Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis

Abstract

Background Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. Methods Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. Results We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients’ own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients’ own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. Conclusions Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.

Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness

“…The dosing strategy informed by the BCCSU guidelines were appropriate for most patients in this setting (Halifax, Nova Scotia) where the illicit drug supply is comprised primarily of pharmaceutical hydromorphone and cocaine, with relatively little fentanyl and methamphetamine availability in the community compared to elsewhere in Canada ( Brothers et al, 2021 , Brothers et al, 2022 , Lapointe-Gagner, 2022 , Schleihauf et al, 2018 ). Compared to Nova Scotia, British Columbia has much higher rates of illicitly manufactured fentanyl, fentanyl analogues, novel benzodiazepines, and methamphetamine availability and use ( Biggar et al, 2021 ).…”

“…Compared to Nova Scotia, British Columbia has much higher rates of illicitly manufactured fentanyl, fentanyl analogues, novel benzodiazepines, and methamphetamine availability and use ( Biggar et al, 2021 ). People who use drugs in Nova Scotia most often use hydromorphone tablets (immediate release or extended release) and cocaine, though rates of illicitly manufactured fentanyl use are increasing ( Brothers et al, 2022 , Brothers et al, 2021 , Brothers et al, 2022 , 2022 ). Largely due to these regional differences in the illicit drug supply, British Columbia experienced a rate of opioid poisoning deaths (39.4 per 100,000 people) eight times higher than Nova Scotia (4.9 per 100,000) from January to June, 2021 ( Special Advisory Committee on the Epidemic of Opioid Overdoses 2022 ).…”

Opioid agonist treatment and risk of death or rehospitalization following injection drug use–associated bacterial and fungal infections: A cohort study in New South Wales, Australia

“…Despite these possible benefits, in many acute care hospitals, OAT is not prioritized as part of treatment planning during and after hospitalization with injecting-related bacterial and fungal infections [ 22 , 29 – 31 ]. This is represented in low rates of OAT prescribing for these patients in multiple studies from North America [ 29 , 31 , 32 ] and in qualitative studies from the UK [ 22 ]. Suboptimal access to OAT may reflect system-level issues that separate addiction care from specialized, acute medical care for infections [ 1 , 22 , 29 , 30 ].…”

“…This is represented in low rates of OAT prescribing for these patients in multiple studies from North America [ 29 , 31 , 32 ] and in qualitative studies from the UK [ 22 ]. Suboptimal access to OAT may reflect system-level issues that separate addiction care from specialized, acute medical care for infections [ 1 , 22 , 29 , 30 ]. In some hospitals, clinicians have tried to overcome this by establishing specialized addiction medicine consultation services [ 33 – 36 ] or by infectious diseases specialists prescribing OAT directly [ 29 , 37 ].…”

“…Suboptimal access to OAT may reflect system-level issues that separate addiction care from specialized, acute medical care for infections [ 1 , 22 , 29 , 30 ]. In some hospitals, clinicians have tried to overcome this by establishing specialized addiction medicine consultation services [ 33 – 36 ] or by infectious diseases specialists prescribing OAT directly [ 29 , 37 ]. While OAT is known to be beneficial for other injecting-related health outcomes, there has been relatively little research on OAT and risk for injecting-related infections.…”