In 2015, Shawn was in the hospital with an abscess on his spine and a life-threatening blood infection. After waiting more than a day in the emergency department, he was withdrawing from heroin – sweating profusely, extremely anxious and in excruciating pain. “It felt like someone was crushing my skull. Tears were running down my face.”
He told his doctor that he spent upwards of $250 on one gram of heroin per day. So his doctor put him on a much higher dose of morphine than he would give to the average patient. “It was enough to take the edge off so that I wasn’t lying there in tears, but I was still feeling the withdrawal.” But when the shift changed, the next doctor cut his dosage to less than a quarter of that. Shawn was about to leave when the first doctor returned. “He flipped out. He said, ‘What are you doing to my patient?’” Shawn was put back on the original dose.
Still, the nurses were often hours late with Shawn’s next dose, which was already much lower than what he would take on the street. Against his doctors’ advice, Shawn decided to leave the hospital after two weeks. He should have stayed on IV antibiotics, but health providers switched him to antibiotics in pill form. He got better initially, but now he has a swollen lump on his spine again. It’s been agonizing for months, but, Shawn says, “I’m not going back to the hospital.” He uses heroin to reduce the pain.
Shawn’s experience isn’t the exception. According to addictions specialists, patients often wait until their infection is unbearable and life-threatening before seeking treatment, due to past negative experiences. They tend to leave the hospital before they’re fully healed, or even before they’re treated at all, because they’re forced to go into withdrawal or because they feel judged by health providers.
“Very vulnerable people aren’t getting effective treatment,” according to Jeff Turnbull, chief of staff at The Ottawa Hospital and medical director of the Inner City Health Project for the homeless in Ottawa. “That could lead to increased disability and even death.”
Harm reduction: the standard of care in the community
For service providers in the community, expecting people to detox to access services is seen as a bygone approach. Earlier this month, for example, Toronto’s city council approved three safe-injection sites, which were recommended by local boards of health. The sites have been shown to reduce the transmission of infectious diseases, like hepatitis C and HIV, and prevent deaths. The driving philosophy behind them – harm reduction – recognizes that, even with counselling and pharmaceutical therapy available, many people will continue to use drugs. The ultimate goal of harm reduction is for patients to stay alive and healthy enough to make it through what is usually a long, up-and-down struggle to recovery.
According to Ahmed Bayoumi, an internal medicine physician at St. Michael’s Hospital in Toronto and an expert in health care for people who use drugs, it’s time hospitals “accept that patients are going to use drugs” and start incorporating harm reduction strategies. A significant portion of people who are highly dependent on drugs or alcohol aren’t ready to quit during the course of a hospital stay, he explains. “If someone is coming in for a complication that’s related to their addiction, such as an infection, that usually means their addiction is pretty significant. And addiction is hard to treat,” he says. “For us to take someone who is coming in for a completely different reason other than their addiction and expect them to suddenly be interested in having their addiction treated, that’s pretty unrealistic.” A common misconception is that even if someone isn’t ready, a required, institutional detox can stop addiction in its tracks. That hardly ever happens, says Peter Selby, director of the addictions program at the Centre for Addiction and Mental Health in Toronto. In fact, forced detox in a prison or hospital dramatically increases one’s risk of dying of an overdose in the week after release.
What happens when someone who uses IV drugs comes to the hospital?
Typically, when someone shows up to the emergency department with track marks, or admits they’ve used opioids, they’re labelled as “drug seeking” and aren’t given painkillers. But once a patient is admitted, many hospital providers will give patients going through opioid withdrawal some level of the drug. Otherwise, “you’re going to have a very sick patient on your hands,” says Turnbull. Still, the dosages aren’t usually enough to avoid withdrawal, says Turnbull, as providers worry about giving someone too much, and being held responsible for an overdose. “Someone might be taking a gram of morphine or using fentanyl, and a doctor in the hospital will give them maybe 10 mg of morphine. That’s like taking a Smartie.”
Of course, health providers need to know the severity of a person’s addiction before they can offer long-term treatment or a temporary medical substitute. Given the stigma many patients with addictions face in health care, however, they don’t often feel comfortable sharing how much or how often they use. And even if they do open up about their addiction, whether morphine or another replacement is offered depends on the provider and the hospital. “You might find a doctor who will help you out a bit, but then the next doctor or nurse has a completely different point of view in regards to harm reduction,” says Sean LeBlanc, who was addicted to opioids for 10 years, and is now a peer support worker.
When LeBlanc himself was suffering from heroin addiction and had to get his tonsils out at a hospital, he was required to abstain. “I didn’t need to be withdrawing from drugs at the same time as I was getting my tonsils out. Detoxing just makes the procedure so much worse,” says Leblanc. He describes withdrawal like this: “Combine the worst flu with the worst hangover, and then add ten rounds of Mike Tyson.”
