Abstract
Keywords
Introduction
Substance use disorders (SUD) represent a significant public health burden. 1 In jurisdictions across North America, an epidemic of opioid overdose deaths has culminated in a public health emergency 2 Between 2016 and 2023, Canada experienced over 40 000 deaths from the toxic drug supply, with Ontario contributing 25% (10 900 fatalities). The persistent nature of SUDs, in the absence of effective treatment, results not only in prolonged suffering for those affected but also in substantial societal costs, including increased healthcare expenses, 3 lost productivity, and a range of social issues.1,4 This issue demands urgent attention and intervention to mitigate its far-reaching impacts on individuals and communities. Therefore, this issue demands urgent attention and intervention to mitigate their far-reaching impacts on individuals and communities. 5
Individuals with SUDs face numerous barriers when seeking treatment, many of which are unique to this condition, particularly in areas where limited access to addiction services.6,7 Stigma remains a pervasive issue, often discouraging patients from seeking the help they need8,9. Therefore, PWUS often turn to hospital care as their last resort when they become severely ill.10,11 Moreover, there is a critical shortage of healthcare providers, especially in smaller communities adequately trained to address the complexities of SUDs.9,12 This lack of specialized knowledge among general healthcare providers means that many patients do not receive the comprehensive care required to manage their condition effectively. 8 Since the hospital often serves as a common point of care for PWUS who seek medical care, acute care presentations offer opportunities for intervention and support.13 -15
In response to these challenges, the Health Sciences North (HSN) has developed an Addictions Medicine Unit (AMU). 16 An AMU has the potential to play a vital role in delivering specialized addiction support by combining medical and psychosocial interventions and facilitating connections to community resources. Its primary goal is to allow PWUS to complete the medical treatments they entered the hospital for while offering support for addiction-related concerns wherever the patient is in their substance use status, in an environment where reducing fear, judgment, and stigma around substance use is the focus. Further details are provided in the recent publication from Morin et al. 16
To date, there have been limited studies evaluating the implementation of addiction-focused care in the acute care setting, particularly in the form of a specialized unit. While the facilitators and barriers of providing addiction services in an acute care setting have been discussed, this discussion has mainly been from the health system or provider perspective, aiming to understand potential integration complexities when developing a service model. 17 Therefore, this study examines the experiences of patients who accessed care in an AMU in a Northern urban setting in Northern Ontario, Canada.
Methods
Setting
HSN is an academic health science center that services the catchment area for approximately 570 000 people across Northeastern Ontario. Ontario is Canada’s largest and most populated province, with over 85% of residents living in southern urban areas.
Approximately 15% (1411 deaths) of the province’s opioid-related deaths (10 900) occurred in northern Ontario, an area known for its sparse population and limited access to health care and health human resources. 13
AMU overview
The AMU is a 20-bed medical unit located in an urban city of Northern Ontario. Established on March 10th, 2021, the unit operates under the guiding principles of the hospital’s harm reduction philosophy. 18 More details are provided in the recent publication from Morin et al . 16
HSN’s harm reduction philosophy 19 elucidates the importance of supporting individuals, whether they are actively using substances, struggling to refrain from using, or recently relapsed and in withdrawal. Substance use is not allowed on hospital property, but patients will not be denied their human right to medical care irrespective of their substance use. The Mental Health and Addictions Program conducted a needs assessment survey to gain insight and feedback on this issue. The survey was conducted to identify service gaps and to help identify what staff need to feel comfortable supporting individuals with substance use who come to us for care.
The development of the AMU was informed by the needs assessment survey. This unit is dedicated to delivering specialized care for individuals at various stages of stability in their substance use. Comprehensively addressing medical and psychosocial needs, the unit offers wrap-around care with a strong focus on medical and addiction treatment. The dedicated team comprises specialized professionals, including addiction medicine physicians, nurses, allied health practitioners, and peer engagement specialists, all collaboratively working toward improved patient outcomes. To be admitted to AMU, patients are required to have an acute medical or psychiatric diagnosis and require ongoing care with concurrent active addiction concerns, or acute withdrawal requiring medical monitoring outside the ICU. In a previously published paper, we describe a sample of 610 AMU patients, with an average age of 42 years old, 63% males, 23% were actively homeless, 31% had a diagnosed mental disorder, the most commonly reported substances included alcohol and opioids with acute medical conditions and the main reason for hospital admission for over 50% of AMU patients was directly related to mental health or substance use. 20
Study design and procedures
The current study is part of a broader mixed-method evaluation of the AMU.16,18 The focus is on qualitative interviews conducted with patients, aiming to investigate the experience of patients who accessed services in an AMU. The study employs a phenomenological approach to deeply explore the essence of participants’ lived experiences.
