Addiction is a chronic, progressive, often fatal condition rooted in trauma, adverse childhood experiences, mental health conditions, and physical pain (Heilig et al., 2021). Although the most commonly addictive substances are alcohol and tobacco, opioid addiction has grown to crisis proportions in the United States; 93,331 people died from opiate poisoning in 2020, more than in any other reported year (Volkow, 2022). Drug overdose mortality rates grew 25x in the last 20 years, with synthetic opioid overdose deaths increasing 50-fold (Volkow, 2022).
Opioid Use Disorder (OUD), and substance misuse in general, is associated with socioeconomic deprivation (Milaney et al., 2022). According to Milaney et al. (2022), sexual and gender minorities experience higher rates of opioid misuse than cis-heterosexuals. Disabled adults are over four times more likely to die from opioid poisoning than the general population. Alongside racialized groups, these minorities experience significant access barriers for adequate health care, higher burdens of mental and physical health issues, and lower socioeconomic status – all compounding risks and harms associated with substance misuse (Milaney et al., 2022).
OUD often leads to unsafe injection practices which elevate risks of serious blood-borne infections including Hepatitis C, HIV, in addition to bacterial infections such as endocarditis, skin abscess, Methicillin-Resistant staph. Aureus (MRSA) infection, and septicemia (Ober et al., 2022). As OUD prevalence rises, hospitalizations for injection-related infections increase too (Barocas et al., 2022). People who inject drugs (PWID) experience poorer health outcomes than non-PWID when hospitalized for bacterial infections (Ray et al., 2020). For instance, treatment for endocarditis frequently requires long-term IV antibiotics, lengthy inpatient hospitalization, and in many cases, heart surgery (Ray et al., 2020). OUD-associated injection drug use complicates endocarditis treatment, due to concerns that PWID will inject into IV ports, or hesitance to perform surgery due to concerns about infection recurrence secondary to continued drug use (Ray et al., 2020).
Multiple recent studies outline strategies to improve outcomes for hospitalized PWID (Barocas et al., 2022, Khan et al., 2022, Lewis et al., 2022, Ober et al., 2022). Those strategies include multi-disciplinary teams of medical providers, social work, and case management to address social care needs of the patients. Many, if not all, of the current interventions require initiation of medication to treat the SUD.
Medication for Opioid Use Disorder (MOUD), as part of a comprehensive treatment plan, is the gold standard of care for OUD. Methadone and buprenorphine are opioid agonists used most frequently to treat OUD (National Harm Reduction Coalition, 2020). Opioid agonists are highly effective in the reduction of drug cravings and withdrawal symptoms. Additionally, MOUD is shown to lessen risk of HIV and Hepatitis C (Ober et al., 2022). Prescription heroin or morphine is successfully used in other countries as opioid agonist treatment for OUD, however, the US has yet to approve those medications (National Harm Reduction Coalition, 2020).
PWID hospitalized for serious infections often receive insufficient MOUD to treat their pain or withdrawal symptoms (Allen et al., 2022). These individuals report feeling judged by healthcare professionals, as if the providers hold the belief that addiction is a moral failing, or a choice (Allen et al., 2022). Hospitalized PWID may feel that their symptoms of pain and withdrawal are being ignored or undertreated (Allen et al., 2022). These experiences of discrimination or stereotyping are due in part to addiction-related stigma in the healthcare setting (Allen et al., 2022). Patients may feel distressed by experiences of stigma, leading to self-managing their symptoms by continuing to inject substances within the facility (Allen et al., 2022). Stigma is a significant predictor of patient discharge against medical advice; moreover, patients may decline MOUD at hospital discharge due to stigmatizing experiences, alongside other social and ecological life factors (Allen et al., 2022).
Few, if any, interventions exist to improve outcomes for PWID who decline MOUD after hospitalization for injection drug use related infections. Scant support for this sub-population leads to patient discontinuation of antibiotic treatment, continued engagement in unsafe injection practices, increased occurrence of secondary infections, recurrences of primary infections, higher hospital readmissions, and increased mortality (Lewis et al., 2022). The proposed intervention is grounded in a health equity framework and aims to improve outcomes for hospitalized PWID who decline MOUD. The primary goal is to remove barriers to abstinence of injection drug use and MOUD acceptance, while also reducing harms associated with injection drug use to the furthest extent possible.
