Harm Reduction Approach to Substance Use Provides Realistic Support for Patients
Abstract
Patients with substance use disorders who are hospitalized for other medical reasons should be treated for withdrawal and craving to reduce or prevent substance use.
A significant number of individuals with a substance use disorder who are hospitalized for treatment of a medical condition continue to use an illicit substance during their hospitalization, challenging physicians with how to respond in an ethical and compassionate manner that supports the patient without supporting the substance use disorder.
Samantha Zwiebel, M.D., M.A., said for many patients with a substance use disorder, abstinence can be difficult or impossible to attain or may not even be their goal.
That was the subject of a panel discussion at the 2023 annual meeting of the Academy of Consultation-Liaison Psychiatry (ACLP), where psychiatrists focused on the use of “harm reduction” strategies in the context of opioid use disorder and in-hospital substance use.
“It’s normal for a lot of physicians to be very surprised and have an intense reaction when a patient is found using in the hospital,” said Samantha Zwiebel, M.D., M.A., an assistant professor of clinical psychiatry at the University of Pennsylvania Perelman School of Medicine. “For those of us who do addiction psychiatry in the hospital, it’s just another day at the office. It’s not surprising.”
Speaking to Psychiatric News after the ACLP meeting, Zwiebel said harm reduction is about recognizing that for many patients with an addiction, abstinence can be a very difficult goal to achieve or may simply not be the patient’s goal. In the community, an example of harm reduction are programs providing safe needle exchanges. In the hospital, harm reduction may mean acknowledging the possibility that patients with substance use disorder (SUD) may use while they are hospitalized and providing medication for withdrawal and craving to prevent such use.
“The way I explain [in-hospital substance use] to my residents is that when I know I am going into the hospital as a patient, I will pack the supplies that I know will help me be comfortable,” she said. “In the same way, patients who are determined to receive medical care despite having a really severe addiction that they don’t think will be managed in the hospital also pack a bag and bring what they need to make themselves comfortable.
“For many physicians who encounter this, their first response is that it indicates patients are not dedicated to receiving treatment. But it’s really the opposite; patients are telling you they do take their medical care seriously—they planned for what they would need while hospitalized, they want to be there to get treatment.”
Zwiebel said patients may bring illicit substances with them into the hospital or they may be brought by visitors, including family members who want their loved ones to stay in the hospital and get the care they need.
A January 2023 commentary in the Journal of Addiction Medicine found that “more than 40% of individuals with substance use disorders use substances during hospitalization to avoid withdrawal, undertreated pain, negative feelings (loneliness, sadness, boredom, urge to use). … In-hospital substance use is associated with increased rates of patient-directed discharges, readmissions, and death. Although in-hospital substance use is common and associated with poor outcomes, little research exists to guide institutional policies.”
Recommendations for Nonpunitive In-Hospital Substance Use Policies
A January 2023 report in the Journal of Addiction Medicine on in-hospital substance use by Mary Marlene, M.D., and colleagues, recommends the following best practices for nonpunitive, in-hospital substance use policies:
Convene an interprofessional group that includes patients to create or review the policy.
Ensure the policy is patient centered and does not include punitive measures, including security as a first responder. If security is included, confirm they are a last resort.
Evaluate the policy with an equity lens to determine who will be disproportionately affected and how, based on policy implementation trends across race/ethnicity and substance use.
Obtain legal, security, regulatory, nursing, and leadership sponsorship of the policy to ensure consistent messaging and support.
Educate health care workers about the policy, evidence-based addiction care, harms of stigma, and inequities, especially around race/ethnicity. Provide best practice scripts of how to respond to in-hospital substance use concerns.
Involve health care workers in policy implementation and a continual improvement process.
Inform all patients, regardless of substance use history, of the policy on admission.
Offer patients adequate pain control, evidence-based addiction treatment, and supportive care that helps them tolerate hospitalization.
The Journal of Addiction Medicine commentary also offered recommendations for nonpunitive management of patients with SUD seeking medical care in a hospital (see box).
Harm Reduction Aims for Humane, Not Moralizing, Approach
Nicholas Kontos, M.D., director of the consultation-liaison psychiatry fellowship at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard Medical School, said the concept of harm reduction, in the context of medical care, goes back to the 18th century. There have been multiple definitions, but he highlighted one outlined in a 2017 review in the Harm Reduction Journal: “interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely.”
Kontos noted that contemporary harm reduction derives many of its principles from public health—most notably the idea of reducing net harm to the population—but is practiced in clinical settings for individual patients. It aims for a humane approach to problematic health behaviors as opposed to a moralizing approach, he said.
APA Position Statement Supports Harm Reduction
In December 2023 APA’s Board of Trustees approved a position statement regarding the implementation of strategies to reduce the harm associated with the illicit use of substances. It was developed by the Council on Addiction Psychiatry in collaboration with the Council on Consultation-Liaison Psychiatry and the Council on Advocacy and Government Relations.
