Commentary Harm reduction in hospitals : is it time ?

Among persons who inject drugs (IDU), illicit drug use often occurs in hospitals and contributes to patient expulsion and/or high rates of leaving against medical advice (AMA) when withdrawal is inadequately managed. Resultant disruptions in medical care may increase the likelihood of several harms including drug resistance to antibiotics as well as costly readmissions and increased patient morbidity. In this context, there remains a clear need for the evaluation of harm reduction strategies versus abstinence-based strategies with respect to addressing ongoing issues related to substance use among addicted hospitalized patients. While hospitalization can be used to stabilize addicted patients as they recover from their acute illness and help them to achieve abstinence, patients unable to maintain abstinence should not be penalized for failing to do so at the expense of their health. This article describes harm reduction activities within hospitals and areas for future investigation. Introduction Soft-tissue infections and other injection-related infections are among the main contributors to health service use among people who inject drugs (IDU) [1-6]. In many settings, the two most common reasons for emergency department (ED) visits relate to soft-tissue infections, and problems related directly to drug use (e.g., overdose)[1,2,4,6]. Not-surprisingly, many IDU use EDs as a regular point of care; IDU are generally less likely to use outpatient services compared to non-IDU[4] and generally face poor access to prevention programs and addiction treatment services [7-9]. As a result, IDU often present to EDs later in the course of their illness, and this in turn increases the likelihood for hospital admission [2,4,5]. Drug-related infections are often painful and may progress to more serious lifeand limb-threatening conditions [10]. More complicated infections such as endocarditis require extended periods of treatment with intravenous antibiotics and thus may require even longer hospital stays. However, IDU are more likely than other patients to discharge from hospitals against medical advice (AMA) [11,12]. A 2002 study noted that IDU were over four times more likely to leave AMA compared to non-IDU [12] and leaving AMA is a strong predictor for frequent readmission [11-13]; Moreover, repeated admissions for chronic medical problems are generally more costly for total days of stay than single, cost-intensive stays [13]. In addition to the high costs associated with increased health utilization, these findings also suggest that patients are not fully recovering from their illness the first time Published: 29 July 2009 Harm Reduction Journal 2009, 6:19 doi:10.1186/1477-7517-6-19 Received: 23 December 2008 Accepted: 29 July 2009 This article is available from: http://www.harmreductionjournal.com/content/6/1/19 © 2009 Rachlis et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.