Harm Reduction in the Hospital: Preventing AMA Discharges and ED Bounce Backs - CAEP Conference

Harm Reduction in the Hospital:
        Preventing AMA Discharges and
              ED Bounce Backs
                        Kathryn Dong MD, MSc, FRCP, DABAM
    Director, Inner City Health and Wellness Program, Royal Alexandra Hospital
Associate Clinical Professor, Department of Emergency Medicine, University of Alberta

Faculty/Presenter Disclosure
Faculty: Kathryn Dong

Relationships with financial sponsors:
      •   Grants/Research Support: Royal Alexandra Hospital Foundation, Canadian Research
          Initiative in Substance Misuse (CRISM), Edmonton Emergency Physicians Association
          (EEPA), AHS Emergency Medicine Strategic Clinical Network
      •   Speakers Bureau/Honoraria: Canadian Institute for Health Research (CIHR), College of
          Physicians and Surgeons of Alberta (CPSA), Covenant Health
      •   Consulting Fees: None
      •   Patents: None
      •   Other: Employee of Alberta Health Services (AHS)

Disclosure of Financial Support
The Addiction Recovery and Community Health (ARCH) Team has
received financial support from:
    Royal Alexandra Hospital Foundation
    Alberta Health Services
    Alberta Health

I receive an administrative salary from Alberta Health Services.

Potential for conflict(s) of interest:
• Speaker has not received an honorarium from CAEP

• No sponsoring organization benefits from the sale of a product that may
  be discussed in this program

Mitigating Potential Bias
None to declare.

HOSPITALS ARE HIGH RISK
ENVIRONMENTS FOR PEOPLE
WHO USE DRUGS

Drug Use in Hospital
•   Contributes to patients leaving
    against medical advice

•   Leads to costly readmissions

•   Patients unable to be abstinent
    should not be penalized at the
    expense of their health

Drug Use in Hospital
•   44% of people who were using drugs
    prior to hospitalization continued to use
    drugs while in hospital

•   Drugs were most commonly used in
    patient washrooms

•   “Harm reduction programs (e.g. needle
    syringe distribution programs and
    supervised drug consumption facilities)
    should be implemented in hospital
    settings.”

Against Medical Advice
•   Patients who leave AMA are
    12x more likely to be
    readmitted within 14 days

•   Doubles the risk of death

•   Prevalence of AMA discharge
    is 25-30% among people who
    inject drugs

Hospitals Are High Risk
“A key finding of this
study is that patients
who use illicit
substances characterize
the health care system
as unsafe…"

Hospitals Are High Risk
                                       Abstinence only policies, inadequate
                                       pain & withdrawal management,
                                       negative stereotypes

                                              Inability to practice harm reduction,
                                              involuntary discharge

                                                      Increased morbidity and mortality

McNeil R et al. “Hospitals as a ‘risk environment’: An ethno-epidemiological study of voluntary and involuntary
discharge from hospital against medical advice among people who inject drugs” Social Science & Medicine 105: 59-66.

ED Presentations are Increasing

Canadian Institute for Health Information. “Opioid-Related Harms in Canada” Chartbook, September 2017
https://www.cihi.ca/sites/default/files/document/opioid-harms-chart-book-en.pdf

Alcohol
      “And while the opioid
      crisis gripping many
      provinces continues to
      grab headlines, experts
      warn that a looming
      alcohol health crisis
      should not be ignored.”
Canadian Institute for Health Information. “Alcohol Harm in Canada: Examining Hospitalizations Entirely Caused by
Alcohol and Strategies to Reduce Alcohol Harm” Ottawa, ON: CIHI; 2017.

A FOCUS ON REDUCING HARM IS
EVIDENCE-BASED AND ETHICAL.

Harm Reduction in Hospitals
      • Focusing on reducing harm may be a more effective way of
        managing substance use in acute care settings

      • When abstinence is not possible, it is not ethical to ignore
        other available means of reducing suffering

      • It should not be easier to access evidence-based health
        interventions in the community than in the hospital

Pauly B “Shifting moral values to enhance access to health care: Harm reduction as a context for ethical nursing
practice” International Journal of Drug Policy 19: 195-204.

