A 50-year-old man with opioid use disorder in sustained recovery for 5 years on buprenorphine and chronic pain stably managed with oxycodone 15 mg every 6 h was admitted to our hospital for an endoscopy and kidney biopsy. His admission was coordinated by his primary care physician (PCP), who prescribes buprenorphine and oxycodone, via a pain agreement. During morning rounds, nursing reported and documented the patient was "caught cheeking" (a derogatory term used in prisons to indicate drug diversion) his oxycodone, which was then relayed to the nurse manager and attending physician. Later, nursing thought they smelled smoke in the bathroom and called security, who recommended searching the patient's belongings and room. Unaware of these events, the patient's PCP came to visit him and found a patient care assistant waiting outside the room, who alleged they knew the patient was using drugs in the bathroom and that they were going into the bathroom after the patient was done to smell the bathroom and confirm this. Upon exiting the bathroom, the patient communicated to his PCP he was aware of these concerns from hospital staff and did not feel comfortable staying in the hospital. This 12-h cascade of events ultimately led him to complete a patient-directed discharge before any intended medical intervention and care was provided. Interactions between healthcare providers and people who use drugs (PWUD) in the hospital are often fraught with chaos, stigma, and institutional violence (e. g. , policy-driven harm, denial of care). 1, 2 Alarmingly, provider and hospital responses can transform hospitals into a carceral environment for PWUD. Despite being legally responsible to provide safe and adequate care for all patients, hospitals sometimes isolate or remove PWUD from emergency rooms, deny care and adequate withdrawal or pain management, or place them under increased surveillance and policing. 3 Instead of promoting understanding, shared decision-making, and collaboration, hospitals may engage in practices that increase mistrust in healthcare, erode patient-provider relationships, and criminalize patients with a substance use disorder (SUD) or substance use history. 1-5 Ultimately, punishing or criminalizing in-hospital substance use (e. g. , heightened surveillance, calling local law enforcement or security, seizing belongings, searching the patient and their belongings, drug testing) can act as a pipeline to arrest; instead of receiving care, patients sometimes receive handcuffs. 2, 6 Presently, no standard guidelines exist. Many hospitals lack explicit or clear policies on in-hospital substance use despite it being common, 2, 6 resulting in providers often using personal beliefs and informal or implicit rules to guide their care, which may be subject to bias and consequent conscious or unconscious perpetuation of drug use criminalization and institutional racism. 2, 4 In fact, a lack of appropriate and clear measures may create a risk environment that produces and reinforces stigma and increases odds of early discharge and poor pain management and care. 1, 2, 4, 7 Notably, a survey of hospitals with accredited addiction medicine fellowships found only 22% had a policy addressing in-hospital substance use and 52% use hospital security always or most of the time when in-hospital substance use occurs. 6, 7 Additionally, hospital security or law enforcement is used just as often as addiction specialists as a response to in-hospital substance use. 6 Other oft-used escalating responses include room and belonging searches, seizure of belongings, visitor restrictions, care contracts, 24/7 video monitoring, and threatened discharge. 6, 7 To be sure, concerns of staff and patient safety are important to address, including harm towards staff and increased risk of treatment disruption, infection, or drug poisoning or overdose due to in-hospital substance use. 8 However, it is simultaneously vital to elucidate whether safety concerns are founded in racism and stigma. 2 Additionally, the immediate dissolution of patient rights cannot be a solution when numerous more patient-centered ones exist. 2, 6 And as threats to both cut access and funding for addiction-related services and research (e. g. , 11 billion in federal funding for addiction and mental health care was recently revoked) 9, 10 and increase law enforcement involvement in the overdose epidemic by the federal government grow, hospitals are increasingly likely to be on the frontline of protecting PWUD from dehumanizing, harmful, and needless arrests, imprisonment, and state-sanctioned violence. Unfortunately, while many members of the healthcare system believe they are preventing undue harm to patients by preventing PWUD access to the medications they need for adequate pain and withdrawal treatment––whether it be due to provider fears of worsening addiction or perceiving PWUD as "drug-seeking"––they are in actuality increasing in-hospital substance use and SUD recurrence, and making patients more vulnerable to illicitly manufactured opioids, the contaminated drug supply, and street use. 5, 11-13 Fortunately, a solution exists. In clinical practice, decades-worth of evidence shows harm reduction (HR) is life-saving and a crucial foundation of SUD treatment. 14 HR is an evidence-based model and cornerstone of national addiction treatment guidelines15 that acknowledges substance use exists, addresses substance use on a spectrum rather than abstinence being the only model of success, and seeks to find ways to minimize the harmful effects of substance use instead of condemning drug use or imposing the cessation of use as the only treatment option. 14 Notably, HR directly aligns with the already existing goals and ethical principles of medicine (e. g. , autonomy, humanism, justice and equity, alleviating suffering, health promotion). 14 With these ethical principles as a framework, hospitals should institute a HR-based strategy to explicitly address in-hospital substance use that mirrors emerging clinical guidelines and adopts a more destigmatizing and humanizing approach (Table 1). Inform all patients upon admission of the hospital's substance use policy and if applicable offer options of lock boxes for post-discharge access or safe disposal of substances or drug use equipment. (Autonomy, Justice and Equity) Establish a relationship with the patient that acknowledges the reality of substance use experiences and symptoms (e. g. , cravings, pain management). (Alleviating Suffering) Encourage preventive discussions with the patient and assess patient knowledge about SUD diagnosis, options, substance use risks, and goals related to substance use. (Health Promotion) Assess openness to treatment. (Autonomy, Health Promotion) Discuss the risks associated with in-hospital substance use. (Health Promotion) Engage in HR education (e. g. , route of administration, drug