Substance use in hospitals can be controlled

Treating withdrawal and pain will make a difference, says Dr. Leslie Lappalainen.

Last week the Ministry of Health announced that it is striking a task force to address substance use occurring in hospitals across B.C., prompted by reports from nurses at multiple health authorities who are being exposed to substance use during their shifts. Without question, staff and patients should have the right to a safe environment while in hospital, which includes not being exposed to second-hand smoke from substances.

As an addictions medicine physician at Kelowna General Hospital, I commend Health Minister Adrian Dix for assembling a task force to address this issue. One suggested intervention was that hospitals should have designated spaces for individuals with substance use disorders to use unregulated substances during their hospital stay.

Having these consumption spaces across all hospitals in the province, as initially proposed, is likely neither feasible, nor an effective use of resources. However, this type of service is long overdue and necessary in many larger hospitals across the province, where a larger cohort of admitted patients would likely access this service if it were available. These spaces will prevent exposure to staff, while also safeguarding people who use drugs after they are admitted to hospital. If an overdose event were to occur in these spaces, there is a prompt response, rather than these events occurring in a locked bathroom or in other covert corners of a hospital.

While designated-use spaces are important, we can substantially decrease the need for such spaces through aggressive treatment of withdrawal and pain for individuals with opioid use disorders while they are in hospital. We are currently missing the mark on this. Despite the fact that drug toxicity is the leading cause of death for people aged 10 to 59 in B.C. — arguably the most pressing public health crisis at present — addiction medicine continues to be under-instructed in medical training.

Addiction medicine continues to be under-instructed.

Since the drug toxicity public health emergency was declared eight years ago, more than 14,000 people have died from toxic drugs in B.C. Substantial efforts have been made to improve access to life-saving opioid agonist treatment in outpatient settings by increasing access to training to prescribe these medications for both physicians and nurses. However, there are major educational gaps on best practices for in-hospital management of substance use disorders. Most nurses and physicians receive little training during nursing school, medical school and residency on how to treat pain, withdrawal and cravings for patients with opioid use disorder who are admitted to hospital.

Typically, the treatment is to initiate opioid agonist treatment, and when this is not sufficient, to provide short-acting opioid medications in doses an order of magnitude larger than what is typically given to patients who are given opioids for acute pain. There is an understandable reluctance to provide these short-acting medications. The fundamental approach to management of opioid use disorder is in contrast to how we approach treating pain, where we have taught health-care providers to be stewards of opioid medications and to use them sparingly in order to prevent dependence. My patients often tell me they struggle to ask for these medications, even when they are ordered, as they are fearful of being labelled as “drug-seeking.” As a result of under-treatment in hospital, patients often self-manage their own withdrawal or pain by using in hospital.

Appropriate education for nurses and doctors on management of cravings, withdrawal and pain for patients admitted to hospital is paramount to preventing patients from self-initiated discharge — such as leaving a hospital against medical advice — and unregulated substance use from occurring in the hospital. While designated spaces for substance use, security, and alignment of policies across the health authorities is important, education on management of substance use disorders to prevent unregulated use needs to be the cornerstone of the approach of the provincial task force.