Complexities of caring for PWUD.

Participants highlighted the complexities of caring for PWUD in comparison to other patient populations. They frequently described care as “challenging”; requiring more time and resources than other patient populations and more than what was available in the ED. One of the challenging aspects of care was that PWUD frequently presented with multiple concurrent physical and mental health concerns. Comorbid chronic pain among PWUD was reported as a complicating clinical factor that required additional time and effort. For some participants, they found their typical pain management assessment and treatment strategies were insufficient for PWUD.

“The patients with opioid use disorders seem to require more, they experience more pain, it’s harder to get their pain under control for specific procedures or for their presenting complaint, just a little bit more challenging. Like, for example, local anesthetic doesn’t seem to work as well.”

(Participant 12)

Some participants also mentioned challenges they and their colleagues faced navigating perceptions of “drug seeking” against legitimate acute and chronic pain.

“So I think what happens is that clinicians and health care providers generally who are working in emergency rooms that are trying to provide care to patients with substance use disorders, is that there is a sort of an assumption that the patient is looking for something, which obviously is not true. I mean, they’re looking for help most times, but there is a perception that they’re going to trick us. […] So that probably is the hardest barrier to overcome in an emergency department.”

(Participant 18)

In addition to multiple comorbidities, participants explained how structural and social determinants of health further increased the time and resources required to effectively care for PWUD. Most participants mentioned the intersection of substance-use related harms and structural vulnerability (e.g., lower socioeconomic status, unstable housing or houselessness, food insecurity, history of incarceration, adverse childhood experiences, experiences of stigmatization/discrimination or trauma in the healthcare system). They indicated that these adverse circumstances complicated care because they can prevent access to follow-up testing, treatment, procedures, and access to wraparound services (e.g., prescription costs, transportation). In addition, the inability for patients to convalesce from acute illnesses in the face of food insecurity, precarious housing, or houselessness also impeded effective discharge planning.

“P: But just because of the population of people [who use drugs] who end up presenting to emergency, I think that they are disproportionately you know, in tenuous housing situations and frequently don’t have employment or on disability with payments of various kinds.

I:Right. And how does that affect the care that they receive in the ED? Or how does that affect your approach or capacity to care for these patients?

P:Well, it makes it more difficult, because you’re not discharging them in as safe a circumstance as you might like.”

(Participant 11)

Thus, regardless of a patient’s stated or perceived social stability, interviewed physicians identified that care for PWUD was practically and cognitively more complex than patients who do not use drugs. This complexity limited their ability to systematically offer harm reduction interventions in the ED.

Harm Reduction in the ED.

Participants described what their existing harm reduction practice looked like in the context of their ED. They spoke about harm reduction as both an approach to care, as well as a set of interventions. As an approach, they defined harm reduction as part of patient-centered and proactive care, where care is tailored to meet patient-identified needs and circumstances.

“I think in every patient that we’re trying to help manage substance use, a tailored, customized approach is always required because everyone has their own specific set of circumstances.”

(Participant 22)

A few participants also stressed the importance of supporting patient autonomy.

“My only caution would be whenever we’re talking intervention and things to do, we have to respect patients’ autonomy. There’s a large subsection of the world who’s using drugs […] and managing and coping and doing quite well, right, in their lives, at least in their framework of what well looks like. And so, you have to give people the autonomy and the freedom to make those choices and so, being willing to have a frank discussion and you know explore whether those are really the optimal choices or the ones they want to make is something that you should be willing and prepared to do. But then you still have to allow people to walk away. The key to this is to be non-judgmental. You know, it’s the, letting people do what works for them.”