In addition to being seen as cruel by addiction specialists, forced detox interferes with a patient’s care. “You have a whole bunch of behavioural issues and you create a conflict with the staff,” says Turnbull. Patients often disappear from hospitals for hours to get drugs, and sometimes they don’t come back.
Katie Keating, program manager of Toronto’s Annex Harm Reduction Program, points out withdrawal is not only happening to opioid users at hospitals – her clients who are dependent on alcohol also leave hospitals because they need to drink. (In the community, people in her managed alcohol program are provided with an alcoholic beverage each hour.) “I think it’s really difficult for health providers to engage in a process of giving someone a substance that is damaging their health. But they don’t see the bigger picture,” Keating says.
Of course, even if withdrawal is managed appropriately, people who are struggling with addiction aren’t usually willing to stay in the hospital for long periods. But according to harm reduction advocates, hospital staff sometimes require these patients to be admitted in the hospital for longer periods than are necessary, in order to get care.
When patients develop infections that require IV antibiotics, health providers will insert a PICC line (a peripherally inserted central catheter which travels from the arm to a large vein near the heart) to avoid having to put a new IV in every few days. Once patients are treated to the point that they no longer require hospital care, they can be discharged with a PICC line and home care nurses can provide IV medications. But providers worry that if patients who use illicit drugs are allowed to leave the hospital, they’ll inject opioids through their PICC lines, possibly with contaminated needles, increasing their risk of developing another infection. So these patients are often expected to stay in the hospital for a month or more, until they no longer need a PICC line. And if they can’t do this, they’re often given oral antibiotics instead. Oral antibiotics often work but aren’t always effective enough to treat life-threatening infections.
Several providers we spoke to, some off the record, understood the logic behind replacing IV antibiotics with oral antibiotics. There’s not only the central line infection risk, but also the risk that patients who live on the streets might not be available for their daily IV antibiotic dose (which can be provided by a community nurse). But others felt these decisions can be based on condescending assumptions – that all patients with severe addictions won’t appreciate the importance of continuing life-saving IV medication, or that they wouldn’t care about, or be able to follow, safe injection practices. In the view of Seonaid Nolan, Providence Health Care’s Addiction lead for medicine and a physician at St. Paul’s Hospital, unless a person has made it clear through conversation or past behaviour that they are highly likely to inject through their PICC line using unsafe practices, they should always be provided “the gold standard of treatment for their underlying condition.”
What would harm reduction look like for IV drug users in the hospital?
A harm reduction approach would start with an honest and judgement-free conversation about what and how much of a drug a patient is using, explains Turnbull. Of course, “you have no idea of the purity of what they’re taking on the street” and patients could overstate their use in hopes of getting more opioids, says Selby. For this reason, LeBlanc recommends peer support workers be available in hospitals to mediate in conversations and help a patient feel comfortable.
Selby and Turnbull argue doctors can start immediately with an opioid dosage that would be the equivalent of about half of what the patient is estimated to be taking. If withdrawal symptoms persist, the amount can be gradually increased until the symptoms disappear. “Your goal is to treat the withdrawal. If you’re making them drowsy, then you’ll want to reduce the dosage,” says Selby.
Selby argues it’s easy for providers to avoid overdose; the issue will be overcoming the moralistic concerns that prevent health providers from prescribing opioids. “People think they’re enabling addiction. This worry is based on ignorance. You’re not getting people high. People need baseline amounts of opiates to keep them comfortable,” he says.
Interactions with prescribed drugs is another reason providers don’t want to sign off on high medical opioid doses, but those interactions will be easier to manage and avoid when it’s clear what substances patients have taken and when, explains Bayoumi. “Is it better to know what drugs they’re taking or to have them disappear off the floor for six hours and come back high?” he asks.
Timed doses of morphine may not be adequate, however. “For people who inject, the process of injecting is part of the addiction itself,” explains LeBlanc. Bayoumi thinks that the injection of illicit drugs should be discouraged, with medical alternatives offered and patients counselled about the risks of taking street drugs when they’re already sick. But, he says, illicit drug use in the hospital still happens, and so clean injecting supplies should be available.
Clean needles are handed out at harm reduction centres throughout many urban areas. A 24/7 needle exchange program is run out of St. Michael’s Hospital’s emergency department. But such programs are not available on any of Toronto’s hospital wards. “How come we give out needles [in the emergency department] on the first floor, but we can’t give them out on the fourteenth floor?” asks Bayoumi.
The only Canadian hospital we heard of that does provide clean needles to inpatients is St. Paul’s Hospital in Vancouver, a hospital renowned for its HIV/AIDS, mental health and addictions programs. Over the past two years, nurses have been instructed to give out sterile injecting equipment to patients who ask for it, while providers have been trained to notify patients who are likely to be injecting drugs during their hospital stay of this option. But, says Nolan, “there are still challenges with education,” with some providers not yet aware of the policy change.
