declined to comment on the study. But hospitals should be aware of their legal liability when it comes to treating patients who use drugs.
“When decisions or policies are guided by stigma toward drug use, substance use disorder, or suspected use, it can lead to violations of anti-discrimination laws like the Americans with Disabilities Act,” Joab said. “For example, a violation is likely where a hospital applies restrictive security measures only to people with a history of substance use disorder. These anti-discrimination laws also prohibit the denial of health services to people currently using drugs —a protection that hospitals should consider when responding to or creating policies about in-hospital drug use.”
42 CFR Part 2, the federal regulation protecting treatment records, may or may not apply. “Part 2 protects SUD treatment records that identify a patient as seeking or receiving services from a Part 2 program,” Seitz said. “It is possible in a hospital setting for an Addiction Medicine Consult team or an alcohol detoxification unit to meet the definition of a Part 2 program, but most of the emergency medical treatment provided in hospitals does not fall under Part 2.”
“Physicians have a lot of blind spots and it is important to include the people we help care for in the decisions that affect them.”
Hospitals are not relaxing places to be. They can produce anxiety in almost anyone. “From the standpoint of people with lived experience, it’s not uncommon for them to have trauma or incarceration in their past,” Donroe said. “When you take a person with a history of incarceration, and you say, ‘You cannot leave, we will bring you your meals, your medication, we will tell you what’s okay in your behavior,’ this will bring up past trauma.”
Changing the hospital environment is not easy, he conceded. “I’m part of the Yale Addiction Medicine Consult Team, and one part of why we did this study is to have this data and start evolving policy. Our next step is to evolve policies that are more partnering with patients. We’re not there yet. This is part of the process.”
“Since we began our consult service, there’s been a palpable transition in the way that hospital providers think about people with lived experience in a less stigmatizing way,” he added.
The clinicians involved in the study all had experience in addiction medicine, “in order to generate recommendations based on expertise with substance use disorders,” Donroe said. But many other “stakeholders who weren’t part of this conversation” will need to be involved in order to actually develop new policies, including hospital security and administration staff, as well as nurses.
Above all, Donroe emphasized, to find out what patients who use drugs need in order to have a beneficial hospital experience, providers must ask them.
“Physicians have a lot of blind spots and it is important to include the people we help care for in the decisions that affect them,” he said. Otherwise, the risk is that they will leave, despite being sick—or just not come at all.
Photograph via Pickpik