checking, overdose reversal). (Alleviating Suffering, Health Promotion) Develop a treatment plan in collaboration with the patient to mitigate symptoms and potential triggers. (Humanism, Alleviating Suffering, Health Promotion) Remind the patient of hospital resources including psychosocial and medical treatment for SUDs including buprenorphine, methadone, and alcohol withdrawal treatments. (Health Promotion) Offer the option of storing substances and substance use supplies in a lock box they can access after discharge or disposing of the substances. (Autonomy) Arrange a meeting between the primary care team and the patient and family members/representatives (if patient provides consent to include family/representatives). (Autonomy) Discuss what triggered their in-hospital substance use and address these triggers as possible. (Alleviating Suffering, Humanism, Health Promotion) If substances are found, remind the patient of hospital policy and be given the option of using a lock box they can access after discharge or disposing of the substances in a pharmaceutical waste bin. (Autonomy) Offering harm reduction supplies (e. g. , take-home naloxone, wound care, test strips) and linkage to follow-up care. (Health Promotion) Harm reduction in the hospital begins upon admission by informing all patients regardless of substance use status of the hospital's policy on in-hospital substance use (Table 1). This can be woven into already standard conversations on rules for patients bringing in and using their home medications. Establishing a relationship with the patient by proactively discussing the reality of substance use experiences and symptoms and acknowledging in-hospital substance use can happen and for a variety of reasons (e. g. , under/untreated pain, withdrawal management, to cope with stressors) is also essential. 1, 2, 7 Patients and providers should create a collaborative care plan to manage symptoms and potential triggers, and discuss openness to SUD treatment––all with the intent of reducing harms and making the hospital as safe an environment as possible. Additionally, asking the patient what their experiences, needs, and preferences are before acting upon what we as providers think they need can reduce hospital-based harm and ensure each action reduces harm and is a discussion that allows for patient to weigh in on their care (Note: "care" is an all-encompassing term and can include medical care, visitor privileges, access to personal belongings, autonomy, and informed decision making). Also, HR education discussions throughout the patient's stay may create space for patient reflection and goal discovery. Furthermore, medical management is also essential to address pain, ongoing substance use, and withdrawal. 16, 17 In the case of patients disclosing or being found to engage in in-hospital substance use or possession of substances during their hospital stay, patients should be provided lock boxes for access post-discharge, offered safe substance disposal, and there should be a meeting between the patient and their primary care team to understand what triggered their substance use, create a de-escalation plan, and discuss psychosocial and medical treatment options. Room searches, security, law enforcement, and surveillance should be last line measures used in cases of imminent harm to patient, visitors, or staff. The seizure of belongings and valuables is unethical and can strip the patient of their identity, autonomy, and humanity, especially in cases where their belongings may be all that they own, which can be especially relevant for people experiencing homelessness. The aftermath of mistrust and physical and mental health trauma due to initiating policing and punitive measures should be considered. 18 Upon discharge or in case of patient-directed discharge, safer use supplies, naloxone, oral antibiotics, wound care kits, and linkage to follow-up care should be offered given discharge is not an absolution of our responsibility to a patient's health. Integrating HR into hospital policy can pave the way toward making the hospital a safer place for PWUD. We must intentionally design policies that acknowledge and address classist and racialized stigmatization, criminalization, and incarceration of drug use. We need to recognize that many PWUD may have prior negative interactions with healthcare, law enforcement, and carceral institutions. As a result, hospitalizations can be traumatic, and the presence of security and law enforcement may be intimidating and are reminders of the criminalization seen during the War on Drugs. A clearly written policy can remove as much gray area as possible. For hospitals that already have in-hospital substance use policies in place, review and revision using a harm reduction lens is necessary. In fact, some have revamped their in-hospital substance use policy by limiting the use of security, surveillance, and law enforcement while prioritizing harm reduction, patient support, and dignity and have seen positive results. 2 Hospital systems across the country should follow suit, implementing similar policies. Returning to our patient case, using a policy that centers around medical management, safe disclosure, and HR would not only have adequately addressed potential substance use concerns from the staff, but also would have ensured the patient received the care he came to the hospital for in the first place. For example, the provider team could have checked in with the patient upon admission about his medications and other needs he may have, contacted his PCP, and engaged in discussion instead of conflict with the patient once substance use was suspected. Of note, the patient's PCP ultimately filed a biased medical error report, which triggered a unit discussion with nurse managers and medical directors and the drafting a new in-hospital substance use policy. The hospital is meant to be a place of healing and safety, but we are failing to ensure that for PWUD. Medicine prides itself on being an inherently evidence-based profession, using cutting-edge science and guidelines to inform clinical care. Additionally, just as medical problems are addressed with medical ethics as the guiding framework, in-hospital substance use is likewise a medical issue requiring the same consideration and care. However, if we do not follow the evidence or our ethical and moral charge, and instead rely on stigma and punitive responses, then we are no longer providing care to one of our country's most marginalized communities. In short, we are continuing to perpetuate injustice, harm, and criminalization of people who use drugs. Opinions expressed are the authors' own and do not necessarily represent the views of Icahn School of Medicine at Mount Sinai. The authors declare no conflicts of interest.
Ormiston et al. (Thu,) studied this question.
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