(Participant 27)

Participants also described harm reduction interventions they have utilized with the aim of reducing drug-use related harms outside of and within the ED. To reduce drug-use related harms after a patient leaves the ED most participants had experience incorporating at least one harm reduction and/or treatment intervention and a few had experience providing several. Most participants reported they were not—but should be—delivering comprehensive harm reduction interventions routinely to all patients who use drugs. Ideally, these interventions would include: discussions on drug-use related risks (e.g., synergistic effects of drug groups) and safer use strategies (e.g., doing a test dose, not using drugs alone); initiating OAT and/or referring patients to community OAT providers; take-home naloxone kit distribution; offering information on local harm reduction services and addiction treatment programs; and sterile consumption supplies distribution. Participants described practice variation that was contingent upon assumptions about the patient’s social situation wherein there were missed opportunities to provide harm reduction services in the ED to PWUD who have or are assumed to have stable income and housing.

“I think we sometimes forget the rest of the populations that are still ‘at risk,’ [from drug-use related harms] but who we don’t judge immediately to have [poor] social determinants of health […] The middle-class, upper middle-class patient who comes in after having had some surgery and given a pile of opioids who comes in and still says they have pain and we’re giving them more opioids. But we sort of judged that they wouldn’t be at risk, so we don’t give them protective support, like a naloxone kit or teaching because we’ve sort of separated into ‘them’ and ‘us’ […] Sometimes we miss the opportunity to treat some people who we haven’t flagged as being a concern because of their social determinants.”

(Participant 26)

As well, some participants working in communities with a large network of outpatient harm reduction services explained that they were likely to omit providing or discussing harm reduction interventions in the ED because they assumed that patients were already aware of harm reduction strategies and existing resources.

“If they’re part of that [inner city] community, chances are they know where the safe injection sites are and how to access them. So [...] I don’t routinely ask people about safe injection site use. Maybe I should.”

(Participant 4)

Most interviewed physicians discussed instances where patients used illegal drugs while in the ED. Apart from the few participants who had access to a nearby or in-hospital supervised consumption service, many participants cited safety concerns for both PWUD (e.g., drug poisoning due to concealed use) as well as staff and other patients (e.g., due to concealed drug consumption supplies). A few participants depicted a recent shift in ED practices away from removing patients who use drugs in the ED from the premises, to adopting a tolerant, non-punitive approach that has improved patient engagement.

“Once upon a time, if you injected drugs in our washroom or in the hospital, you got thrown out. Now we allow people to inject. If you were to inject in the bathroom, it’s like, “Oh, my God, why did you pass out in the bathroom?” But we don’t throw them out, we treat them and see if they want further information about dealing with their addiction.”

(Participant 2)

Most participants were supportive of the concept of a supervised consumption service available to ED patients but stated that the reality was such a service was not likely to be a funding priority or accepted by hospital or political leadership.

Discordance in care goals.

Some participants found that the circumstances under which some PWUD were brought to the ED and the way in which the ED operated led them to question the appropriateness of having prolonged conversations about harm reduction, which they believed may not be desired or understood and retained by patients. In particular, the participants discussed the challenges they faced engaging patients in harm reduction interventions who were brought in via paramedics and treated for an overdose. These patients were described as drowsy, sedated, agitated, and importantly, that “[T]hey didn’t mean to come to emergency. They weren’t actually actively seeking the help.” (Participant 31) and therefore were not perceived to be interested in engaging in a conversation about subsequent care. In comparison to PWUD who sought out ED care themselves, this participant explained how for patients who present following a non-fatal overdose, conversations about harm reduction end up “falling on deaf ears”.

“So say maybe someone who’s an IV drug user, and they’re coming in with an abscess, and they’re not acutely high that’s a time when you’re able to have a reasonable conversation. Often [I] find when you’re talking to some of these patients and they just did overdose, or they’re in withdrawal, I feel it’s… everything you’re going to be saying is going to be falling on deaf ears, ‘cause they’re not in the cognitive state for those things. Unfortunately, just because of… the nature of these presentations, it’s not as– there’s not as many ideal situations as I would hope. So I think I don’t do it as frequently as I probably should, but I think it’s really turned me to being a bit of a nihilist. Of thinking, ‘this guy is vomiting, or withdrawing, or is still somnolent or is wanting to get back on the street to get another hit.’ Me having prolonged conversations about harm reduction probably isn’t going to be well-received at this point.”

