Access to supervised consumption services is considered part of the standard of care for people with opioid use disorder and is recommended across the treatment continuum. People who use substances ...require acute care services more frequently, and past research indicates that many will continue to use substances in hospital. Written or unwritten expectations of abstinence, stigma and untreated pain or withdrawal may result in patients selfmedicating with illegal substances, taking measures to conceal drug use (most commonly by using in a locked hospital washroom), leaving hospital for prolonged periods of time or being involuntarily discharged. Canadian cohort data suggest that 68.2% of people who inject drugs would be willing to access a supervised consumption service for inpatients. 6 Medical experts have identified the embedding of supervised consumption services into acute care hospitals as a key next step. Supervised consumption service models in acute care should reflect the local needs of patients and hospital staff.
To capture pandemic experiences of people with opioid use disorder (OUD) to better inform the programs that serve them.
We designed, conducted, and analyzed semi-structured qualitative interviews ...using grounded theory. We conducted interviews until theme saturation was reached and we iteratively developed a codebook of emerging themes. Individuals with lived experience of substance use provided feedback at all steps of the study.
We conducted phone or in-person interviews in compliance with physical distancing and public health regulations in outdoor Vancouver parks or well-ventilated indoor spaces between June to September 2020.
Using purposive sampling, we recruited participants (n = 19) who were individuals with OUD enrolled in an intensive community outreach program, had visited one of two emergency departments, were over 18, lived within catchment, and were not already receiving opioid agonist therapy.
We audio-recorded interviews, which were later transcribed verbatim and checked for accuracy while removing all identifiers. Interviews explored participants' knowledge of COVID-19 and related safety measures, changes to drug use and healthcare services, and community impacts of COVID-19.
One third of participants were women, approximately two thirds had stable housing, and ages ranged between 23 and 59 years old. Participants were knowledgeable on COVID-19 public health measures. Some participants noted that fear decreased social connection and reluctance to help reverse overdoses; others expressed pride in community cohesion during crisis. Several participants mentioned decreased access to housing, harm reduction, and medical care services. Several participants reported using drugs alone more frequently, consuming different or fewer drugs because of supply shortages, or using more drugs to replace lost activities.
COVID-19 had profound effects on the social lives, access to services, and risk-taking behaviour of people with opioid use disorder. Pandemic public health measures must include risk mitigation strategies to maintain access to critical opioid-related services.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
People who inject drugs in North America often continue to inject while hospitalized, and are at increased risk of premature hospital discharge, unplanned readmission, and death. In-hospital access ...to sterile injection supplies may reduce some harms associated with ongoing injection drug use. However, access to needle and syringe programs in acute care settings is limited. We explored the implementation of a needle and syringe program integrated into a large urban tertiary hospital in Western Canada. The needle and syringe program was administered by an addiction medicine consult team that offers patients access to specialized clinical care and connection to community services.
We utilized a focused ethnographic design and semi-structured interviews to elicit experiences and potential improvements from 25 hospitalized people who inject drugs who were offered supplies from the needle and syringe program.
Participants were motivated to accept supplies to prevent injection-related harms and access to supplies was facilitated by trust in consult team staff. However, fears of negative repercussions from non-consult team staff, including premature discharge or undesired changes to medication regimes, caused some participants to hesitate or refuse to accept supplies. Participants described modifications to hospital policies regarding inpatient drug use or access to an inpatient supervised consumption service as potential ways to mitigate patients' fears.
Acute care needle and syringe programs may aid hospital providers in reducing harms and improving hospital outcomes for people who inject drugs. However, modifications to hospital policies and settings may be necessary.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) ...intervention, varies widely across Canadian EDs.
We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence.
We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources OR 6.91, high OUD prevalence OR 4.45, and metropolitan location OR 2.39,) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup.
Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Assessing for the risk of self-harm in acute care is a difficult task, and more information on pertinent risk factors is needed to inform clinical practice. This study examined the relationship of 6 ...forms of implicit cognition about death, suicide, and self-harm with the occurrence of self-harm in the future. We then attempted to develop a model using these measures of implicit cognition along with other psychometric tests and clinical risk factors. We conducted a prospective cohort of 107 patients (age > 17 years) with a baseline assessment that included 6 implicit association tests that assessed thoughts of death, suicide, and self-harm. Psychometric questionnaires were also completed by the patients, and these included the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974), Barratt Impulsiveness Scale (Patton, Stanford, & Barratt, 1995), Brief Symptom Inventory (Derogatis & Melisaratos, 1983), CAGE questionnaire for alcoholism (Ewing, 1984), and the Drug Abuse Screening Test 10 (Skinner, 1982). Medical and demographic information was also obtained for patients as potential confounders or useful covariables. The outcome measure was the occurrence of self-harm within 3 months. Implicit associations with death versus life as a predictor added significantly (odds ratio = 5.1, 95% confidence interval 1.3, 20.3) to a multivariable model. The model had 96.6% sensitivity and 53.9% specificity with a high cutoff, or 58.6% sensitivity and 96.2% specificity with a low cutoff. This scale shows promise for screening emergency department patients with mental health presentations who may be at risk for future self-harm or suicide.
Abstract
Background
People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers ...may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers’ perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care.
Methods
We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model.
Results
Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients’ ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs.
Conclusions
Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care’s ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently ...present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement.
We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN.
Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval 1.63, 8.37), or if they had smoked or injected an illegal opioid (AOR 6.05 2.15,17.0 and AOR 3.78 1.32,10.9, respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 0.19, 0.88), if they were admitted to the hospital (AOR 0.46 0.22,0.97, or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 0.22, 0.97).
In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The ...objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay.
Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use).
Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis.
After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.
Many health professions learners report feeling uncomfortable and underprepared for professional interactions with inner city populations. These learners may hold preconceptions which affect ...therapeutic relationships and provision of care. Few tools exist to measure learner attitudes towards these populations. This article describes the development and validity evidence behind a new tool measuring health professions learner attitudes toward inner city populations.
Tool development consisted of four phases: 1) Item identification and generation informed by a scoping review of the literature; 2) Item refinement involving a two stage modified Delphi process with a national multidisciplinary team (n = 8), followed by evaluation of readability and response process validity with a focus group of medical and nursing students (n = 13); 3) Pilot testing with a cohort of medical and nursing students; and 4) Analysis of psychometric properties through factor analysis and reliability.
A 36-item online version of the Inner City Attitudinal Assessment Tool (ICAAT) was completed by 214 of 1452 undergraduate students (67.7% from medicine; 32.3% from nursing; response rate 15%). The resulting tool consists of 24 items within a three-factor model - affective, behavioural, and cognitive. Reliability (internal consistency) values using Cronbach alpha were 0.87, 0.82, and 0.82 respectively. The reliability of the whole 24-item ICAAT was 0.90.
The Inner City Attitudinal Assessment Tool (ICAAT) is a novel tool with evidence to support its use in assessing health care learners' attitudes towards caring for inner city populations. This tool has potential to help guide curricula in inner city health.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objectives
The objective of this study was to examine the perspectives of Canadian emergency physicians on the care of patients with opioid use disorders in the emergency department (ED), in ...particular the real‐world facilitators to prescribing buprenorphine/naloxone (BUP) in the ED.
Methods
We conducted semistructured qualitative interviews using a multi‐site–focused ethnographic design. Purposive sampling via an existing national research network was used to recruit ED physicians. Interviews were conducted by phone using an interview guide and continued until theoretical data saturation was reached. Interviews were transcribed and analyzed using latent content analysis. Interviews took place between June 21, 2019, and February 11, 2020.
Results
A total of 32 physicians were included in the analysis. Participants had a median of 10 years of experience, and most (29/32) worked in urban settings. Clinical care of patients with opioid use disorder was found to be variable and physician dependent. Although some physicians reported routinely prescribing BUP, others felt that this was outside the clinical scope of emergency medicine. Access to clinical pathways, incentivized training, dedicated human resources, and follow‐up care were identified as critical facilitators for supporting BUP prescribing. Participants also identified a shared responsibility between patients and the ED, including the importance of a patient‐centered approach that enhanced patient autonomy. ED BUP prescribing became self‐reinforcing over time.
Conclusions
Although there remains practice variability among Canadian emergency physicians, successful implementation of ED BUP prescribing has occurred in some locations. Jurisdictions wanting to facilitate BUP uptake should consider providing incentivized training, treatment protocols, dedicated human resources, and streamlined access to follow‐up care.
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