“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

“Maybe that’s part of the nature of the illness, you progress, and then you kind of hold your breath and then it slips again … at least with IMPACT at the table I can say we’ve done the best we can for this person.”

Perceived limitations of IMPACT:

Providers noted several key limitations of IMPACT, including that hospital-based interventions do not address poverty and have limited ability to address socioeconomic determinants such as “social support, … housing, or nutrition.” Providers also felt that IMPACT had limited ability to alleviate patients’ feelings of boredom and isolation associated with prolonged hospitalization, and that IMPACT had limited effectiveness for highly ambivalent patients (Table 2).

Finally, while many described increased confidence managing SUD after working with IMPACT, others cautioned against deferring too much to specialists. As one resident doctor said:

“We shouldn’t forget that all providers should know how to handle some form of people with addiction … I just don’t want it to be like, ‘oh, well, no, I don’t need to think about this … because we have an addiction specialist.’”

Participants across disciplines repeatedly suggested formal, ongoing initiatives to educate and train providers to manage SUD independently.

This study explores provider perspectives on care for hospitalized adults with SUD. Before IMPACT, providers felt care was chaotic, unsafe, and frustrating. Providers perceived variable care quality, resulting in untreated withdrawal, inconsistent care plans, and poor patient outcomes, leading to widespread “moral distress” and feelings of futility among providers. Yet this experience was not inevitable. Providers described that a hospital-based intervention to treat SUD reframed addiction as a treatable chronic disease, transformed culture, and improved patient care and provider experience.

Our findings are consistent with and build on previous research in several ways. First, widespread anxiety and difficulty managing patients with SUD was not unique to our hospital. In a systematic review, van Boekel and colleagues describe that healthcare providers perceived violence, manipulation, and poor motivation as factors impeding care for patients with SUD.⁹ Our study demonstrates the resulting feelings of powerlessness and frustration may be alleviated through an intervention that provides SUD care.

Second, our study is consistent with a recent survey-based study by Wakeman and colleagues that found that a hospital-based SUD intervention improved providers’ feelings of preparedness and satisfaction.²⁰ Our study provides a rich qualitative description and elucidates mechanisms by which such interventions may work.

The finding that a hospital-based SUD intervention can shift providers’ views of addiction is important. Earlier studies have shown that providers who perceive addiction as a choice are more likely to have negative attitudes toward people with SUD.¹¹ While our intervention did not provide formal education aimed at changing attitudes, participants reported that seeing firsthand effects of treatment on patient behaviors was a powerful tool that radically shifted providers’ understanding and reduced stigma.

Stigma can occur at both individual and organizational levels. Structural stigma refers to practices, policies, and norms of institutions that exclude needs of a particular group.²¹ The absence of systems to address SUD sends a message to both patients and providers that addiction is a not a treatable or worthy disease. IMPACT was in and of itself a systems-level intervention; by creating a consultation service, hospital-wide policies, and pathways to care after hospitalization, IMPACT ‘legitimized’ SUD and reduced institutional stigma.

Several studies have shown the feasibility and effectiveness of starting medications for addiction (MAT) in the hospital.^13-15 Our study builds on this work by highlighting systems-level elements valued by providers. These elements may be important to support and scale widespread adoption of MAT in hospitals. Specifically, providers felt that IMPACT’s attention to hospital policies, use of addiction medicine specialists, and direct linkages to outpatient SUD treatment proved instrumental in shifting care systems.

Our study has several limitations. As a single-site study, our goal was not generalizability, but transferability. As such, we aimed to obtain rich, in-depth information that can inform implementation of similar efforts. Because our study was conducted after the implementation of IMPACT, providers’ perspectives on care before IMPACT may have been influenced by the intervention. However, this also strengthens our findings by allowing participants the opportunity for insights under a different system. It likely leads to distinct findings compared to what we might have uncovered in a pre-post study. While respondents noted perceived limitations of IMPACT, there were few instances of negative remarks in the data we collected. It is possible that providers with more negative interpretations chose not to participate in interviews; however, we elicited wide viewpoints and encouraged participants to share both strengths and weaknesses. Finally, IMPACT implementation depends on regional as well as local factors such as Medicaid expansion, community treatment resources, and the existence of addiction medicine expertise that will differ across settings.

Despite these limitations, our study has several important implications. For clinical practice, our findings highlight the importance of treating withdrawal to address challenging patient behaviors and the value of integrating MAT into the hospital setting. Our findings also underscore the role of expert consultation for addiction. Importantly, our results emphasize that reframing SUD as a brain disease can have significant implications for clinical care and providers’ well-being. Provider distress is not inevitable and can change with the right support and systems.

At the hospital and health systems level, our findings suggest that hospitals can and should address SUD. This may include forming interprofessional teams with SUD expertise, providing standardized guidelines for addiction care such as patient safety plans and methadone policies, and creating rapid-access pathways to outpatient SUD care. By addressing SUD, hospitals may simultaneously improve care and reduce provider burnout. Providers’ important concerns about shifting SUD treatment to a specialty team and their discomfort managing SUD pre-IMPACT suggest the need to integrate SUD education across all levels of interprofessional education. Furthermore, provider concerns that IMPACT has limited ability to engage ambivalent patients underscores the need for hospital-based approaches that emphasize harm reduction strategies.

As the SUD epidemic worsens, SUD-related hospitalizations are skyrocketing, and people are dying at unprecedented rates.^2,3 Many efforts to address SUD have been in primary care or community settings. While important, many people with SUD are unable or unlikely to seek primary care. ²² Hospitals need a workforce and systems that can address both the physical and behavioral health needs of this population. By implementing SUD improvements, hospitals can support staff and reduce burnout, better engage patients, improve care, and reduce stigma from this devastating disease.