Chan Carusone, Cobb, Cooper, Guta, Kandel, Stewart, Strike
Experience of PHAs who use substances in hospital (Carol, Soo, Adrian) o Background –problem issue and basic stats o Present data from two studies o Overview of AIMED intervention Case examples (Chris Kandel) Small group discussion (35 minutes) o Small group discussion for 4 of 5 AIMED elements, moderated by a team member (Soo, Adrian, Curtis, Ann) o Discuss how to modify AIMED for inpatient settings and challenges of doing so o AIMED based on AMA as the trigger; what is the ‘trigger’ for acute care stay? Report back and group discussion Discuss next steps
Prevalence of drug and alcohol use is higher than gen pop Estimated up to 70% of people living with HIV/AIDs (PHAs) used illicit drugs or o reported hazardous alcohol use, past year Present at ED and are admitted to hospital more frequently than the general population ~ 8 to 11% of all ED presentation in Canada are related to substance use o Report poor access to care from health service providers and perceive their care to be inferior to the care received by non‐users. Labelled as ‘challenging, manipulative, drug‐seeking and demanding’ Health care providers, often feel they are not prepared, trained or willing to meet o needs of people who use substances High rates of leaving AMA/patient initiated or premature discharge among people who use substances 25% to 30% of PWID – Vancouver (Chan et al., 2004; Jafari et al., 2015; Riddel et al., o 2006)
Correlates of premature Outcomes departure o Increased mortality o Drug and alcohol use o Increased health care costs (readmissions) o Aboriginal ancestry o Weekends o Welfare cheque day Correlates non‐premature discharge o Older age Motivators o In‐hospital methadone o Experiences of stigma/discrimination o Referral to transition team to manage deep tissue infection o Withdrawal/desire to use o Poor pain management Ti and Ti. Leaving the hospital against medical advice o Poor management of addiction among people who use illicit drugs: a systematic review. AJPH. 2015, 105 (12): e53‐e59.) o Increased suffering
•Experience Experience of being of being client client in a hospital in a hospital (Case (Casey House) with HR House) with HR policy (OHTN) policy (OHTN) 1 •(Strike et al., International Journal of Drug Policy 2014 May;25(3):640-9 doi: 10.1016/j.drugpo.2014.02.012) •Clinician per Clinician perspectiv pective and e and practice practices in s in ac acut ute c e care set settings (CIH ngs (CIHR) R) •How does substance use among PHA/HCVs influence care and relationships 2 •What strategies are used negotiate/manage patients’ substance use •What are the key ethical issues and challenges •Patient per Patient perspectiv pective and e and practices practices in acut in acute e care care se settin ttings (OHT (OHTN) N) 3 •How do PHA/HCVs experiences in acute care setting •What policies and practices are necessary to improve care experience •AIMED (assess, in AIMED (assess, investi stigat ate, mitiga e, mitigate, e , explain, and plain, and document; CIHR) document; CIHR) •Use case scenarios to adapt AIMED. 4 •Conduct formative evaluation (acceptability, duration, salience, format and length). •Develop a research proposal to pilot test the adapted AIMED at selected site
• Community driv Community driven t en topics using a pics using a CBR model designed and CBR model designed and 1 test sted f ed for PHA who use substances r PHA who use substances 2 • Multi-disciplinar Multi-disciplinary t teams – ams – community ommunity, clinicians, resear , clinicians, researcher chers s 3 • It Iterativ erative – e – use se evidence fr idence from one om one pr project t oject to guide the guide the ne next xt • Goal is Goal is to de develop e lop evidence-based recommendations f idence-based recommendations for changes r changes to practice practice and policy and policy
Stigma experienced and care impacted regardless of �me/type of drug history → strategies: ‘good pa�ent’, ‘squeaky wheel’, avoid certain organizations. Lack of communication, trust and consistency contributes to unsafe use and compromises health & care. Pain management is insufficient and unreliable. Pain management impacts: satisfaction with care; behaviour and interactions with staff; ability to stay in hospital; use of non‐prescribed drugs, and; willingness to seek care. (Substance use DOES happen during admissions.)
