Drug use in hospitals: Is there a role for harm reduction?

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Drug use remains a cause of significant health and social harm for individuals, communities and the health care system. High rates of infectious diseases, overdose and traumas among people who inject drugs (IDU) result in much preventable human suffering and present challenges for the health care system. Despite these challenges, recent evidence from Vancouver gives reason for hope.

A report released this year by the Urban Health Research Initiative of the British Columbia Centre for Excellence in HIV/AIDS, Drug Situation in Vancouver (http://uhri.cfenet.ubc.ca/images/Documents/dsiv2013.pdf), indicates that much has improved for IDU in Vancouver. Rates of HIV infection and other indicators of drug-related harm have plummeted. This is very good news given that in the late 1990s the Vancouver/Richmond Health Board declared a public health emergency in response to soaring rates of HIV infection and overdose among local IDU.

The improvement in the health of IDU in Vancouver can largely be attributed to increasing access to addiction treatment, HIV treatment, but also the implementation of a range of harm reduction programs. Harm reduction programs seek to reduce the harms of drug use without requiring abstinence from drugs. Such programs place very few requirements or conditions on IDU and are considered to be “low-threshold” interventions.

This approach is consistent with growing awareness among experts that addiction is often a chronic relapsing condition, with periods of active use occurring in between periods of abstinence. Examples include syringe and crack pipe distribution programs, and supervised injection sites where IDU can inject drugs under the supervision of health care professionals. The positive impact of harm reduction in Vancouver is not surprising given that the World Health Organization and the United Nations’ Joint Program on AIDS recommend harm reduction programs as best practices.

Although progress in reducing the harms of illicit drug use can be seen in community settings throughout Canada, the same cannot be said about hospitals. It is well known that many IDU avoid primary care and often overrely on emergency departments for care. As a result, many IDU show up late in the course of illness and require admission to a hospital bed. Sadly, research undertaken in Canada shows that far too many IDU leave hospital long before they should.

A study undertaken in Vancouver showed that one quarter of all IDU admissions resulted in a patient leaving hospital against medical advice (AMA), and others have shown that IDU are about four times more than likely than their non-IDU counterparts to leave hospital AMA.

Leaving hospital AMA often results in more serious illness and greater health care costs. The more commonly reported causes of AMA among IDU include active addiction, withdrawal, and untreated pain. Not surprisingly, research has also shown that many IDU inject drugs in hospital to deal with their withdrawal and pain. However, when faced with abstinence-based policies and the associated sanctions for drug use in hospital, many IDU simply leave.

So what could hospitals do to address the problem of AMA among IDU? One approach would be to implement and evaluate hospital-based harm reduction programs. Past research has shown improvements in retention in primary care when harm reduction approaches were implemented. Likewise, the use of substitution therapies for opiate addiction, such as methadone and buprenorphine, has been associated with improved hospital care, including reduced AMA. Providing opiates or benzodiazepines to patients experiencing withdrawal can also reduce the likelihood of premature discharge.

A further innovation would be the inclusion of drug consumption facilities within hospitals. Recent evaluations of Vancouver’s supervised injection facility, known as Insite, have shown positive results in terms of reductions in infectious disease transmission, overdose, and disorder arising from use of drugs in public spaces. The evaluation also showed increases in access to addiction treatment and no negative impacts, such as increased crime or drug use. A supervised consumption room has also been implemented in the Dr. Peter Centre Day Health Program, which serves individuals living with HIV/AIDS and was at one time located in St. Paul’s Hospital. An evaluation of this program revealed that staff at the Centre found that the drug consumption room helped facilitate care and reduce overdose risk by reducing the need to punitively manage drug use onsite.

Active illicit drug use continues to present challenges within health care settings throughout Canada. However, there is growing consensus that harm reduction programs can play an important role in mitigating the health and social harms of drug use, and can also promote more effective engagement in care and treatment. Given the significant problem of AMA among IDU, and given that harm reduction programs have become key features within community settings, it seems that the time has come for a new agenda of harm reduction program development and evaluation for hospitals in Canada.