Case

A 28-year-old man with a past medical history notable for severe opioid use disorder and aortic valve endocarditis requiring valve replacement was admitted with recurrent bacteremia, prosthetic valve endocarditis, and acute kidney injury. His hospital course was complicated by poor control of his substance use disorder (SUD) and delayed engagement with the addiction medicine team. He had multiple episodes of suspected injection drug use during his hospitalization that were ultimately confirmed with urine toxicology and mass spectrometry analysis. A lack of a clear hospital policy for addressing in-hospital substance use contributed to variable responses from health care team members and the enactment of primarily punitive measures which severely eroded the patient-physician relationship. Ultimately, the patient developed worsening bacteremia and fungemia complicated by septic emboli. He was deemed not to be a candidate for repeat valve replacement, and he died after a prolonged hospitalization.

Overview of the issue 

Hospitalizations related to SUD are rising, and evidence suggests that patients with SUD may commonly use substances during hospitalizations.^1,2 Prospective cohort studies of patients with SUD in Canada found that 43.9% of participants had used substances during a hospital stay.³ The most common reasons cited for ongoing drug use included “wanting to use” and “being in withdrawal.” A smaller prospective cohort study including hospitalized patients with a history of injection drug use found continued in-hospital drug use in 40.5% of participants.⁴ A separate ethnographic study highlighted patients may take measures to conceal substance use from clinicians while hospitalized, such as injecting alone in locked bathrooms.⁵

In addition to a lack of formal prevalence studies on in-hospital substance use, there are associated adverse outcomes such as bloodstream infections, increased length of stay, or unintentional deaths, which are also not well quantified. Although there may be ad-hoc processes for documenting episodes, such as completing an anonymous safety report at the unit level, standardized systems that systematically track these metrics are rare and do not exist within our hospital systems.

While patients with opioid use disorder should be counseled on harm reduction, offered medication-assisted therapy, and connected with outpatient behavioral health and addiction medicine resources, there is often little discussion about what health care professionals or hospital systems should do in response to in-hospital substance use by hospitalized patients.^6-8

Published guidelines or comprehensive best practices are lacking. Here we describe some of the challenges associated with addressing in-hospital substance use and propose recommendations for the development and implementation of hospital policies to respond to this complex issue. 

Challenges of addressing Issue

Applying an ethical lens, there is a tension between valuing beneficence and patient autonomy: “I must do good by my patient” and yet “this person makes their own decisions.” Ensuring patient safety is an important component of providing high-quality health care, with adverse outcomes of in-hospital substance use including the real possibility of overdose and death. Not only is this distressing for the medical team, but it also carries a theoretical risk of liability for both the clinician and the hospital, because patients are considered dependents while hospitalized in some states. However, to our knowledge, there is no legal precedent of hospital or clinician culpability for a hospitalized patient’s overdose death from their own substance use. While beneficence is often prioritized, there is the competing issue of respect for patient autonomy. Patients may make decisions that don’t always prioritize their own health, including ongoing substance use. We recognize their disease yet accept their decision to use drugs. Non-judgmental acceptance of patients with SUD is an important facilitator of a patient pursuing treatment.

In our current state, systems may often use authoritarian responses to ongoing in-hospital substance use including room and belongings searches, visitor restrictions, privilege limitations, and the placement of cameras and safety attendants. These punitive responses, especially without objective confirmation of in-hospital substance use, may negatively impact physicians’ therapeutic alliances with their patients and may further marginalize an already vulnerable patient population. Without clear institutional guidelines, there may also be tensions between transdisciplinary clinicians who may share different viewpoints on how to respond to episodes of in-hospital substance use. There is increasing recognition that structural factors, such as organizational policies, bias, and mutual mistrust between patients and clinicians contribute to adverse outcomes among patients with SUD.^3,5,9,10 Pervasive stigmatization by health care workers against patients with SUD, especially racial/ethnic minorities and those of lower socioeconomic status, may be compounding these factors.^5,11,12  

Recommendations for the development of hospital responses: We believe that policies to address the ongoing use of opioids by hospitalized patients should be locally developed and implemented in a manner that balances the tension between patient safety and maintaining an alliance with this vulnerable population. In developing health system approaches, it is necessary to involve relevant stakeholders including not only members of the health care team but also patients, patient advocates, and representatives from legal, ethics, security, and hospital administration. Collaboration during the development of response reduces the risk of interdisciplinary misalignment. 

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We recommend universal screening of all patients for SUD at the time of admission. Early recognition of SUD may allow hospitalists to take proactive measures to decrease a patient’s desire to use substances in the hospital, particularly by ensuring adequate pain management, addressing withdrawal symptoms, initiating clinical treatment for SUD, and engaging addiction medicine service if available.^3,6,10 Adequately treating an individual’s SUD will decrease the risk of ongoing substance use by hospitalized patients, though it may not prevent it entirely, as in our patient’s case. 

Punitive or restrictive measures should not be implemented solely because a patient has a history of SUD. If there are objective concerns for active substance use, such as witnessed possession of an illicit substance or confirmed in-hospital use, health systems should have a standardized strategy for addressing these episodes. 