Harm Reduction as Health Equity
Health equity is achieved when everyone has the chance to reach their own full health potential and no one is denied this opportunity due to any socially defined circumstance (CDC, 2022). Increasingly centered in public health goals and interventions, a health equity framework seeks to address and correct the social determinants of health which are the true root causes of differences in health outcomes (CDC, 2022).
Harm reduction is a movement which arose in challenge to the legal oppression and medical and social stigma experienced by drug users (Milaney et al., 2022). Compassionate care is at the center of the model, with the priority on health, humanity, and autonomy of the drug user (Milaney et al., 2022, National Harm Reduction Coalition, 2020). In the context of OUD and injection drug use, a harm reductionist approach includes the provision of clean needles and injection supplies, naloxone kits, and education about opiate poisoning reversal and supervised injection facilities. (Milaney et al., 2022). A harm reductionist does not actively seek to change the behavior of PWID, but rather attempts to help them stay alive and healthy while using (Milaney et al., 2022). In addition to drug use harm reduction, the model prioritizes individual empowerment towards positive behavior change by working to alleviate some of the social contexts leading to drug use in the first place (Allen et al., 2022). This work includes but is not limited to helping find food, clothes, and shelter, as well as providing culturally sensitive and trauma informed mental and emotional healthcare (Milaney et al., 2022).
The individual’s choice to transition to MOUD is not simple. Substance misuse is rooted in many systemic, cultural, and social conditions which constitute an individual’s surrounding social environment (Milaney et al., 2022). Many PWID feel that drugs are their only effective coping tool, perhaps even using the substance to cope with the negative impacts of their substance use itself (Allen et al., 2022). As such, this proposed intervention uses a nested-model approach to behavior change. Following the framework of the individual level Transtheoretical Model of Behavior, social-ecological interventions are proposed to reduce and remove barriers at every level of change (Glanz et al., 2015, pp. 73-83, 149-154).
The Transtheoretical Model (TTM) describes behavior change as not a discrete event but rather a progression through several stages, often in a nonlinear fashion (Prochaska & Velicer, 1997). This intervention program operates under an assumption that for PWID, barriers to change at every stage are ecologic in nature. It is from within that framework that several actions are proposed to support the population of hospitalized PWID declining MOUD. Prochaska and Velicer (1997) described the TTM stages as the following:
Precontemplation: The individual does not intend to change behavior in this stage. They may not be informed of the risks/benefits of the behavior, or they may experience insurmountable barriers to change.
Contemplation: The individual is more aware of the pros and cons of behavior change in this stage, but remains ambivalent about taking action. They may not have yet made a decision, or they may have decided to change but have not yet taken action towards that goal.
Preparation: This stage is sometimes characterized in the literature as ‘determination.’ The individual has decided to change their behavior soon and is taking steps to prepare for action
Action: This is the stage in which the individual changes their behavior in pursuit of their goal.
Maintenance: An individual is considered to be in this stage after six months of successfully maintaining the behavioral change. Relapse is still a significant risk.
Termination: This stage marks the individual’s full self-efficacy as it relates to maintenance of their new behavior. These individuals are fully confident in their ability to resist temptation to relapse into the unhealthy behavior.
Recruitment and Measures
Program participants will be enrolled over a period of 12 months. Eligibility criteria include hospitalization for an infection likely due to injection drug use, and the individual must be over 18 years old, have a diagnosis or probable diagnosis of OUD, and is declining MOUD at discharge. Informed consent is important, so potential participants will receive a thorough explanation of the intervention’s goals and methods.
The expected outcomes are increases in infection treatment completion rates, lower 180-day mortality, reduced readmissions due to primary infection recurrences, and more transfers into standard OUD treatment in the study population. Participant outcome measures will be measured against the measures of a retrospective cohort control group, taken from hospital electronic medical records. Lastly, participant perspectives and opinions will be recorded via qualitative surveys before and after the end of the intervention.
Pain/Withdrawal Management Intervention
PWID may decline MOUD while in acute care for several reasons. They may have had negative experiences due to medical providers’ stigma, leading to distrust in the medical system, or perhaps past attempts at treatment had harmful or painful side effects (Allen et al., 2022). Regardless of reason, patient autonomy to make decisions about their own care must be respected, just like with any other chronic medical condition.
