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Hospitals as a 'risk environment' : An ethno-epidemiological study of voluntary and involuntary discharge… McNeil, Ryan, 1982-; Small, Will; Wood, Evan; Kerr, Thomas Mar 1, 2014

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Hospitals as a `risk environment: An ethno-epidemiologicalstudy of voluntary and involuntary discharge from hospitalagainst medical advice among people who inject drugsRyan McNeil1, Will Small1,2, Evan Wood1,3, and Thomas Kerr1,31British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 BurrardStreet, Vancouver, BC, Canada, V6Z 1Y62Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada3Department of Medicine, University of British Columbia, Vancouver, BC, CanadaAbstractPeople who inject drugs (PWID) experience high levels of HIV/AIDS and hepatitis C (HCV)infection that, together with injection-related complications such as non-fatal overdose andinjection-related infections, lead to frequent hospitalizations. However, injection drug-usingpopulations are among those most likely to be discharged from hospital against medical advice,which significantly increases their likelihood of hospital readmission, longer overall hospital stays,and death. In spite of this, little research has been undertaken examining how social-structuralforces operating within hospital settings shape the experiences of PWID in receiving care inhospitals and contribute to discharges against medical advice. This ethno-epidemiological studywas undertaken in Vancouver, Canada to explore how the social-structural dynamics withinhospitals function to produce discharges against medical advice among PWID. In-depth interviewswere conducted with thirty PWID recruited from among participants in ongoing observationalcohort studies of people who inject drugs who reported that they had been discharged fromhospital against medical advice within the previous two years. Data were analyzed thematically,and by drawing on the `Risk Environment' framework and concepts of social violence. Ourfindings illustrate how intersecting social and structural factors led to inadequate pain andwithdrawal management, which led to continued drug use in hospital settings. In turn, diverseforms of social control operating to regulate and prevent drug use in hospital settings amplifieddrug-related risks and increased the likelihood of discharge against medical advice. Given thesignificant morbidity and health care costs associated with discharge against medical adviceamong drug-using populations, there is an urgent need to reshape the social-structural contexts ofhospital care for PWID by shifting emphasis toward evidence-based pain and drug treatmentaugmented by harm reduction supports, including supervised drug consumption services.© 2014 Elsevier Ltd. All rights reservedCorresponding Author: Thomas Kerr, PhD British Columbia Centre for Excellence in HIV/AIDS 608- 1081 Burrard StreetVancouver, BC V6Z 1Y6's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptSoc Sci Med. Author manuscript; available in PMC 2015 March 01.Published in final edited form as:Soc Sci Med. 2014 March ; 105: 59–66. doi:10.1016/j.socscimed.2014.01.010.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptINTRODUCTIONCurrent estimates suggest that more than 15 million people worldwide regularly inject drugs(Mathers et al., 2008). The health sequelae of injection drug use can be severe, and includeinfectious disease acquisition and other direct complications of injecting (e.g., overdose). Asa consequence, people who inject drugs (PWID) suffer from disproportionately high levelsof HIV/AIDS (Mathers et al., 2008) and hepatitis C (HCV) infection (Aceijas & Rhodes,2007) that, together with high rates of non-fatal overdose (Warner-Smith et al., 2002),injection-related soft tissue infections (Cooper et al., 2007; Lloyd-Smith et al., 2008), andother co-morbidities common among this population, lead to frequent hospitalizations (Geboet al., 2003; Kerr et al., 2005; Palepu et al., 2001). As a result, PWID are admitted tohospital significantly more often than the general age-adjusted population (Kerr et al., 2005).There is also clear evidence that PWID are one of the populations most likely to bedischarged from hospital against medical advice (Anis et al., 2002; Choi et al., 2011;Jeremiah et al., 1995; Yong et al., 2013). For our purposes, discharges against medicaladvice are understood to be inclusive of discharges occurring among patients who have lefthospital prior to completing treatment (whether they have notified hospital staff they areleaving or not), as well as those who have been involuntarily discharged prior to completingtreatment (e.g., discharge for breach of hospital policies). Discharges from hospital againstmedical advice among PWID can exacerbate health complications, and this population issignificantly more likely to be readmitted for the same condition and have longer eventualhospital stays than those who have completed treatment (Anis et al., 2002; Choi et al., 2011;Glasgow et al., 2010; Hwang et al., 2003). Furthermore, those discharged against medicaladvice are at an increased risk of mortality (Choi et al., 2011; Yong et al., 2013), with oneCanadian study finding that this population is approximately three times as likely to die inthe year following their initial discharge (Choi et al., 2011).Whereas epidemiological analyses of hospital admissions and discharge data have identifiedcrude demographic risk factors for departures against medical advice among PWID,including female gender, younger age, and Aboriginal ancestry (Anis et al., 2002; Chan etal., 2004), comparatively