Ethical Considerations in the Care of Hospitalized Patients with Opioid Use and Injection Drug Use Disorders

“Lord have mercy on me, was the kneeling drunkard’s plea.”

—Johnny Cash

The Diagnostic and Statistical Manual of the American Psychiatric Association defines opioid-use disorder (OUD) as a problematic pattern of prescription and/or illicit opioid medication use leading to clinically significant impairment or distress.¹ Compared with their non-OUD counterparts, patients with OUD have poorer overall health and worse health service outcomes, including higher rates of morbidity, mortality, HIV and HCV transmission, and 30-day readmissions.² With the rate of fatal overdoses from opioids at crisis levels, leading scientific and professional organizations have declared OUD to be a public health emergency in the United States.³

The opioid epidemic affects hospitalists through the rising incidence of hospitalization, not only as a result of OUD’s indirect complications, but also its direct effects of intoxication and withdrawal.⁴ In caring for patients with OUD, hospitalists are often presented with many ethical dilemmas. Whether the dilemma involves timing and circumstances of discharge or the permission to leave the hospital floor, they often involve elements of mutual mistrust. In qualitative ethnographic studies, patients with OUD report not trusting that the medical staff will take their concerns of inadequately treated pain and other needs seriously. Providers may mistrust the patient’s report of pain and withhold treatment for OUD for nonclinical reasons.⁵ Here, we examine two ethical dilemmas specific to OUD in hospitalized patients. Our aim in describing these dilemmas is to help hospitalists recognize that targeting issues of mistrust may assist them to deliver better care to hospitalized patients with OUD.

In the inpatient setting, ethical dilemmas surrounding discharge are common among people who inject drugs (PWID). These patients have disproportionately high rates of soft tissue and systemic infections, such as endocarditis and osteomyelitis, and subsequently often require long-term, outpatient parenteral antibiotic therapy (OPAT).⁶ From both the clinical and ethical perspectives, discharging PWID requiring OPAT to an unsupervised setting or continuing inpatient hospitalization to prevent a potential adverse event are equally imperfect solutions.

These patients may be clinically stable, suitable for discharge, and prefer to be discharged, but the practitioner’s concerns regarding untoward complications frequently override the patient’s wishes. Valid reasons for this exercise of what could be considered soft-paternalism are considered when physicians unilaterally decide what is best for patients, including refusal of community agencies to provide OPAT to PWID, inadequate social support and/or health literacy to administer the therapy, or varying degrees of homelessness that can affect timely follow-up. However, surveys of both hospitalists and infectious disease specialists also indicate that they may avoid discharge because of concerns the PWID will tamper with the intravenous (IV) catheter to inject drugs.⁷ This reluctance to discharge otherwise socially and medically suitable patients increases length of stay,⁷ decreases patient satisfaction, and could lead to misuse of limited hospital resources.

Both patient mistrust and stigmatization may contribute to this dilemma. Healthcare professionals have been shown to share and reflect a long-standing bias in their attitudes toward patients with substance-use disorders and OUD, in particular.⁸ Studies of providers’ attitudes are limited but suggest that legal concerns over liability and professional sanctions,⁹ reluctance to contribute to the development or relapse of addiction,¹⁰ and a strong psychological investment in not being deceived by the patient¹¹ may influence physicians’ decisions about care.

Closely supervising IV antibiotic therapy for all PWID may not reflect current medical knowledge and may imply a moral assessment of patients’ culpability and lack of will power to resist using drugs.¹² No evidence is available to suggest that inpatient parenteral antibiotic treatment offers superior adherence, and emerging evidence showing that carefully selected patients with an injection drug-use history can be safely and effectively treated as outpatients has been obtained.^13,14 Ho et al. found high rates of treatment success in patients with adequate housing, a reliable guardian, and willingness to comply with appropriate IV catheter use.¹³ Although the study by Buehrle et al. found higher rates of OPAT failure among PWIDs, 25% of these failures were due to adverse drug reactions and only 2% were due to documented line manipulations.¹⁴ This research suggests that disposition to alternative settings for OPAT in PWID may be feasible, reasonable, and deserving of further study. Rather than treating PWIDs as a homogenous group of increased risk, contextualizing care based on individual risk stratification promotes more patient-centered care that is medically appropriate and potentially more cost efficient. A thorough risk assessment includes medical evaluation of remote versus recent drug use, other psychiatric comorbidities, and a current willingness to avoid drug use and initiate treatment for it.

Patient-centered approaches that respond to the individual needs of patients have altered the care delivery model in order to improve health services outcomes. In developing an alternative care model to inpatient treatment in PWID who required OPAT, Jafari et al.¹⁵ evaluated a community model of care that provided a home-like residence as an alternative to hospitalization where patients could receive OPAT in a medically and socially supportive environment. This environment, which included RN and mental health staff for substance-use counseling, wound care, medication management, and IV therapy, demonstrated lower rates of against medical advice (AMA) discharge and higher patient satisfaction compared with hospitalization.¹⁵