(Participant 1)

Participants offered concrete strategies for creating a conducive environment to empowering and engaging PWUD in harm reduction interventions in the ED. One key strategy was to have open communication characterized by honesty and trust, the success of which hinged on building good patient-provider rapport. They also stated that engaging family members or peer support workers in patient care created meaningful interactions, where open communication and engagement increased with the encouragement, comfort, and advocacy provided by these supports.

“I think [peer support workers] would partially address the sense of stigma [...]. Having somebody who has a somewhat shared experience or coming from a similar background, and they understand and are able to predict barriers and sensitivities that might not be otherwise obvious to a healthcare provider.”

(Participant 7)

Participants who did not have access to peer support workers were highly supportive of their role in the ED and anticipated similar benefits. They also mentioned the benefits of ED-based peer support workers would be enhanced if paired with existing community services. By creating continuity with community services, they believed patients would be more willing to engage with peer support workers in the ED and community follow-up care.

Competing ED priorities and stigma.

Participants highlighted the diversity in ED environments and resources across Canada, stating that this can either facilitate or hinder harm reduction interventions in the ED. Most physicians agreed that a harm reduction approach meant that all ED staff have the shared goal of reducing drug-related harms through patient-centered, empathetic, and trauma-informed care.

However, they stated, the complete adoption of a harm reduction approach in the ED is shaped by several, often competing, influences and can contradict a prevailing ED practice of throughput-oriented treatment of the presenting condition alone. Participants explained how available services can be hindered by political resistance from policymakers and hospital and provincial leadership (i.e., incompatible policies and budgets), communities (i.e., reducing already limited access to healthcare, reluctance to host services in neighbourhood), and staff (i.e., concerns over safety, effect on care of other patients). For example, one physician explained that although they supported the ideas of peer support workers and an in-hospital supervised consumption service in principle, their community’s political realities and constrained resources prevented them from advocating for such services in their ED:

“We’re a tiny department in a small community with very limited access to almost every staff of health care… In times of just, of austerity, I think we need to have reasonable understanding of the political realities of your community. And I, so no, [an acute care supervised consumption service and peer support workers] would not be something I would advocate for, for right now. And I, that sounds like, horribly conservative to say but I, these are things that I want to see happen, but we are just not, I would not favour allocating those resources to that right now just because of the local blowback we would have for a population who’s already furious that they don’t have access to health care.

(Participant 19)

Further, staff attitudes and stigma can perpetuate an environment that is not conducive to a harm reduction approach to care.

“These patients are stigmatized and treated differently than the general population […] a lot of the time, they’re physically not let in the main department. They’re kind of left in the main waiting room until they’re waiting to be seen. So I think often there’s a lot of frustration of knowing that […] they’re not worthy of getting a bed or that they’re having to stay outside. At the same time […] they’re quite disruptive to other patients and staff, and rightly or wrongly, the nursing staff here and other places have a pretty low level of patience with them, and they’re often placed in kind of non-care areas so that they don’t become as big a drain on emergency department resources. So I think certainly it’s frustrating and annoying, and probably stigmatizing towards them […] But it’s just kind of the sad reality.”

(Participant 1)

Participants described a perceived cycle of stigma in the ED characterized by staff stigma towards PWUD contributing to negative patient experiences, patient mistrust in care providers, and disruptive patient behaviour in the ED. In turn, disruptive patient behaviour contributed to staff frustration with treating this population and gave way to learned helplessness among staff, which fed back into the cycle of stigma.

“So, I think that would be again, one of the reasons why staff attitudes could change in the way, in, I think, maybe some of it is as big as transference and counter-transference like, you know if it’s discouraging to keep seeing the same patient and so, you don’t know what else you could do differently. And I also think there’s a feeling of, you know, I guess despair or just, as if you want to give up.”