less attention has been paid to contextual forces underlying thisphenomenon. Several studies have noted that these departures are most likely to occur in thedays immediately surrounding the disbursement of social assistance payments (Anis et al.,2002; Riddell & Riddell, 2006), and that these may be mitigated to some degree byproviding access to inpatient methadone maintenance treatment (Chan et al., 2004).However, the lack of attention to the potential role of intersecting social, structural, andenvironmental forces operating within hospitals in shaping discharges against medicaladvice among PWID means that these explanations are incomplete. In addition, theseindividual-level explanations primarily attribute discharges against medical advice to `activedrug use' in a manner that risks locating responsibility for these outcomes solely with PWID.This overlooks social and structural-environmental characteristics of hospitals thatpotentially lead to discharges against medical advice, and creates a missed opportunity tomodify these environmental characteristics to promote better retention of PWID in care.This research gap is particularly striking given more than a decade of evidencedemonstrating the need for increased attention to `risk environments' - that is, social andphysical settings in which factors exogenous to the individual (i.e., social situations,structures, and places) interact to produce or reduce drug-related harms (Rhodes et al., 2005;Rhodes, 2009). The emergence of the `risk environment framework' has focused attention onhow the interplay between physical, social, economic, and policy factors operating acrossthe micro-, meso-, and macro-environmental levels produce harm among PWID (Rhodes,2002; Rhodes, 2009). Concepts of structural vulnerability and everyday violence haveMcNeil et al. Page 2Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptfurther proven instructive in framing the suffering experienced by drug-using populations(Fairbairn et al., 2008; Shannon et al., 2008). Structural vulnerability refers to how socialarrangements embedded in the organization of society render particular populationsdisproportionately vulnerable to harm (Quesada et al., 2011). Everyday violence refers to thenormalization of suffering within any particular context due to the contextual forces thatrender it invisible (Scheper-Hughes, 1992). Together, these concepts give focus to how thestructural context of drug use (e.g., drug criminalization) produces vulnerability to an arrayof drug- and health-related harms, and reflect dominant power structures that normalizethese harms as the natural consequences of drug use. Sorting out the complex contextualforces operating within the risk environments of people who use drugs is critical tounderstanding their role in shaping health outcomes - in this case, discharges againstmedical advice - and informing social-ecological interventions.While qualitative research into the experiences of injection drug-using populations inhospital settings is limited, and has yet to systematically explore the experiences of thosedischarged against medical advice, it has generated preliminary insights into the socialforces operating within the hospital `risk environment' (Berg et al., 2009; Merrill et al.,2002; Neale et al., 2008). In an ethnographic study exploring patient-physician interactionsin an American urban teaching hospital, Merrill and colleagues (2002) outlined how `mutualmistrust' frames the hospital care of PWID. Whereas physicians attributed their difficulty inmanaging pain to the fear of being `deceived' by `drug-seeking' patients and the lack ofclinical protocols for pain management among injection drug-using populations, PWIDviewed physicians with suspicion and believed that their treatment was primarily shaped bydiscrimination (Merrill et al., 2002). Whether or not this, together with other contextualfactors, plays a role in discharges from hospital against medical advice warrants furtherattention.These issues are of considerable relevance in Vancouver, Canada, the site of a longstandinginjection drug use epidemic and home to an estimated 15,000 PWID (McInnes et al., 2009).The majority of the city's injection drug-using population will visit an emergencydepartment each year (Kerr et al., 2005), with approximately 17% of these visits resulting inhospitalization (Fairbairn et al., 2011; Palepu et al., 2001). In Vancouver, PWID are coveredby universal, publicly-funded health care insurance. However, while comprehensive harmreduction services, including a supervised injection facility, are integrated into the localpublic health system and local hospitals struggle with the optimal management ofhospitalized PWID, hospitals generally operate under abstinence-based drug use policies(Providence Health Care, N.D; Vancouver Coastal Health, 2008). While abstinence-basedpolicies in part reflect anti-drug laws, they are also framed as necessary in promoting patientand staff safety. In addition, prescribing principles promoted by the British ColumbiaCollege of Physicians and Surgeons regarding prescription opioids have been primarilydeveloped for non-drug-using populations, and warn against prescribing opioids to `high-risk' populations (British Columbia College of Physicians and Surgeons, 2012). Pastresearch has shown that PWID in this setting are frequently discharged from hospital againstmedical advice (Anis et al., 2002; Choi et al., 2011; Palepu et al., 2001), and in one urbanteaching hospital account for more than half of such discharges (Choi et al., 2011).We undertook this ethno-epidemiological study to explore how intersecting social,structural, and