We developed semi-structured interview questions in collaboration with AMU peer support workers, nurses, social workers and addiction workers. The interview questions were not validated. While existing measures were reviewed, they did not fully capture the unique aspects of the population or specific research questions. Developing custom questions provided greater flexibility and allowed for a deeper exploration of themes that standardized instruments might not cover adequately, incorporating input from individuals with lived and living experience.
From February 1, 2023, to March 31, 2023, researchers invited every patient admitted to the AMU to participate. No exclusion criteria was applied. All 17 patients admitted consented to participate. None of the patients declined to participate or withdrew during the study. The average time of the interview was 5 days after admission. The average length of stay in the AMU is 11 days.
A trained nursing graduate student, with prior qualitative interview experience and community volunteer background, conducted the interviews. Patients could choose immediate or later interview sessions. All interviews were conducted on the AMU at Health Sciences North Hospital with the principal investigator present for the first three to ensure the interviewer’s comfort with the process. The research staff obtained the participants’ consent and then conducted interviews in person utilizing key questions.
Participants received a $10 gift card as compensation. Interviews, lasting between 15 and 30 minutes, were audio-recorded, transcribed, and stored securely. Data collection continued until saturation, achieved after 17 interviews, with no new information or themes emerging. The data was shared with the AMU and hospital for quality improvement and scientific publication. Practical considerations, such as the availability of participants within the specified timeframe and the resources required for data collection and analysis, were taken into account as well.
Transcriptions were made using Microsoft Teams software and checked for reliability by the research coordinator. No field notes were taken during the interviews. An inductive thematic analysis was conducted using Microsoft Excel Themes were derived from the data. This approach involved several steps: first, verifying the electronically transcribed interviews, reading the transcripts, and creating notes; second, conducting a second reading to identify concepts present and code them; and next, developing and refining an initial list of codes. These codes were then organized into primary groupings, and coded excerpts were reviewed to ensure their alignment with these groupings. This iterative process allowed for further refinement and the identification of overarching themes related to the groupings and underlying subthemes from the concepts. A second coder reviewed and revised the codes, with minor adjustments made to enhance logical flow and coherence, and additional participant quotes included to support findings.
Quality strategies included establishing an audit trail, collaboratively coding transcript subsets with PWUS, and holding frequent meetings to assess coding and ensure the reliability of the analysis. Additionally, the study questions were developed, and the interviews were collected together with PWUS.
Results
Factors identified by patients that lead to positive experiences in an AMU
Factors identified by patients that lead to positive experiences in an AMU included: (1) treatment by staff; (2) efficient access to high-quality acute medical care; (3) the unit environment; (4) addiction-specific care; and (5) additional care – support with non-medical related needs. The themes are listed in the order that the themes emerged in the data, but not by weight or importance. Participants frequently shared negative past experiences within the same hospital as a contrasting example of what accessing medical care in an AMU looked like for them.
The perceived efficient access to high-quality healthcare providers facilitated participants’ willingness to engage with an AMU. Participant R expressed this sentiment: “Well, whenever I needed something, I mean health-wise, it was readily available.” This encompassed a combination of standard acute medical and addiction-specific care. Participant L highlighted the comprehensive support: “They helped me with my injuries. They helped me deal with that. And helped me with my addiction.” Participants often acknowledged the value of having access to specialized psychiatrists and physicians with expertise in addiction, emphasizing the positive impact on their care plans.
Participants frequently commented on the marked difference between their experiences in the AMU and their past attempts to access care in outpatient and inpatient settings.
From the patient perspective, nurses constituted the central component of their interactions with healthcare providers, and as such, they were credited for fostering the general environment of the AMU. Participant P conveyed appreciation, stating, “
A key factor that contributed to a positive experience in the AMU was the additional support participants received for non-medical related needs, most often referencing social workers.
Participants also described how peer workers helped establish trust within the healthcare system for participants and effectively conveyed and advocated for participants with healthcare practitioners.
The results underscored multiple factors contributing to positive patient experiences with the AMU. Central to these positive experiences were the unique multi-disciplinary personnel of the team and their interactions with patients, forming the overarching concept when discussing what leads to a positive experience in an AMU.