(Participant 16)

The appropriateness of engaging with patients through a harm reduction approach was also reported as a product of the patient’s physical location in the ED environment. EDs by nature were described as ‘busy’ but also ‘overcrowded’ and not conducive to private, meaningful conversations. Physical space constraints meant that patients may be displaced to hallways. A few participants mentioned that PWUD specifically were more likely to be placed in the hallway. Discussing harm reduction under these circumstances was seen as inappropriate and a breach in confidentiality.

“We often just put them [PWUD] in a hallway. We’re expected to assess them in the hallway which is extra challenging because it’s often really sensitive topics that you want to discuss but it’s really not appropriate and it breaches their confidentiality to talk about it in the hallway so this really frustrates me.”

(Participant 25)

In addition, some questioned the appropriateness of a harm reduction approach in EDs more broadly, indicating that it was ‘out-of-scope’ and should be primarily addressed in community settings.

“I think that there’s a risk that the ED is becoming everything to everyone [...] But there’s so many other places that exist in [metro area name redacted] for these other things that I think is probably more appropriate for people to sit down with somebody who can have the time to discuss some of these issues with them. [...] Whether they’re pharmacists, peer support workers, nurses, what have you, social workers, who specifically already have this training and is maybe not being accessed or used to their maximum.”

(Participant 5).

Physicians who perceived this care to be outside the scope of emergency medicine cited the lack of wraparound supports in their ED as a rationale for diverting care to community resources because participants perceived these services to be better equipped to manage the complex needs of PWUD.

Conversely, some participants with more direct experience of harm reduction in their EDs expressed how the implementation of harm reduction interventions preceded practice and culture change; whereby initial staff reluctance to an in-hospital sterile syringe program shifted over time towards favourable attitudes about the program and harm reduction principles.

I would say it’s getting to be a routine practice. It was, again, hospital policy, it was a struggle for some people to come to terms with the fact that we’re giving needles out for patients to harm themselves but you know, coming around to the idea of harm reduction, it’s better to have a clean needle than a dirty needle, most people are on board I think.

(Participant 15)

To further facilitate the uptake of a harm reduction approach, participants emphasized how having dedicated harm reduction champions in the ED, and sharing patient success stories would increase staff engagement in harm reduction-oriented care.

“I guess you call that trauma-informed care, whatever. That’s sort of been an epiphany here […] Changing behaviour is the super challenging thing. So, all you can do is offer this smorgasbord of options and hope some people will be receptive […] It would be nice for us to share those stories of people for whom our interactions have actually made a difference […] because it would be helpful for us to have the spirit to continue the work that we do.

(Participant 9)

Education and training.

Though emergency physicians felt well trained and prepared to treat acute medical concerns, such as reversing opioid toxicity and treating infections and abscesses, they did not feel that emergency medicine training had adequately prepared them to manage non-acute substance use-related concerns. Many physicians highlighted a desire to learn more about the local substance use epidemiology; opioid prescribing practices, opioid withdrawal, and drug interactions; identifying problematic substance use; available substance use services; and how to reduce stigma and increase compassion for PWUD among ED staff and other physicians.

“Ways to avoid stigmatizing the patients for both the nursing staff and the physicians. I think that’s one of the biggest issues […] I think that teaching for the medical staff around compassion, empathy, you know, how a person might present. How to potentially identify drug seeking behaviour versus legitimate pain. Not dehumanizing the patients. So I think some training in that regard. I think that the physicians might benefit from some training around how to […] if the decision is made that you might treat someone who has opiate addiction with opiates, how to select the proper one. How to dose it, so that it is effective. You know, things about prescribing if you discharge a patient who has known addiction and you do send them home with an opiate prescription, you know what’s the evidence of that’s going to be, be harmful versus not giving them a prescription.”

(Participant 23)

Many emergency physicians stated that because they are trained in acute care medicine, they often needed to access supplemental training through certification programs, preceptorships with addiction medicine physicians, reading literature, or attending conference lectures, seminars, and/or grand rounds focused on substance use. For participants that had personally sought ancillary training or had ‘hands-on experience’, they stated that this facilitated comprehensive ED care for PWUD. When describing their experience with addiction medicine preceptorships, one participant explained:

“I didn’t [feel like I had the skills required to care for patients with OUD] until I personally pursued more training in that field. I think I wouldn’t have any idea what I was doing unless I had done, I did, like a preceptorship with the addictions team. Now I work there so every month I’ll do, like, a week there and so that has helped a lot to take those skills back to the emergency department but I think without that formal training it’s tough. Because it is like a different field.”