Royal Alexandra Hospital

Addiction Recovery and Community
       Health (ARCH) Team
•   Standardized intake and assessment procedure
•   Comprehensive, evidence-based addiction management
•   Interventions to Maximize Social Determinants of Health
    – Housing, Income supports, ID
•   Health Promotion
    – STBBI screening, PAP smears, immunizations, fertility management
•   Linkage to community and primary care directly from acute care or
    via a Transitional Clinic

ARCH Team
•   Comprehensive, evidence-based addiction management
    – Treatment of complicated intoxication and/or withdrawal
    – Initiation or maintenance of opioid agonist treatment
    – Harm reduction including sterile injection equipment, overdose response
      kits, supervised consumption
    – Managed alcohol program
    – Counseling, motivational interviewing, relapse prevention, treatment
      referrals
    – Identification and referral for co-morbid mental health conditions

ARCH Team
•   Physicians
•   Nurse Practitioners
•   Social Workers
•   Peer Support Workers
•   Addiction Counsellors
•   Pharmacist
•   RNs / LPNs

Syringe Exchange
      •      Evidence is “overwhelming” that
             syringe exchange programs
             substantially reduce HIV rates

      •      Cost effective

      •      Can increase recruitment into drug
             treatment and possibly into
             primary health care

World Health Organization. “Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among
Injecting Drug Users” Geneva: WHO; 2004.

Syringe Exchange
Patient M
• I: What do you think about our hospital
    having a needle exchange program?
• P: I think that’s great.
• I: Why do you think it’s great?
• P: So, people don’t get infection when
    they’re in the hospital. You’re trying to get
    better when you come to the hospital so
    having a needle exchange takes away
    the risk for having another, or making it
    worse.

Syringe Exchange
Patient H
• I: What did you think when you first heard
    about our needle exchange program?
• P: Oh, I wanted to come here when I got
    sick. Told a few friends about it. Yeah.
• I: Do you think having a needle exchange
    program here, does it make it?
• P: Easier, way easier. Yeah.
• I: It makes it easier to come here?
• P: Oh yeah. Yeah. Mm-hm. Very easy.

Managed Alcohol Programs
• Participants drank more
  days, but significantly fewer
  drinks per drinking day

• Significantly reduced
  alcohol-related harms in the
  domains of health, safety,
  social, legal and withdrawal

Managed Alcohol Programs
• Patient eligibility

• Patients have to sign a
  ‘Patient Agreement’

• Assessed for intoxication
  prior to each dose

Supervised Consumption Services
“Participants singled out
hospital-based supervised
drug consumption services
as having the greatest
potential to enable them to
complete hospital treatment
despite continued drug use.”

Supervised Consumption Services

Supervised Consumption Services
                P: They should have a place to do it there. Especially if they’re
                giving the supplies, they might as well supply a safe place. –
                Patient Q
                P: Yeah, it’s a little bit awkward, don’t want to get caught,
                security guards, they’ll only let you stay in the bathroom for so
                long and then they’ll come knocking on the door. Like why are
                you taking so long, right. – Patient R

                P: if you feel rushed you end up getting more and more
                frustrated. And then if you draw blood, these things going to
                gel up in you … I sometimes go there [to McDonald’s across
                the street] and there’s a big line up ... when I’m in there … I
                start hurrying, hurrying, missing. – Patient U

                P: A lot of them can say they don’t care but I know that’s a lie.
                Of course, we all care and of course it would be, if I was in
                there and got caught sticking a needle in my arm and what
                would happen is they would probably change my meds. –
                Patient N

Supervised Consumption Service
• For inpatients only
• Risks, benefits, alternatives and consequences of
  using the service are discussed
• Patients sign:
   – Patient agreement
   – Consent form
• Injection, intra-nasal and oral use are permitted

Supervised Consumption Service

Key Points
•   Hospitals are high risk environments for people who use drugs

•   A focus on reducing harm is evidence-based and ethical

•   Syringe exchange, managed alcohol programs and supervised
    consumption services have the potential to reduce AMA discharges
    and the harms associated with ongoing drug and alcohol use in
    hospital settings

Thank you!