Harm reduction in hospitals

Despite the high rates of hospitalization among people who use drugs (PWUD), harm reduction interventions have not been widely adopted in inpatient settings. We list several harm reduction practices that we believe should be considered in hospitals. Interventions to decrease stigma, including guidance regarding language and partnering with people with lived experience of drug use, can be implemented expeditiously. Hospitals with a high prevalence of drug use can establish addiction consultation services to address issues including initiation of medication-assisted therapy. Prescription opioids as a treatment for opioid addiction for select patients require further implementation science research to determine how to adapt this intervention for inpatient settings. While the evidence base for needle and syringe programs in the community is strong, implementation science research is required to address how best to integrate such programs in hospitals. Such research is also required to determine the optimal programs to ensure continuity of care post-discharge and retention in addiction-related care. We believe that new evidence generation is required to address the optimal use of peripherally inserted central venous catheters, to determine the relative benefits and harms of treatment contracts for inpatients, and to assess the efficacy of supervised injection services for inpatients. The need for harm reduction programs in hospitals emphasizes the need for a pragmatic, patient-centered, non-judgmental approach to the care of PWUD. Few publications have addressed how to integrate harm reduction approaches into the care of hospitalized PWUD. Such questions are compelling given the marked increase in opioid use in North America, the high rates of hospital admissions among PWUD, and the strong evidence and increasing adoption of harm reduction interventions in community settings. To date, the literature on care for PWUD in hospitals has focused on recognition and management of medical complications of drug use and overdose, withdrawal, pain management, and initiation of medication-assisted therapy (MAT) [1]. In many hospital settings, these interventions may be incompletely implemented while other harm reduction interventions are rarely used, leading to poor quality care for PWUD, non-adherence to management plans, and early discharge against medical advice. In this commentary, we outline several harm reduction practices that we believe should be considered by hospital-based practitioners. We classify such interventions into three categories. First, we list interventions that should be implemented immediately because of a strong evidence base or compelling ethical arguments. Second, we list interventions for which there is a solid evidence base in community settings but insufficient evidence regarding implementation in hospitals; such interventions require an implementation science approach to identify methods to optimally introduce these interventions into inpatient settings [2]. Third, we list interventions for which there is sufficient uncertainty or controversy such that additional clinical research is needed prior to implementation. Interventions to be implemented immediately De-stigmatizing interventions Drug use is among the most stigmatized conditions in health care [3]. De-stigmatizing interventions starts with educational programs for all health care providers. Lists of terms to avoid and acceptable substitutes can be easily provided to hospital personnel [3]. Involving people with lived experience of drug use as partners in clinical care delivery and hospital policy committees can help more fully address discrimination and stigma. * Correspondence: [email protected] Maple Leaf Medical Clinic, Toronto, ON, Canada Division of Infectious Diseases, St. Michael’s Hospital, Toronto, ON, Canada Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sharma et al. Harm Reduction Journal (2017) 14:32 DOI 10.1186/s12954-017-0163-0