Individuals declining MOUD while hospitalized may need opioids to maintain proper pain control and treat withdrawal (Allen et al., 2022). Because improper pain/withdrawal control is a significant predictor of patient directed discharge and incomplete treatment, providers must ensure patients receive sufficiently large and frequent doses of narcotics (Allen et al., 2022). In addition to improving treatment completion rates, this strategy lessens harms associated with continued injection of illicit opioids (Allen et al., 2022). The patient should have a standing order of PRN naloxone to reverse any accidental opioid poisoning in treatment (Allen et al., 2022).
Cooperative and compassionate care may help to reduce experiences of stigma and shame in the vulnerable population of PWID, which increases therapeutic rapport and trust between patient and provider (Allen et al., 2022). Increased trust may lead to changes in the individual’s appraisal of risks/benefits of MOUD, facilitating a transition from precontemplation towards contemplation of behavior change.
Nearly half of PWID in Michigan report experiences of homelessness (MDHHS, n.d.). Generally speaking, individuals experiencing homelessness suffer disproportionately higher rates of substance misuse and addiction than individuals who are not homeless (Polcin, 2016). Likely associated factors include harmful living conditions with associated trauma, and insurmountable barriers to healthcare access (Polcin, 2016). In addition, adverse childhood experiences (ACE) and other forms of toxic stress impact substance misuse, as well as contribute to housing instability (Allen et al., 2022).
The care needs of PWID are significant and often unmet. Many housing programs are conditional on complete drug abstinence (Polcin, 2016). If or when an individual recovering from SUD has a relapse of substance misuse, they may consequently experience housing eviction (Tsemberis et al., 2004). Eviction-related stress complicates an individual’s ability to transition back into the action stage of SUD recovery, which perpetuates the cycle of addiction (Tsemberis et al., 2004).
The proposed intervention will partner with Community Rebuilders, a housing organization seeking to end homelessness in Grand Rapids, MI by promoting equitable and affordable housing for needy individuals (King, 2021). The organization has an established program to provide permanent housing solutions for individuals with verified, permanent disabilities and who experiencing homelessness.
Homeless PWID in our program will receive the designation ‘Permanently Disabled’ in order to qualify for housing assistance. This support is available for PWID irrespective of drug abstinence, following a Housing First model to address a significant upstream social determinant of substance misuse (Tsemberis et al., 2004). Housing security and stability may facilitate feelings of safety, allowing the individual to exit survival mode and begin to contemplate change.
Meeting Unmet Social Support Needs Intervention
The interpersonal level of the social-ecological model of health describes the potential impacts of social support on health outcomes (Glanz et al., 2015, p. 175). Importantly, the individual’s level of perceived support is strongly associated with health outcomes. According to Glanz et al (2015, p. 175), perceived support refers to the level of support the individual expects to receive when they need it. When the support is perceived as closely matched to needs, better health outcomes are likelier.
Intervention participants will be linked to trained peer support specialists with lived experiences of OUD and who have been in their own OUD recovery for at least two years. Peer specialists are important because they are in an optimal place to understand the needs of PWID and provide social support responsive to those needs (Magidson et al., 2021). The specialist will be in contact with the patient weekly or biweekly. Meetings may include informal relationship building over coffee, or meeting the patient in their community to help response to social crises or provide clean needles (Jack et al., 2017). In addition, support specialists may provide connections to food and clothing resources if needed.
The intervention will provide donated cellphones collected from community members to participants who lack access. This may improve participant perception of availability of social support, as well as lessen barriers to healthcare via telehealth technology. Peer specialist interventions may support the individual transition from precontemplation towards contemplation, as well as from contemplation towards preparation for behavior change.
Physical and Mental Health Management Intervention
The health management part of the intervention will enable participants’ positive behavior change by reducing mortality associated with injection drug use (Milaney et al., 2022). Many PWID lack adequate health insurance (Ghulam et al., 2022). Hospitalization may be an important opportunity to link patients to life-saving medical interventions, access to which may otherwise be limited. Intervention participants will be connected to a social worker who is responsible for case management and brief psychotherapeutic interventions as necessary. Referral to community mental health will be available for individuals requiring more intensive and urgent mental health care. Participants will also be connected to a nurse, who is responsible for infection and antibiotic follow-up. The nurse may provide education about safer injection practices, when indicated, to reduce infection recurrence risk (CDC, 2018). Education may include tips about sanitizing used needles with bleach if clean needles are unavailable, or mixing drugs in water instead of saliva, or avoiding licking the needle before injection, etc (CDC, 2018). Clean needles, other injection materials, and naloxone kits will be available at nurse appointments in take-home fanny packs for ease of carrying. Nurses and social workers may provide referrals to The Grand Rapids Red Project for supervised injection or needle exchange services when indicated (The Grand Rapids Red Project, n.d.).
