Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care

Abstract

In the United Kingdom, increases in premature mortality among the intersecting populations of people made homeless and people who inject drugs map onto the implementation and solidification of fiscal austerity policies over the past decade, rather than drug market fluctuations and trends as in North America. In this context, it is crucial to explore how poverty, multi-morbidity and care delay interplay in exacerbating vulnerability to mortality among an aging population of people who use illicit drugs. The mixed methods Care & Prevent study generated survey data with 455 PWID and in-depth qualitative interviews with a subsample (n = 36). Participants were recruited though drug treatment services and homeless hostels in London from October 2017–June 2019. This paper focuses on qualitative findings, analysed thematically and contextualised in relation to the broader survey sample. Survey participants report an extensive history of rough sleeping (78%); injecting-related bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts emphasise engagement with the medical system as a ‘last resort’, with admission to hospital in a critical or a “near death” condition common. For many severe physical pain and debility were normalised, incorporated into the day to day. In a context of everyday violence and marginalisation, avoidance of medical care can have a protective impetus. Translation of cultural safety principles to care for people who inject drugs in hospital settings offers transformative potential to reduce serious health harms among this population.

Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK

“…It is well evidenced that PWID face significant barriers in accessing appropriate healthcare due to stigma and discrimination from healthcare professionals as well as structural difficulties in accessing and attending medical appointments [ 29 – 31 ]. Qualitative participant data, reported elsewhere [ 22 ] illustrate that delays in seeking medical care are informed by a complex interplay of social structural issues, including limited time due to money generation demands; limited hope and expectation of adequate care; fear of opiate withdrawal in the hospital system; and normalised pain in a context of pervasive everyday violence. We emphasise therefore, the resilience demonstrated when seeking care in constrained circumstances and the need for structural, rather than purely educational, interventions in capacitating change [ 22 ].…”

“…Qualitative interviews provided specificity regarding time taken to seek care and the contexts which acted to facilitate or delay engagement with medical services. These findings are published separately [22].…”

“…Qualitative participant data, reported elsewhere [22] illustrate that delays in seeking medical care are informed by a complex interplay of social structural issues, including limited time due to money generation demands; limited hope and expectation of adequate care; fear of opiate withdrawal in the hospital system; and normalised pain in a context of pervasive everyday violence. We emphasise therefore, the resilience demonstrated when seeking care in constrained circumstances and the need for structural, rather than purely educational, interventions in capacitating change [22]. Nearly half (46%) of participants with an SSTI reported undertaking self-care as the first response to their worst infection.…”

Towards health equity for people experiencing chronic pain and social marginalization

“…Because cultural safety requires addressing racism, the pernicious stereotypes directed toward Indigenous people that deter health care access and quality (57-60) would be explicitly addressed in relation to chronic pain. Cultural safety is also a framework adapted to LGBTQ2S health (61) as well as to people who use drugs (62)(63)(64), among others.…”

Towards Health Equity for People Experiencing Chronic Pain and Social Marginalization

“…Because cultural safety requires addressing racism, the pernicious stereotypes directed toward Indigenous people that deter health care access and quality (43)(44)(45)(46) would be explicitly addressed in relation to chronic pain. Cultural safety is also a framework adapted to LGBTQ2S health (47) as well as to people who use drugs (48)(49)(50), among others.…”