(Participant 14)

Participants reported a large barrier to the adoption of harm reduction interventions in the ED was staff reluctance towards new harm reduction programs and policies. In many cases, physicians perceived this reluctance to be related to a lack of education and training on the benefits of adopting a harm reduction approach.

We do have a methadone clinic that is set up in our hospital [...] Just the fact that it is in our hospital […] there are all sorts of rumours circulating “Oh we have a shooting gallery in our hospital”, “Patients are going to rob us, aggress us in the parking lot when we leave after our shift”, […] there would really need to be increased awareness beforehand for the hospital staff […] Perhaps offer some collateral benefits to the ED staff […] then perhaps the nursing staff will see more advantages to this.

(Participant 32)

In depicting their ideals for ancillary training, physicians indicated a desire for education incentives, consisting of professional development credits or financial incentives to cover both training and time away from clinical practice. They also emphasized experiential education, such as preceptorships; short and practical information presented in emails, posters, and lectures; and self-directed, online learning modules.

Standardized practices.

Participants observed substantial variability in the delivery of harm reduction interventions in the ED and highlighted how standardized protocols and guidelines have previously facilitated the adoption of new practices in the ED, such as the distribution of take-home naloxone kits. However, they also expressed a desire for the development and implementation of materials (i.e., protocols, guidelines, consensus statements, best practices) that would more broadly standardize care of PWUD in the ED, thus ensuring that every PWUD who seeks ED care also receives the offer of comprehensive substance use care.

Patients come in with the same complaint on different days, they should get something resembling the same care and unfortunately this is sort of one of the highest, right now, the highest practice variance pieces of our group and so, you know, it’s sort of, was chief, I guess chief of our group I would really like to get some other support so we can improve and minimize our variance […] I sometimes wonder whether it would be better to just, to not, to not do it at all because so it’s so suboptimal. But at the same time, and primarily my concern is to the [regulatory] college and that our practice environment is such that, you know, there’s this sort of focus on people shouldn’t be prescribing opioids out of the emergency department and yet, there’s no other option… I think there are times where that does put some of our patients at risk [of withdrawal] and it, I would like to see sort of better, better pathways.”

(Participant 19)

These resources would include guidance for physicians and ED staff on the delivery of harm reduction interventions, how to manage certain patient behaviours (e.g., using opioids in undesignated spaces), and opioid prescribing practices related to pain and withdrawal management.

ED resources.

Participants described the facilitating impacts of having specialized, multidisciplinary care teams and dedicated general ED staff with experience caring for PWUD and knowledge of harm reduction and community resources. Multidisciplinary teams or centralized outpatient addiction services in the hospital were perceived as key strategies to provide essential wraparound social and mental health supports resulting in comprehensive and quality care for PWUD, rather than ‘piece-meal’ harm reduction interventions. In addition, participants advocated for access to reliable in-person or virtual addiction consultation services to facilitate the delivery of harm reduction interventions and addiction treatment in the ED. Though participants stated that consults with addiction services or clinicians with addiction medicine training enabled high-quality ED care for PWUD, a lack of evening or weekend coverage created a barrier to care during ‘non-conventional hours.’

“There’s a physician-based consult service as well as an addiction nurse specialist [...] outside of the hours of maybe like 11pm ‘til 7am, there’s someone there who can see the patient while they’re there. It’s quite amazing.”

(Participant 22).

Despite identifying expert consultations, multidisciplinary teams, and experienced staff as the ideal environment, participants recognized how the implementation of such services is constrained by the hospital’s fiscal responsibilities and available human resources.