The opioid epidemic may be viewed, perhaps, as a symptom of a larger social illness within the community. Hospitalization for sequalae of injection drug use such as serious bacterial infection is a burden on hospital resources, and is an often-ugly side of the opioid epidemic (Barocas et al., 2022). PWID may sometimes frustrate medical staff due to frequent relapse and readmission, as well as unpleasant behavior displayed by the individual while extremely stressed (Allen et al., 2022). It is important to remember that individuals in addiction situations are likely using drugs to cope with toxic life stress, and hospitalization is an additional stressor (Allen et al., 2022). “Drug-seeking” or otherwise difficult behavior may be a sort of acting-out on the part of the stressed individual (Allen et al., 2022). It is important for staff to remain compassionate, and to utilize hospitalization as an opportunity to improve outcomes for an often-unreachable population.
The proposed intervention will be expensive. Hospitals may see cost savings, however, due to reduced readmissions of uninsured individuals and possibly fewer opioid poisoning hospitalizations (Barocas et al., 2022). Notably, overall hospital-acquired MRSA infections may decrease due to fewer PWID with community-acquired MRSA being hospitalized and shedding the pathogen (Skov et al., 2009). Additionally, the program will leverage relationships with existing community resources by partnering with Community Rebuilders and the Red Project in Grand Rapids. Community partnership may facilitate fund intermingling for program interventions, possibly reducing costs for all parties.
The proposed intervention is limited to the scope of this project, which means that there are plenty of social-ecological needs in PWID that are left unaddressed. Those needs include but are not limited to lack of access to transportation, severe and untreated comorbidities, experiences of medical stigma, and legal trouble associated with injection drug use (Milaney et al., 2022). These unaddressed needs will provide opportunities for future community health interventions.
Allen, D., Brouwer, J., Dong, K., Dyer, D., Etches, N., Evans, L., Eyford, H., Gilani, F., Gill. H. S., Gill, S., Gurney, R., Hayer, L., Henderson, R., Hyshka, E., Lee, M., Leung, E., McCorkell, T., Meador, K., Morris, H., … & Weis, J. (2022). Guidance Document on the Management of Substance Use in Acute Care. Canadian Research Initiative in Substance Misuse. Retrieved August 8, 2022, from https://crismprairies.ca/management-of-substance-use-in-acute-care-settings-in-alberta-guidance-document/
Barocas, J. A., Savinkina, A., Adams, J., Jawa, R., Weinstein, Z. M., Samet, J. H., & Linas, B. P. (2022). Clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic: A modelling study. The Lancet Public Health, 7(1). https://doi.org/10.1016/s2468-2667(21)00248-6
Centers for Disease Control and Prevention. (2018, July 19). Strategies for disease prevention in persons who inject drugs. Centers for Disease Control and Prevention. Retrieved August 13, 2022, from https://www.cdc.gov/pwid/disease-prevention.html
Centers for Disease Control and Prevention. (2022, March 3). Health equity.Centers for Disease Control and Prevention. Retrieved August 8, 2022, from https://www.cdc.gov/chronicdisease/healthequity/index.htm
Glanz, K., Rimer, B. K., & Viswanath, K. (2015). Chapter 8: Introduction to Models of Interpersonal Influences on Health Behavior. In Health behavior: Theory, research, and Practice (5th ed.). Jossey-Bass.