Factors identified by patients that should be considered when implementing an AMU
When participants described barriers to a positive experience, they often touched on AMU’s drug use policy and harm reduction philosophy. Saturated concepts reflecting what participants found most difficult while at the AMU were: (1) the ease of access to or presence of substances on the unit, (2) interactions with other patients, and (3) self-stigma and internalized discrimination.
The results revealed a complex interplay between patients who perceive the AMU as a pathway to abstinence-based treatment, those seeking physical stabilization while continuing to use substances, and those viewing it as a potential home for both.
Participants admitted to the AMU who aimed for abstinence articulated that the mix of active substance use and abstinence present a significant barrier.
This conflicting dynamic among participants manifested in expressions of resentment and the use of discriminatory language when describing patients with active use patterns. . Participants actively distanced themselves, exemplified by Participant O’s remark, “I don’t even hangout with those people.” Divergent beliefs on whether patients should be using substances contributed to negative interactions between patients. Participant A’s experience was illustrative: “I found there was a lot of drug use up here. And I was a big advocate against it. I got in a couple of altercations over it.” This polarization created challenges in fostering a positive experience in the AMU for all involved.
However, participants’ opposing views on harm reduction were not aligned with a complete absence of substance use. Instead, these views more accurately reflected their attitudes toward their substance use, highlighting the ingrained belief that abstinence is the only option. Participants frequently exhibited feelings of shame and internalized discrimination regarding their drug use, as evidenced by participants’ spontaneous efforts to prove abstinence, explain prescribed treatment medications (e.g. opioid agonist therapy), or validate current substance use to researchers without prompting.
“
It was clear that participants understood the acceptance of active substance use patterns, without punitive action, such as discharge. However, they demonstrated a lack of understanding regarding the purpose of harm reduction, as illustrated by statements like, “I just don’t see the wisdom behind getting people better by facilitating their habit” (Participant G).”
The results revealed specific barriers to fostering a positive experience within an AMU. The complexity existed within the interplay between the unit’s harm reduction approach and the participants’ self-stigma.
Patient perception on the impact of an AMU
When participants discussed their treatment goals, they prioritized both medical concerns (such as the reasons for their hospitalization) and substance-use-related issues.
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This dual emphasis signifies the AMU’s success in delivering comprehensive treatment and integrating medical and addiction care for patients during acute care hospital stays. It underscores the unit’s achievement in its primary objective of physically stabilizing patients and addressing addiction-related concerns. The harm reduction philosophy implemented in the AMU allowed patients to access medical care despite substance use, preventing premature exits against medical advice. The AMU distinguished itself by providing efficient and high-quality care, different from participants’ previous hospital experiences. This distinctiveness contributed to trust-building for the patients within the health care system. The AMU staff’s embodiment of the harm reduction philosophy, as evident in their interactions with patients, coupled with the incorporation of a diverse team employing various approaches to engage with patients, not only bolstered positive experiences but also facilitated the restoration of trust in the healthcare system. “
The core principle of a harm reduction philosophy is to create opportunities for individuals to engage with the healthcare system, recognizing that each interaction holds the potential for patients to be introduced to substance use treatment options. This was notably successful with AMU patients, as evidenced by all study participants engaging in conversations about substance use and a substantial number participating in addiction-specific treatment.
However, the AMU faced challenges in effectively addressing long-embedded self-stigma and internalized discrimination that patients grappled with during self-reflection. There was a need for enhanced support for patients in understanding and navigating a harm reduction model of care, indicating an avenue for further improvement within the AMU’s approach.
Discussion
This study explores the patient perspective of harm reduction-oriented inpatient AMU within a Northern Ontario hospital, offering valuable insights into perceived factors that lead to positive experiences in an AMU and patient-identified factors to consider when implementing an AMU.
Key recommendations based on our findings include: 1) Harm Reduction Philosophy - The AMU’s emphasis on non-judgmental, compassionate care that accommodates patients regardless of their substance use status is highly valued by patients; 2) Multidisciplinary Team Composition – Including peer support workers in the team enhances patient-provider trust and helps bridge communication gaps; 3) Addiction Consult Service and Staff Education - Initiatives like the Addiction Consult Service and staff education programs on harm reduction and substance use improve patient experiences by increasing staff readiness and strengthening support systems within the hospital; 4) Skill Development - Using the AMU stay as an opportunity to develop skills related to managing triggers and addressing self-stigma associated with substance use is beneficial.