“In a perfect world, I think it would be a very integrative, collaborative, inter-professional group that includes physicians, nurses, social workers, pharmacists, peer support workers, allied health, psychologists, psychotherapists, so on and so forth, that can address the full spectrum and the full physical and mental health needs of individuals who have this problem. But like I said, all of those things require money and resources which I think are tight, right? It’s bringing them all together in one unit that in a perfect world, again, would be operating 24 hours a day, 7 days a week, 365 days a year.”

(Participant 20)

In many interviews, participants indicated that a lack of space, funding, and staff prevented the full implementation of harm reduction interventions into ED care and advocated for more funding to increase ED capacity to support PWUD. Additional funding could enable modifications to ED infrastructure, such as changes to washrooms to improve the safety (e.g., adding call bells and alarms, adding three-quarter length doors to stalls). Upon discussing the addition of supervised consumption services in the ED, physicians described the need for additional funding to create a dedicated space and to hire staff. Without this funding in place, one physician described how the potential increase in workload would hinder buy-in from current ED staff:

“The big issue for us is obviously funding, if they could provide us with a dedicated nurse, and a dedicated space then, and dedicated security then I think [a supervised consumption service within the ED is] something that would certainly be worth discussing. I think that again, it’s the idea of an added work for the emergency department, is always the fear for many of my colleagues.”

(Participant 13)

Participants’ perspectives on essential harm reduction resources were often determined by the perceived demand for addiction services in the ED as well as the availability of local community resources. Although most participants held favourable attitudes toward supervised consumption services, sterile syringe distribution programs, take-home naloxone programs, and peer support workers, many indicated that their EDs do not offer these services.

“It’s a function of how big you are, like I would love to have supervised consumption booths in our [ED] and on the inpatient ward would be amazing but it’s not really realistic for our volume here, we just don’t have that many patients. In you know, in [a larger urban centre], absolutely you should have it, and if I was working there I’d be pushing it too.”

(Participant 15)

Participants who worked in rural settings, with limited ED and community harm reduction services described how enhancing access to primary care, and the capacity of generalist providers would be a more effective and practical strategy to improve care for PWUD.

Like I think that, that’s my concern with some of this stuff that this sort of like, high level urban focused practice opioid use stuff, what my patients that we’re taking care of with this need is, is someone with a general skill set and a degree of specialized knowledge and that, and to have sort of more of that generalist thrust, or generalist contribution to the research, I think that’s really important.[…] And it’s particularly important in the rural populations that, at least where I live, just have terrible access to primary care.

(Participant 19)

As such, participants stressed the importance of having harm reduction resources in the ED that are tailored to the local context.

Community follow-up care.

There was consensus among participants that timely, reliable, and low-barrier access to community harm reduction, mental health, addiction treatment, and social support follow-up services facilitated ED care for PWUD. However, many participants reported being unfamiliar with the local resource landscape and were particularly concerned with improving care transitions to minimize loss to follow-up. To circumvent loss to follow-up, participants suggested establishing integrated care pathways and referral protocols to community resources; creating formalized community partnerships; and having specialized addiction human resources or experienced support staff (e.g., nurse, social worker) to help coordinate follow-up care and linkage to community resources from the ED.

“What would really help in general is having, whatever you want the title to be, but somebody ideally from a social work background who is able to be like a patient navigator […] so, we could start medical therapy in the ED, especially for opioid use disorder, but getting them in contact with all of the services that may be available to them getting them hooked up with detox, rehab, etcetera, that’s all way beyond what we have the time for in ED or honestly the expertise for. So, a patient navigator that’s maybe on call or just someone that they could get in touch with the next business day would be great. And we don’t have that.”

(Participant 15)

Participants who described having access to centralized community intake and referral services, integrated outpatient addiction clinics, or who had established formal partnerships with community prescribers (e.g., opioid agonist treatment clinics, pharmacists) reported being satisfied with the accessibility of follow-up care in their communities. However, other participants, particularly those in rural areas, noted the absence of, or inadequate access (e.g., limited capacity) to, follow-up care as a large barrier to providing comprehensive care in the ED.