Heilig, M., MacKillop, J., Martinez, D., Rehm, J., Leggio, L., & Vanderschuren, L. J. (2021). Addiction as a brain disease revised: Why it still matters, and the need for consilience. Neuropsychopharmacology. https://doi.org/10.1038/s41386-020-00950-y
Jack, H. E., Oller, D., Kelly, J., Magidson, J. F., & Wakeman, S. E. (2017). Addressing substance use disorder in primary care: The role, integration, and impact of recovery coaches. Substance Abuse, 39(3), 307–314. https://doi.org/10.1080/08897077.2017.1389802
Khan, G. K., Harvey, L., Johnson, S., Long, P., Kimmel, S., Pierre, C., & Drainoni, M. L. (2022). Integration of a community-based harm reduction program into a Safety Net Hospital: A qualitative study. Harm Reduction Journal, 19(1). https://doi.org/10.1186/s12954-022-00622-8
King, J. (2021, March 18). Housing + Support Services. Community Rebuilders. Retrieved August 8, 2022, from https://communityrebuilders.org/endinghomelessness/programs/
Lewis, S., Liang, S. Y., Schwarz, E. S., Liss, D. B., Winograd, R. P., Nolan, N. S., Durkin, M. J., & Marks, L. R. (2022). Patients with serious injection drug use–related infections who experience patient-directed discharges on oral antibiotics have high rates of antibiotic adherence but require multidisciplinary outpatient support for retention in care. Open Forum Infectious Diseases, 9(2). https://doi.org/10.1093/ofid/ofab633
Magidson, J. F., Regan, S., Powell, E., Jack, H. E., Herman, G. E., Zaro, C., Kane, M. T., & Wakeman, S. E. (2021). Peer Recovery Coaches in general medical settings: Changes in utilization, treatment engagement, and opioid use. Journal of Substance Abuse Treatment, 122, 108248. https://doi.org/10.1016/j.jsat.2020.108248
MDHHS Division of HIV and STI Programs. (n.d.). HIV Testing and Needle Usage Among Persons Who Inject Drugs (PWID) Experiencing and Not Experiencing Homelessness.MDHHS. https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder50/Folder5/HIV_Testing_and_Needle_Usage_Among_PWID_Experiencing_and_Not_Experiencing_Homelessness_Fac.pdf?rev=81d4de9bd6994579831ea19e42f1509f
Milaney, K., Haines-Saah, R., Farkas, B., Egunsola, O., Mastikhina, L., Brown, S., Lorenzetti, D., Hansen, B., McBrien, K., Rittenbach, K., Hill, L., O'Gorman, C., Doig, C., Cabaj, J., Stokvis, C., & Clement, F. (2022). A scoping review of opioid harm reduction interventions for equity-deserving populations. The Lancet Regional Health - Americas, 12, 100271. https://doi.org/10.1016/j.lana.2022.100271
National Harm Reduction Coalition. (2020, September 8). Medication for opioid use disorder (MOUD) overview. Retrieved August 13, 2022, from https://harmreduction.org/issues/facts/
Ober, A. J., Murray-Krezan, C., Page, K., Friedmann, P. D., Chan Osilla, K., Ryzewicz, S., Huerta, S., Mazer, M. W., Leamon, I., Messineo, G., Watkins, K. E., Nuckols, T., & Danovitch, I. (2022). The Substance Use Treatment and Recovery Team (START) study: Protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder. Addiction Science & Clinical Practice, 17(1). https://doi.org/10.1186/s13722-022-00320-7
Polcin, D. L. (2015). Co-occurring substance abuse and mental health problems among homeless persons: Suggestions for research and practice. Journal of Social Distress and the Homeless, 25(1), 1–10. https://doi.org/10.1179/1573658x15y.0000000004
Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of Health Behavior Change. American Journal of Health Promotion, 12(1), 38–48. https://doi.org/10.4278/0890-1171-12.1.38
Ray, V., Waite, M. R., Spexarth, F. C., Korman, S., Berget, S., Kodali, S., Kress, D., Guenther, N., & Murthy, V. S. (2020). Addiction management in hospitalized patients with intravenous drug use–associated infective endocarditis. Psychosomatics, 61(6), 678–687. https://doi.org/10.1016/j.psym.2020.06.019
Skov, R. L., & Jensen, K. S. (2009). Community-associated meticillin-resistant Staphylococcus aureus as a cause of hospital-acquired infections. Journal of Hospital Infection, 73(4), 364–370. https://doi.org/10.1016/j.jhin.2009.07.004
The Grand Rapids Red Project. (2022, March 9). Red Project: Syringe Access, HIV/HCV testing, Overdose Education. Retrieved August 8, 2022, from https://redproject.org/
Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health, 94(4), 651–656. https://doi.org/10.2105/ajph.94.4.651
Volkow, N. (2022, January 7). Drug overdose deaths in 2020 were horrifying. radical change is needed to address the drug crisis. National Institutes of Health. Retrieved August 8, 2022, from https://nida.nih.gov/about-nida/noras-blog/2021/08/drug-overdose-deaths-in-2020-were-horrifying-radical-change-needed-to-address-drug-crisis