Hospitals could go even further, with supervised injection sites, where patients can inject in a clean environment with sterilized equipment, and are monitored for signs of overdose (in which case, an anti-overdose medication is administered). According to Nolan, St. Paul’s Hospital in Vancouver is involved in the early stages of an application for a Health Canada exemption to operate a supervised injection site for inpatients only. “We know that substance users are using on hospital premises. They tend to either find a dark corner or lock themselves in the bathroom, which puts them at a higher risk due to overdose,” explains Nolan.
Innovative programs to help IV drug users continue IV antibiotics in the community
Another key aspect of hospital harm reduction for IV drug users is ensuring that patients can continue prescribed IV medications, such as antibiotics, outside of the hospital setting. Through Ottawa’s Inner City Health program, patients who inject illicit drugs are discharged with PICC lines in, but they’re checked in with daily by nurses who work out of shelters and in the community. Patients are informed about the risks of injecting IV drugs through their PICC line, and instructed not to do so, but providers also tell patients about safe techniques for injecting with a PICC line if they suspect that’s likely to happen, says Turnbull. “We know occasionally patients will use the PICC line to inject but…the alternative is to stay in hospital for four to six weeks, which they’re not going to do.”
The Community Transitional Care Team (CTCT) in Vancouver goes further, providing rooms – complete with a washroom and kitchen – to accommodate patients who otherwise wouldn’t have a stable living environment, have substance use issues and need IV medications. People stick around. One study found only two of 165 individuals left the program against medical advice over a five-year period. By comparison, 48 patients with deep-tissue infections left the hospital against medical advice in that same period.
“We encourage ownership, we want people to feel ‘This is my room,’” says Darwin Fisher, manager of the CTCT program, as well as InSite, Vancouver’s safe injection site in the community. Patients are told to avoid injecting through their PICC lines, and they’re encouraged to use InSite when they do need to inject.
“Occasionally, a person might disappear, so we would be looking for that person in the community, and when they come back, even if it’s been days, we would just continue the IV therapy,” says Fisher. “But if I’m getting my IV therapy in a hospital and I need to leave to score, the next thing I know I’ve been down there for a day and a night. In the meantime, that bed could be turned over to the next patient.”
The CTCT’s converted former hotel has nine rooms. When hospital staff at St. Paul’s identify patients who might benefit from the program, a CTCT staff member will visit the ward to explain how the centre works. The patient can then decide if the program is right for them.
Importantly, patients at the CTCT aren’t kicked out after four to six weeks, when their IV antibiotic therapy is complete. “Even though you have a clean bill of health, you’re going to be at jeopardy for returning to using on the streets and reacquiring infections,” Fisher explains, so staff work to find longer-term housing that patients can move directly into.
Embracing harm reduction in hospitals – what will it take?
Despite the fact that addiction to substances, including opioids and alcohol, is a leading cause of death in Canada, many hospitals don’t have addictions treatment centres. “If there was an epidemic respiratory illness, hospitals would set up a clinic, so why are hospitals not setting up addictions clinics?” asks Selby. While more health providers are beginning to learn about “the neurophysiology behind addictions,” the perception of addiction as a “lifestyle choice and not a chronic, relapsing disease,” is still pervasive, according to Nolan. As a result, most hospitals don’t yet have addictions experts who can “champion harm reduction within the hospital walls,” she explains.
And there are legal issues that hospital managers need to clarify for staff. As just one example, many providers aren’t clear on which types of drug activities they are legally or professionally obligated to report.
In addition, medical guidelines are necessary to help doctors in many areas of hospital-based harm reduction, including the best way to avoid opioid withdrawal, for instance, or how to talk to patients about illicit drug use in a way that isn’t stigmatizing.
But to Selby, “the knowledge gap” isn’t the biggest barrier to overcome. “It’s the attitude gap. It’s about seeing people with this kind of suffering as being worthy.”
When Rob, who uses opioids, went to an emergency department for an abscess on his leg, he remembers the doctor was kind and gentle as he drained the abscess, until he asked how he got it. Rob replied, “I missed,” meaning he missed his vein when he was injecting. “He just switched,” recalls Rob. “He started ramming the needle in, just stabbing me. I was screaming in pain.”
He finds it ironic that the health providers he’s encountered weren’t more empathetic, especially since he only became addicted after he was given high amounts of OxyContin for the entire duration of a three-month hospital stay, which involved several surgeries. (He had a well-paying job and a house he shared with his family before the addiction began 15 years ago.) “When you go to the hospital, and you don’t even really need painkillers, they’ll give you the world,” Rob says. “And when you really need them, you get nothing.”