Finding a better way to handle inpatient substance use

Hospitals' policies on substance use by their patients are often a mystery even to the staff most knowledgeable on the subject, according to a recent study.

Researchers at Yale University in New Haven, Conn., surveyed 77 clinicians affiliated with addiction medicine fellowships about their institutions' current practices and policies regarding inpatient substance use, as well as what they thought an ideal policy would include. Of the 55 hospitals represented, 21.8% had a policy that the surveyed clinicians were aware of and 49.1% did not have a policy that clinicians were aware of. At the remaining 29.1%, clinicians weren't sure whether a policy existed.

Current practices also differed from respondents' ideal policies, the study found. Typical practices included involvement of hospital security or police, patient-directed discharge, room searches, and visitor restrictions, while addiction experts would prefer to emphasize access to harm reduction services and substance use disorder treatment.

The study was published in the September Journal of Hospital Medicine. Lead author and ACP Member Zina Huxley-Reicher, MD, formerly a member of Yale's Primary Care Residency Program and now an addiction medicine fellow at Montefiore Medical Center in New York, recently spoke to ACP Hospitalist about the findings.

Q: What led you and your coauthors to do this study?

A: A few of us had had the experience of caring for patients in the hospital and not seeing any clear, consistent policy, having lots of different folks on the care team not knowing how to respond when they were concerned for inpatient substance use, and that having a detrimental impact on a lot of our patients. When I was a resident, I remember reaching out to one of my attendings and asking, “Do we have a policy?” They kind of went up the chain of command with the feeling of “Oh, we don't know if we have a policy or not.”

Then, when we actually saw our policy, we recognized its limitations. It felt discordant with what we thought was the most patient-centered way to respond to these situations. This drove us to think about what was going on in other places and to try to understand a little bit more about the context of hospital policies across the country.

Q: Did anything about your findings surprise you?

A: I guess I shouldn't have been surprised by the finding that not many of the folks in our study knew whether they had a policy on this, given that those of us at our institution also didn't really know what our policy was. My guess is that most institutions do have a policy, but where does that policy live? Where is it coming from? It's not in the hands of the folks who are caring for patients on the day to day in most cases. It really drove home that this is not something that's being developed with either the patients or clinicians in mind, in most cases.

Q: What is the basis for policy development?

A: When these policies exist, they're mostly living in more of that legal space rather than in the clinical space. There's room to work with institutions to include patients and include clinicians and other care team members in creating better policies. … In doing this research, we spoke with a few folks at other institutions who had recently redone their policies and focused much more on questions like “What do you actually do when you're having this concern? How do we do this safely for patients? How do we keep patients in mind?”

Q: Would an ideal policy have some kind of decision tree or triaging guidelines for clinicians?

A: We did speak with a few different institutions that recently recreated or made new policies that felt more in line with what clinicians that we surveyed were asking for. A lot of those policies include that kind of decision tree, having different moments of escalation—for example, at what point does hospital security need to be involved?—and really setting expectations [about substance use] from hour zero of the hospitalization with patients so that it's not a surprise, making clear to clinicians what to do if they are worried about inpatient substance use, and also trying to understand what is driving that substance use. Can we as a care team address that, whether it's pain or withdrawal or another issue? Having that decision tree built into a policy supports not just hospitalists but also nursing staff. Nursing staff end up dealing with these issues a lot, and so these policies should consider how to support them in those moments where they're having to make these decisions quickly.

Q: Would you expect involvement of law enforcement or patient discharge to be more common in institutions that don't have a protocol?

A: Yes, and in places where there is a protocol and people don't know about it, as well as in spaces where there might not be an addiction medicine team to help think through some of these questions and providers may just feel very uncomfortable with how to care for folks. My guess is that at those institutions you may see more involvement of hospital security and law enforcement in those moments where both providers and nursing staff may feel less comfortable.

Q: Could protocols for inpatient substance use be built into electronic health records?

A: We certainly have lots of protocols within Epic at my institution that lay out a lot of those pathways and give you links to specific referrals or orders to put in depending on where you are, kind of a tiered pathway. It could be really great to use something like that to help clinicians and other folks think through what those tiered steps are [in case of potential substance use]. … Maybe you start with a referral to addiction medicine if your hospital has that, and directly addressing some underlying concerns that may be driving the substance use, whether that's withdrawal or pain. If there's concern that the substance use is continuing, then you can think about things like a behavioral agreement, and you can move through those tiered responses. If you really address why someone is using substances while they're hospitalized, if they're able to be comfortable and have their pain addressed, then we get better outcomes across the board.

Q: How can institutions ensure that inpatient substance use is handled equitably?

A: As institutions are thinking about developing and changing protocols, it's important that this piece be directly baked in. One institution we spoke with that had recently redone their protocols included as a requirement that conversations about substance use happen with everyone at baseline, that every inpatient receive the same information and get the same materials at admission. That's certainly one way to make sure this is done equitably and we're not specifically targeting certain folks because we think they're more likely to have issues with inpatient substance use. That's probably the place to start. And then, again, having those conversations openly and sooner in a hospitalization before the problem happens is probably the best way to think about how to keep things equitable, and also probably to just make relationships between care teams and patients better.

Q: Should hospitalists get involved in developing these policies, and if so, how would they go about it?

A: It's definitely something that folks can talk to their institutions about and start thinking about. For us, in terms of our research team, our next step is to gather groups of people who are representative of a care team as well as patients and use a Delphi method to come up with a consensus-based, best practice recommendation of what policies like this could include. I do think opening up these conversations at your own institution is reasonable, and just making sure that you're involving the various actors at the table to think about those policies is really important, including patients and their experiences.

Q: What are the most important take-home messages from your research?

A: Think about how your institution thinks about this specific issue and how folks respond and whether there is an avenue to open that conversation up. Clearly, there's a lot of room for improving what happens. Also, really center the patient in how you think about addressing inpatient substance use and what is driving it. It's your responsibility as the care team, as a clinician, to really address that and try to help patients, to the best of our ability, stay in the hospital. We need to be there, be present for their treatment, and help them have the best outcomes possible. The third big takeaway is just that we have a lot of room for more infrastructure development across institutions and hospitals to provide services to folks with substance use disorders as well as those who are using substances in the hospital for whatever reason. We can really build those infrastructures to allow for patient-centered responses to these moments and provide excellent treatment and care.