“Substance use disorder (addiction) is a chronic, remitting-recurring medical disorder,” according to the statement. “A core, evidence-based principle of substance use disorder treatment is to reduce the harms of substance use (harm reduction). The implementation of harm reduction strategies reduces the spread of infection, decreases the potential for serious or fatal overdose, provides mechanisms for care of patients experiencing substance-related medical emergencies, increases opportunities to engage patients in treatment and care, and represents a cost-effective public health intervention. Despite a substantial evidence base for the effectiveness of harm reduction, the legality of, patient access to, and training opportunities for harm reduction approaches remain inconsistent and underutilized. In the current era of high rates of fatal substance poisonings and other substance-related morbidity, it is critical to ensure that economic, legislative, and other barriers to these effective public health interventions are decreased so they can be as widely utilized as possible.”
In comments to Psychiatric News, Jeremy Kidd, M.D., a member of the APA Council on Addiction Psychiatry, said, “If someone is admitted to the hospital with opioid use disorder [OUD], there should immediately be a discussion about starting that person on medications for OUD, particularly buprenorphine. This could be thought of as ‘harm reduction’ particularly if someone isn’t interested in long-term OUD treatment. Illicit opioid use in the hospital by people with OUD could simply be a manifestation of untreated OUD/opioid withdrawal in a restricted setting. The harms that could be reduced with buprenorphine include opioid withdrawal, discharges against medical advice, and inadequate treatment of the underlying medical issue that led to admission. Postdischarge buprenorphine is associated with reduced opioid overdose risk and higher likelihood of engagement in outpatient treatment.”
Lief Fenno, M.D., also a member of the council, added, “Every interaction with a patient with SUD is an opportunity to engage that individual in treatment—brief intervention and referral, motivational interviewing, medication assisted treatment, or harm reduction. Managing withdrawal and cravings in the inpatient setting can be helpful in improving patient engagement with treatment, reducing tension with the treatment teams, and building trust with health care providers. This also includes the management of dependence on legal substances, such as offering nicotine replacement therapy to patients who use nicotine.”
In December 2023, the APA Board of Trustees approved the Position Statement on Harm Reduction. In comments to Psychiatric News, members of the APA Council on Addiction Psychiatry, which helped write the statement, emphasized that if someone is admitted to the hospital with opioid use disorder (OUD), there should be a discussion about starting that patient on medications for OUD, particularly buprenorphine. (see box)
Some strategies are more controversial. For instance, should hospitals preemptively search a patient’s belongings for substances or paraphernalia?
“This is a major source of contention within the field,” Zwiebel said. “On the one hand, it’s dangerous when people use in a locked hospital bathroom, and it’s foreseeable and it’s likely. But [on the other hand], you are judging the patient and making an assumption that may be unfair or stigmatizing.”
Hospitals Need Patient-Centered Policies on Substance Use
Also highly controversial is the idea of safe injection sites (SIS) in a hospital; hospitals in several countries allow SIS, but none are in the United States. “The argument for it is that if we know patients are going to be using in the hospital but we want them to have medical care, isn’t it more dangerous if they are doing this surreptitiously when we can’t know if they will overdose or be using dirty needles?” Zwiebel asked.
At the ACLP panel, Miyuki Fukui, M.D., M.A., presented data from a 2015 survey in the Journal of Hospital Medicine showing that of 54 young adults who used opioids for nonmedical reasons, 62% would be willing to utilize an in-hospital SIS. Of those willing to use an SIS, 45.9% said it would enable them to stay in the hospital; 37.9% said it would reduce drug-related risks; and 19.4% said it would “reduce stress associated with being kicked out of the hospital because they were using drugs.”
She is a clinical assistant professor of psychiatry at Keck School of Medicine at the University of Southern California.
Fukui also presented data from a 2020 study in Patient Safety titled “In-Hospital Substance Use and Possession: A Study of Events From 38 Acute Care Hospitals in Pennsylvania.” Of 106 cases in which a patient was found to use substances in the hospital, just two were administered medications for withdrawal or craving either before or after using a substance. After the event, the most common responses were searching the room and the patient’s personal property, restricting visitors, moving the patient to another room closer to the nurses station, assigning a “sitter,” or monitoring the patient by video.
Some hospitals, however, are working to strike a middle ground between enforced surveillance of patients and “turning a blind eye,” she said. This includes developing clear policies that are patient centered and incorporate input from professional groups as well as people with SUD, education of staff about the objective signs and symptoms of substance use and training in the administration of naloxone, and incorporation of harm reduction including treatment of substance withdrawal and craving regardless of the patient’s desire to be abstinent.
Said Zwiebel, “At my hospital we try to offer aggressive treatment for OUD. I can have a conversation with the patient and say, ‘Our goal is that you do not suffer and that you do not have to use. I know that some patients bring substances into the hospital. I do not assume that you have, but I do know you may be going through withdrawal. If you are, please tell your nurse that we should be offering you more medication.’ ” ■
