“We’ve Learned It’s a Medical Illness, Not a Moral Choice”: Qualitative Study of the Effects of a Multicomponent Addiction Intervention on Hospital Providers’ Attitudes and Experiences
BACKGROUND: Substance use disorders (SUD) represent a national epidemic with increasing rates of SUD-related hospitalizations. However, most hospitals lack expertise or systems to directly address SUD. Healthcare professionals feel underprepared and commonly hold negative views toward patients with SUD. Little is known about how hospital interventions may affect providers’ attitudes and experiences toward patients with SUD.
OBJECTIVE: To explore interprofessional hospital providers’ perspectives on how integrating SUD treatment and care systems affect providers’ attitudes, beliefs, and experiences.
DESIGN: In-depth semi-structured interviews and focus groups. The study was part of a formative evaluation of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction medicine service with rapid-access pathways to post-hospital SUD treatment.
SETTING: Single urban academic hospital in Portland, Oregon.
PARTICIPANTS: Multidisciplinary hospital providers.
MEASUREMENTS: We conducted a thematic analysis using an inductive approach at a semantic level.
RESULTS: Before IMPACT, participants felt that hospitalization did not address addiction, leading to untreated withdrawal, patients leaving against medical advice, chaotic care, and staff “moral distress.” Participants felt that IMPACT “completely reframes” addiction as a treatable chronic disease, improving patient engagement and communication, and humanizing care. Participants valued post-hospital SUD treatment pathways and felt having systems to address SUD reduced burnout and provided relief. Providers noted that IMPACT had limited ability to address poverty or engage highly ambivalent patients.
CONCLUSIONS: Providers’ distress of caring for patients with SUD is not inevitable. Hospital-based SUD interventions can reframe providers’ views of addiction and may have significant implications for clinical care and providers’ well-being.
© 2018 Society of Hospital Medicine
As expected, the style of IIs differed from that of FGs and informants were able to provide information specific to their roles. Overall, the information provided by IIs was complementary to that of FGs and helped triangulate findings. Thus, we combined them in the results.18
RESULTS
We organized our findings into 3 main groupings, including (1) care before IMPACT, (2) care with IMPACT, and (3) perceived limitations of IMPACT. We included a table (Table 2) with additional quotations, beyond those in the body of the results, to support emergent themes described below.
Care before IMPACT
Providers felt hospitalization did not address addiction for many reasons, including ethical and legal concerns, medical knowledge gaps, and lack of treatment options.
Before IMPACT, many participants noted that hospitalization ignored or avoided addressing addiction, leading to a chaotic care environment that adversely affected patient care and provider experience. As one social worker stated, “prior to IMPACT we provided assessments, and we provided resources. But we didn’t address addiction.”
Providers cited multiple explanations for this, including the common misperception that using methadone to treat withdrawal violated federal regulations, and concerns about the ethicality of using opioids in patients with SUD. Across disciplines, providers described a “huge knowledge gap” and little confidence in addressing withdrawal, complex chronic pain, medications for addiction, and challenging patient behaviors. Providers also described limited expertise and scarce treatment options as a deterrent. As one attending reflected, “I would ask those questions [about SUD] before, but then … I had the information, but I couldn’t do anything with it.”
Providers felt the failure to address SUD adversely affected patient care, leading to untreated withdrawal, disruptive behaviors, and patients leaving against medical advice (AMA).
Participants across disciplines described wide variability in the medical management of SUD, particularly around the management of opioid withdrawal and pain, with some providers who “simply wouldn’t prescribe methadone or any opiates” and others who prescribed high doses without anticipating risks. As one attending recalled:
“You would see this pattern, especially in the intravenous drug-using population: left AMA, left AMA, left AMA … nine times out of ten, nobody was dealing with the fact that they were gonna go into withdrawal.”
Respondents recalled that disruptive behaviors from patients’ active use or withdrawal frequently threatened safety; imposed a tremendous burden on staff time and morale; and were a consistent source of providers’ distress. As one patient advocate explained:
“[Providers] get called to the unit because the person is yelling and throwing things or comes back after being gone for a long period and appears impaired … it often blows up, and they get discharged or they leave against medical advice or they go out and don’t come back. We don’t really know what happened to them, and they’re vulnerable. And the staff are vulnerable. And other patients are distressed by the disruption and commotion.”
Absent standards and systems to address SUD, providers felt they were “left to their own,” resulting in a reactive and chaotic care environment.
Providers noted inconsistent rules and policies regarding smoke breaks, room searches, and visitors. As a result, care felt “reckless and risky” and led to a “nonalliance” across disciplines. Providers frequently described inconsistent and loose expectations until an event -- often active use – triggered an ad hoc ratcheting up of the rules, damaging patient-provider relationships and limiting providers’ ability to provide medical care. Facing these conflicts, “staff gets escalated, and everybody gets kind of spun up.” As one attending reflected:
“I could not get any sort of engagement even in just her medical issues … I was trying to talk to her and educate her about heart failure and salt intake and food intake, but every time I walked in the room … I’d have to come in and be like, ‘your UDS [urine drug screen] was positive again, so here’s the changes to your behavioral plan, and OK, let’s talk about your heart failure …’ At that point, the relationship had completely disintegrated until it was very nonproductive.”
Providers described widespread “moral distress,” burnout, and feelings of futility before IMPACT.
Consequently, providers felt that caring for people with SUD was “very emotionally draining and very time consuming.” As one patient advocate described:
“We’ve been watching staff try to manage these patients for years without the experts and the resources and the skills that they need … As a result, there was a crescendo effect of moral distress, and [staff] bring in all of their past experiences which influence the interaction … Some staff are very skilled, but you also saw some really punitive responses.”