Due to a lack of primary care and psychosocial care in the community, PWUS heavily rely on hospital-based services for managing acute and chronic medical conditions, as reflected in admission rates and emergency department presentations exceeding those of the general population.21,22 Hospitals are crucial touchpoints in PWUS’s care pathways,13,14 yet challenges persist, exemplified by higher patient discharges against medical advice (AMA). 23 Factors contributing to AMA discharges include untreated withdrawal, uncontrolled pain, discrimination by hospital staff, and imposed patient restrictions.23 -25 The patient perspective of the AMU highlighted addiction-specific care and positive interactions with hospital staff as critical facilitators of a positive experience. At the same time, the harm reduction approach of the AMU minimizes imposed patient restrictions inherent in standard acute care. This study demonstrates that a positive experience can become “the norm” between healthcare providers and the PWUS community, making the AMU an effective model of care to prevent leaving AMA.
Hospital policies have the potential to significantly impact the PWUS experience. Current policies and practices in hospitals are often inadequate, inadvertently perpetuating stigma and discouraging their engagement with healthcare.26,27 The opportunity to advance equity, reduce stigma, and prioritize evidence-based addiction care within hospital settings remains. 28 A systems-level change that embraces a harm reduction approach is crucial for improving acute care experiences for PWUS. Given the limited capacity of a 20-bed inpatient unit, the trust built with patients while admitted to the AMU could quickly be diminished through hospital interactions outside of the unit. Mistreatment from healthcare providers is well established as a common experience for PWUS29,30 and a barrier to the successful integration of harm reduction models. 31
The AMU stands out for providing efficient and high-quality medical care, contrasting with the established elevated risk of harm PWUS experience in standard care pathways.8,24,29 The AMU creates a trustful environment for patients, contrasting with the historical patient experience of hospitals being a “risky setting” 29 full of mutual mistrust that has permeated (47).
Lennox et al 27 outlined seven areas for institutional policy change, including the use of non-prescribed substances in hospitals, supporting inpatient addiction consultation services, in-hospital supervised consumption spaces, supply and distribution of safe drug use equipment and naloxone, the role of security services and personal searches, use of hospital restrictions, and involved of PWUS in policy development. 27 Expanding on this framework, this study suggests that improving the broader acute care environment requires delivering efficient access to high-quality acute medical care, providing addiction-specific care, and offering support for non-medical needs, all implemented through a harm reduction lens. The significant strength of the AMU lies in its shift in focus from substance use to patient needs, a philosophy exemplified by the multidisciplinary makeup of the team. For example, peer workers, whose value stems from shared lived experiences rather than professional training and expertise, can form meaningful connections with patients, acting as a communication bridge – encouraging trust in healthcare providers for patients and contextualizing patient experiences to support providers revising their patient approach. 32 Peer support workers enhance the patient experience and can be a powerful tool leveraged in addiction care. 32 The results of this study reinforce the importance of healthcare organizations’ understanding, recognition, and support of the peer worker role.
This study identified that patients admitted in the AMU struggled to accept harm reduction as an appropriate care model, both because of the difficulty witnessing their peers in active substance use while they were trying to remain abstinent and because of the self-stigma and internalized discrimination of PWUS, evident throughout patient interviews, are well-established phenomena.33,34 Patients’ experiences were facilitated because of the non-judgmental compassionate lens of the harm reduction philosophy – patients could access medical care regardless of drug use or engagement in substance use treatment. However, participants didn’t believe they were deserving of the level of care provided unless they were participating in an abstinence-based treatment plan. The patients identified that the AMU had a positive impact on them, regardless of this barrier. The AMU provides an excellent opportunity to develop skills for addressing both self-stigma and the triggers associated with interacting with individuals who are actively using substances. By leveraging the critical factors established in this study to facilitate a positive patient experience, the AMU can further cultivate trust between PWUS and the health care system. This effort will contribute to diminishing the stigma felt by this patient group and cyclically reducing its impact as a barrier to a positive experience in the AMU.
The pervasive impact of societal attitudes on PWUS creates internalized discrimination,35,36 a formidable barrier for individuals seeking addiction-specific care and accessing medical care. 37 Recognizing this interplay is crucial for developing interventions like the AMU, and any efforts to mitigate stigma can potentially improve outcomes for PWUS.38,39 While cultural shifts and societal attitudes toward drug use take time to change, this study provides optimism that a harm-reduction inpatient addiction service, such as the AMU, can yield positive outcomes in the interim despite these challenges. The recognized gap between research findings and their real-world application underscores the importance of addressing this stigma congruently when implementing a harm reduction approach in healthcare systems and public policies.