You want to be free to be able to tell but you're also afraid to tell them, because then you know they're going to cut you down, or they're not going to give you what you want. And, that is a serious reality, because, yeah, I mean, like, you don't want to tell them that 'Oh yeah, I smoke crack.' or 'I do this and I do that.' because immediately you're screwed. Oh, now you're reduced to Percocets instead. But I need morphine. I don't need Percocets. I need morphine. But try to tell them that, right? And this is what happens. (PAT29) I was scared, because I wasn't sure whether I should really be doing this. But my whole body just ached, and ah, and the ibuprofen wasn't doing anything for me. (PAT39)
Education: understand drugs, effect of drugs, mental health, harm reduction Maybe being a little bit more comfortable with your patients. Like, talk to them and Respect find out about, that, we're still, even though we're drug user and we have HIV or Engage in a conversation hepatitis C and whatever, we are still Harm reduction approach people. And we don't need to be treated like criminals. (PAT31) Individualized: medical context & role of substance use Pain/withdrawal managed Environment: ER; something to do; ensure confidentiality
Stigma: Participants described ongoing stigma towards and questions about the trustworthiness of substance use/users, and shifted blame for this stigma and resulting poor care between physicians and nurses. Knowledge: Many did not understand how illicit drugs are used, effects of drugs, and interactions with prescribed medications On‐site use: Many acknowledged substance use happens during admissions (including on‐site) and posed a risk. Policies: Participants were generally unaware of any policies in their organizations to inform how to respond to or manage substance use and/or prescribing (e.g. for opiates and benzodiazepines) Responses: Participants responded in a range of ways from ignoring, punishing, to accommodating and *contracting Discharges: Participants recognized that hospital conditions and cultures led to early and unplanned discharges.
Participants described challenges they experienced communicating with patients about their substance use and many questioned whether they could trust patients. I think, as a provider, one of the things that It depends upon is whether they're also is hard for people is that you have honest; whether they're actively using accept that [patients] are going to lie to you, right? And people who use or not really affects care. Whether substances, sort of, I think, frequently you can get rapport; whether they will learn that to sort of get around, you have to trust you, um, to tell you the truth, so hide certain things from people. So, and that you can maybe connect and at until you sort of enter into their circle of least talk about harm reduction. (OT- trust, they're going to lie to you. TO-MD MD)
Some participants described accommodating substance use (especially opiates) by matching doses used in the community to prevent or lesson withdrawal symptoms in hospital; others were opposed to this practice I'm more concerned about under dosing I've done this for a long time and my personal these drugs in people that chronically philosophy is that if somebody comes in the hospital abuse these types of medications than for a medical problem and is addicted to drugs, I'm over prescribing. I've never heard of not going to be able to change them with one hospital anybody who has ah, drug addictions to stay. So I tend to try and take the easy route and be overdosed in the hospital. I think it provide them what I think they need, what they crave, happens in these, ah, opiate naive because otherwise, you just run into trouble and they patients. PH-TO leave hospital against medical advice. MD-TO
Participants identified the need for harm reduction and integrated it in their practice; others advocated for a treatment approach You know, the patient who So we need a harm reduction approach, which means we need is injecting through her to teach people how to inject if they insist on injecting…Like, if PICC, I told her just to be nurses or doctors can say 'Okay, you need to get your water really careful, like, cleaning from here. This is how you're going to inject. This is how you're her PICC, because if she going to put the tourniquet on. This is how you're going to look for….' Like that whole stuff, I think is really important. The gets an infected PICC, it's educational component should be happening in the hospitals. just going to make things Should be happening everywhere. It can be everywhere there's much worse. MD-TO a point of connection. MD-OT
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