We advocate the involvement of a multidisciplinary team including members from medicine, addiction medicine, social work, psychology, pharmacy, and bedside nursing to implement a response that includes: 1) identification and mitigation of hospitalization-associated psychosocial stressors⁹; 2) medication titration to address cravings (i.e. increase the dose of as-needed medication or change from an as-needed to a standing-dose schedule); 3) education to dissuade the patient from using a medication in a way other than prescribed (i.e. injecting oral medications); 4) provision of naloxone to be kept at the bedside; and 5) if illicit substances are found, they should be in a personal belongings locker not accessible to the patient until the time of discharge. 

Clinicians need to be deliberate about the language used to openly communicate these policies to their patients.¹³ Ideally, this language should capitalize on the therapeutic alliance and highlight the need to ensure patient safety without perpetuating bias. Given the illegality of substance use, medical providers may be tempted to engage law enforcement in the response to in-hospital substance use. The presence of security may be traumatizing for vulnerable populations, and we recommend that these approaches minimize the direct engagement of hospital security.

Once developed, these policies should be publicized and easily locatable. All staff members should be educated on these workflows and the frontline health care team should work collaboratively to ensure appropriate and consistent execution of these responses. Health systems should study the implementation of these measures over time—both to understand efficacy and to ensure policies do not disproportionately affect specific populations who experience provider bias and structural racism.

Back to the case

Although our patient was appropriately started on methadone on the day of admission, the available addiction medicine team was not formally involved in our patient’s care until over a month into his hospitalization, after the patient had injected oral prescribed medications into his central line. Punitive measures were enacted throughout his hospitalization even before his in-hospital substance use was confirmed. Involvement of hospital security, visitor restrictions, and the creation of informal care agreements contributed to patient stigmatization and led to significant mistrust between our patient and clinicians. The lack of clear institutional protocols for responding to in-hospital substance use created confusion, and at times tension, among the health care team, as well as mixed messages for our patient. Reflecting on our patient’s case, we acknowledge that more could have been done within our health system to address psychosocial stressors during his prolonged hospitalization, limit his interactions with hospital security, and reduce the significant stigma he experienced.

Bottom line

Health systems need to develop and implement measures to respond to episodes of in-hospital substance use with strategies that balance the tension between ensuring patient safety and caring for a vulnerable population.

Dr. Flynn

Dr. Azari

Dr. Esmaili

Dr. Raffel

Dr. Flynn is a hospitalist in the division of hospital medicine at the University of California San Francisco. Dr. Azari is a hospitalist in the division of general internal medicine at San Francisco General Hospital, University of California San Francisco. Dr. Esmaili is a hospitalist in the division of hospital medicine at the University of California San Francisco. Dr. Raffel is a hospitalist in the division of hospital medicine at Denver Health, Denver. 

References: 

1. Peterson C, et al. Opioid-related US hospital discharges by type, 1993–2016. J Subst Abuse Treat. 2019;103:9-13. doi:10.1016/j.jsat.2019.05.003.
2. Ronan MV and Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002-12. Health Aff. 2016;35(5):832-7. doi:10.1377/hlthaff.2015.1424.
3. Grewal HK, et al. Illicit drug use in acute care settings. Drug Alcohol Rev. 2015;34(5):499-502. doi:10.1111/dar.12270.
4. Fanucchi LC, et al. 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. 2018;92:64-9. doi:10.1016/j.jsat.2018.06.011.
5. Merrill JO, et al. Mutual mistrust in the medical care of drug users: the keys to the “narc” cabinet. J Gen Intern Med. 2002;17(5):327-33. doi:10.1046/j.1525-1497.2002.10625.x.
6. Alfrandre D and Geppert C. Ethical Considerations in the Care of Hospitalized Patients with Opioid Use and Injection Drug Use Disorders. J Hosp Med. 2019;14(2):123-5. doi:10.12788/jhm.3100. 
7. Linker A, et al. Treatment of opioid use disorder in hospitalized patients; an opportunity for impact. The Hospitalist. Dec 14, 2021. doi: https://www.the-hospitalist.org/hospitalist/article/249902/neurology/treatment-opioid-use-disorder-hospitalized-patients. Accessed September 2, 2022.
8. Calcaterra SL, et al. Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines. J Hosp Med. 2022 July 26. doi:10.1002/jhm.12908.
9. McNeil R, et al. 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;105:59-66. doi:10.1016/j.socscimed.2014.01.010.
10. Ti L, et al. Denial of pain medication by health care providers predicts in-hospital illicit drug use among individuals who use illicit drugs. Pain Res Manag. 2015;20(2):84-8. doi:10.1155/2015/868746.
11. Meltzer EC, et al. Stigmatization of substance use disorders among internal medicine residents. Subst Abuse. 2013;34:356–62. doi:10.1080/08897077.2013.815143.
12. van Boekel LC, et al. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1-2):23-35. doi:10.1016/j.drugalcdep.2013.02.018.
13. Metzl JM and Hansen H. Structural competency: Theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-33. doi:10.1016/j.socscimed.2013.06.032.

For additional reading from the Journal of Hospital Medicine: Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines  and Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine