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

Transcription

1 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

2 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)

3 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.

4 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

5 Mitigating Potential Bias None to declare.

6 HOSPITALS ARE HIGH RISK ENVIRONMENTS FOR PEOPLE WHO USE DRUGS

7 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

8 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.

9 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

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

11 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:

12 ED Presentations are Increasing Canadian Institute for Health Information. Opioid-Related Harms in Canada Chartbook, September

13 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.

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

15 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:

16 Royal Alexandra Hospital

17 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

18 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

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

20 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.

21 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.

22 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.

23 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

24 Managed Alcohol Programs Patient eligibility Patients have to sign a Patient Agreement Assessed for intoxication prior to each dose

25 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.

26 Supervised Consumption Services

27 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

28 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

29 Supervised Consumption Service

30 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

31 Thank you!