environmental forces shape the experiences of PWID in hospitals settings andcontribute to discharges against medical advice. We were particularly concerned with therole of abstinence-based drug policies in hospital settings in framing the social andstructural-environmental contexts of hospital care, pain management practices, and in-hospital drug use. Finally, we aimed to identify ways in which the hospital `riskMcNeil et al. Page 3Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptenvironment' could be modified to minimize the potential for adverse outcomes, includingdischarges against medical advice.METHODSThis ethno-epidemiological study was undertaken in connection with two ongoingprospective cohort studies: the Vancouver Injection Drug Users Study (VIDUS) and theAIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS). These cohortstudies include more than 2000 current and former drug users, and their methods have beendescribed in detail elsewhere (Strathdee et al., 1997; Wood et al., 2003). Ethno-epidemiology seeks to uncover how social meanings and contexts influence patterns of drugand health harms by merging epidemiological and qualitative methods (Lopez et al., 2013;Wagner et al., 2012). Increased understanding of the contextual forces that shape patternsand distributions of harm is critical to informing the development of structural andenvironmental interventions to minimize harms (Rhodes et al., 2006). Between December2011 and February 2013, we undertook qualitative interviews with thirty cohort participantswho reported that they had recently been discharged from hospital against medical adviceduring follow-up surveys that are part of their participation in the aforementioned cohortstudies. All study activities were approved by the Providence Healthcare/University ofBritish Columbia Research Ethics Board.Participant recruitmentCohort participants were eligible for participating in this study if, during routine follow-upsurveys completed in the past two years, they answered “yes” to the following question: “Inthe past six months, did you leave hospital before your treatment was complete?” We chosethis follow-up period to ensure an adequate pool of potential participants, while minimizingbiases due to poor recall of events. We used recruitment quotas to ensure that women andpeople of Aboriginal ancestry were adequately represented in our sample. Eligibleparticipants were identified through database queries of cohort data and contacted by studypersonnel, who described this study and invited them to participate in an interview. Studypersonnel also recruited those who reported that they had been discharged against medicaladvice during follow-up surveys administered over the course of our study.Data CollectionInterviews were conducted by the lead author (RM) at the cohort study office. Prior to theinterview, the lead author explained the study to participants, answered questions, andobtained written informed consent. There were no refusals to participate and no dropouts.Participants each received a $20 CAD honorarium upon completion of the interview.Interviews were facilitated through the use of an interview topic guide adapted fromprevious qualitative work on health care access among PWID (Krusi et al., 2009; Small etal., 2008), and revised to include questions specific to our study objectives. This interviewtopic guide aimed to facilitate discussion regarding how contextual forces shape experiencesin hospitals and lead to discharges against medical advice. Interviews were audio recordedand averaged approximately 45 minutes in length. Interviews were transcribed verbatim andreviewed for accuracy by the lead author.Data AnalysisData collection and analysis took place concurrently, and emerging themes informed lines ofinquiry during subsequent interviews. We imported interview transcripts into NVivo(version 9) to facilitate data management and coding. Transcripts were coded thematicallyusing an inductive and iterative process (Corbin & Strauss, 2008), and regular meetingswere held to discuss emerging themes. Once the final themes were established, the leadMcNeil et al. Page 4Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptauthor re-coded sections of the transcripts to enhance the reliability and validity of thesecategories. To advance beyond thematic description, we then drew upon the riskenvironment framework and concepts of structural vulnerability and everyday violence tointerpret our themes.Sample CharacteristicsThirty individuals participated in in-depth interviews, including sixteen men, thirteenwomen, and one transwoman. Participants were an average of 45 years of age (range 29–59years). Seventeen participants reported Aboriginal ancestry, while the remaining participantsself-identified as Caucasian (n=12) and African Canadian (n=1). Half of our participantswere living with HIV, while twenty-two had been diagnosed with HCV. Five participantsliving with HIV reported suboptimal adherence to highly-active antiretroviral therapy(HAART) prior to hospitalization, while another five reported that they were not takingHAART. Prior to their most recent hospitalization, participants reported that they lived insingle room occupancy hotels (n=17), non-market housing (n=5), emergency shelters (n=3),or were unhoused (n=5). All participants had a history of injection drug use, and twenty-twocurrently injected drugs. All participants had used drugs in the thirty days prior to their mostrecent hospitalization, with crack cocaine (n=22), heroin (n=18), powdered cocaine (n=12),and prescription opioids (n=7) identified as the most commonly used drugs. The