Strengths and limitations
This study represents one of the initial endeavors to capture patient perspectives regarding an AMU. As a single-site study, the goal is not generalizability but transferability of the results for discussion within the literature. The findings offer valuable insights into patients’ perceived experiences on an AMU. However, it is crucial to acknowledge certain limitations. Firstly, although the questions were developed with a peer consultant (a person with lived experience in the AMU) and with AMU staff, the questions were not validated or piloted. Self-selection to participate may have led to some biases. The qualitative interviews were conducted over a short period during winter, which might introduce bias in patients’ motivations to engage with hospital services, as some may have sought hospital care as a refuge from cold weather. Participants may have hesitated to express honest opinions about the AMU due to concerns about potential discharge, inadequate care, or mistrust of institutional settings. Lastly, we did not include a sample size calculation because we interviewed the entire sample of patients.
Further research is necessary to capture patients’ perspectives over extended periods, in different seasons, and potentially employ peer researchers to ensure a more accurate representation of patient viewpoints. Notably, the study did not explore the perspectives of hospital staff, although qualitative data collection with these stakeholders was conducted as part of the broader program evaluation. 16 The study’s relatively short duration precluded an assessment of the long-term impacts of the AMU on patients. Additionally, the potential positive (or negative) effect of the other addiction-focused services implemented within the same hospital could not be stratified. For example, a consult service also exists at the same hospital. 15
Future direction for this work could involve the development of a more detailed interview script to extract additional information regarding the discussed positive and negative experiences. For negative experiences, non-medical related supports were identified in the thematic analysis, particularly in interactions with social workers. More follow-up conversations around helpful aspects might assist the AMU in prioritizing outpatient and community services to build referral pathways and apply a more comprehensive, continued care lens. For example, recognizing the prevalence of housing instability within the PWUS community, participants were asked about their current housing situation. However, since this topic was only briefly covered in interviews, the paper could not accurately speak to the reality of needs, only that the AMU provided a safe and stable place to stay while they were admitted to the hospital.
It is important to note that AMU in this study was implemented alongside an Addiction Consult Service (AMCS) and extensive initiatives aimed at educating staff about substance use and harm reduction. These efforts included two dedicated nurse educators, harm reduction kit distribution and education throughout the hospital, a dedicated harm reduction committee, and simulation training for suboxone induction in the emergency department.
Conclusions
The implementation of a novel AMU within a Northern Urban acute care hospital in Ontario has garnered positive feedback from patients. The unit has effectively contributed to favorable patient experiences by delivering efficient access to high-quality acute medical care, providing addiction-specific care, and offering support for non-medical related needs. Notably, the AMU’s strengths lie in its harm reduction philosophy and multidisciplinary team, which present valuable lessons for potential adoption by the entire hospital environment. Overcoming the self-stigma and internalized discrimination experienced by PWUS remains a crucial ongoing challenge. The AMU serves as a successful starting point in rebuilding trust between individuals who use drugs and a healthcare system that historically has not prioritized their needs. Integrating harm reduction principles into hospital settings is a pivotal aspect of evidence-based addiction care. Exploring the perspective of PWUS within a hospital context provides an avenue to integrate and better facilitate inpatient addiction services more seamlessly.
Supplemental Material
sj-docx-1-sat-10.1177_29768357241280579 – Supplemental material for The Patient Perspective of an Inpatient Addiction Medicine Unit Implemented in an Urban Northern Acute Care Hospital in Ontario, Canada
Supplemental material, sj-docx-1-sat-10.1177_29768357241280579 for The Patient Perspective of an Inpatient Addiction Medicine Unit Implemented in an Urban Northern Acute Care Hospital in Ontario, Canada by Kristen A Morin, Adele Bodson, Karla Ghartey, Krysten A Patrick, Shannon Knowlan, David C Marsh, Natalie Aubin and Tara Leary in Substance Use: Research and Treatment
Supplemental Material
sj-docx-2-sat-10.1177_29768357241280579 – Supplemental material for The Patient Perspective of an Inpatient Addiction Medicine Unit Implemented in an Urban Northern Acute Care Hospital in Ontario, Canada
Supplemental material, sj-docx-2-sat-10.1177_29768357241280579 for The Patient Perspective of an Inpatient Addiction Medicine Unit Implemented in an Urban Northern Acute Care Hospital in Ontario, Canada by Kristen A Morin, Adele Bodson, Karla Ghartey, Krysten A Patrick, Shannon Knowlan, David C Marsh, Natalie Aubin and Tara Leary in Substance Use: Research and Treatment
Footnotes
Author Contributions
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Declaration of Conflicting Interests:
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Data availability statement
Supplemental Material
References
Supplementary Material
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