mostcommonly reported reasons for hospitalization were injection-related infections (n=8),pneumonia (n=5), and traumatic injury (n=4). Nearly all participants (n=28) reportedmultiple hospitalizations within the past five years, with half reporting four or morehospitalizations.RESULTS“They felt maybe I was getting high” – `Drug-seeking' and pain managementOur analysis of participant accounts underscored the role of social and structural forces inshaping pain management practices and producing suffering that framed experiences inhospital settings. All participants reported co-morbidities that, together with their presentingillness or injury, resulted in complex pain management needs. The vast majority of ourparticipants (n=25) had histories of opiate dependency, and those who were injecting heroinor prescription opioids at the time of their hospitalization indicated that their painmanagement needs were compounded by `dopesickness'—that is, the extreme discomfortand pain accompanying opiate withdrawal. Participants described their level of pain as“excruciating” and “like being stuck with electric volts”, with those experiencingdopesickness adding that they felt “nauseous” and like they were “coming unglued”. Thefollowing excerpts highlight experiences of pain and opiate withdrawal, respectively, typicalamong our participants:It was really, really bad at the beginning…I got shots of pain that were so severeactually cried… I had to cry out more once or twice within two or three hours. Itwas really, really excruciating. Every fifteen minutes or so, like, the pain was justunbelievable. [Participant #29, African-Canadian Male, 53 years old]I was constantly tired, no energy. Nauseous all the time, vomiting, couldn't eat, and[had] the runs. My eyes were leaking all the time. My nose was leaking. To me,that was all withdrawal symptoms. [Participant #13, Caucasian Female, 44 yearsold]With very few exceptions, however, participants reported that their pain management needswere unmet. Participant accounts underscored how narcotics control (macro-structural force)intersected with stereotypes of `drug-seeking addicts' (macro-social force) to frame painMcNeil et al. Page 5Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptmanagement practices in hospitals. Whereas these intersecting social-structural forces aresituated within larger cultural discourses characterizing drug use as `immoral',`irresponsible', and `pleasure-seeking', participants positioned their `dopesickness' as alegitimate medical concern and emphasized how opiate maintenance was necessary to “getbetter” or “get straight”. Furthermore, even among those experiencing opiate withdrawal,most participants viewed narcotics as necessary to alleviate the pain caused by their primarydiagnoses (e.g., osteomyelitis, broken ribs).Our findings underscore how the perception that participants were `drug-seeking' wascritical in shaping the social-environmental context of hospital care, and likely delegitimizedthe very real pain and suffering that they endured. Nearly all participants spoke of how theywere routinely denied pain medication or given dosages that did not account for heightenedtolerance. Some participants spoke of how physicians and nurses dismissed their concernsand characterized them, in the words of one participant, as “just another junkie addictlooking for free drugs”. Many participants of Aboriginal ancestry further expressed thatinstitutionalized racism reinforce the view among hospital staff that they were `drug-seeking'. This approach to pain management was experienced as a form of everydayviolence, in that the pain and suffering experienced by participants was normalized as anatural part of their care that was reproduced through the routine denial of pain medication.For example:I was in pain and I didn't want to bitch about being in pain‖The last time I went inthere and I told them, “Excuse me, I'm very sore and it's taking forever. Could Iplease see somebody or get something?” And, they said, “We can't give youanything until you see a doctor.” […] Because I was there often with this problem[abscess in leg], they thought I was looking for pain pills. [Participant #11,Aboriginal Female, 51 years old].They [nurses] were very combative with me. When I was done my surgery, it wasvery painful and I needed my morphine upped because it just wasn't working…Ican only guess and say that maybe they felt maybe I was getting high or something.I kept trying to tell them that it's not enough…I had major surgery on my colon. Icouldn't even move…The nurses wouldn't listen to me they're. I felt they didn'tbelieve me and they were a little combative in speaking with me. [Participant #20,Aboriginal Male, 45 years old]Furthermore, the minority of participants (n=6) who were administered methadone inhospital reported disruptions in their regular dosing schedules and amounts. While theseparticipants acknowledged that hospital staff lacked experience in methadone maintenancetreatment, they also expressed that methadone withdrawal was a low priority among nursesand physicians.I have to have methadone every day. I'm on fifty milligrams and, if I don't have it,I'm in bad shape. I kept asking them, “I take it at five thirty every morning and Iwant it.” […] Well, they did it whenever they felt like it. They don't understand thatmethadone is keeping me functional. […] I wanted to get the heck out of there.[Participant #24, Caucasian Female, 55 years old]“Between a rock and a hard spot” – The need to manage pain and withdrawalMost participants expressed that heroin and prescription opioid injection were the onlyavenues available to them to address pain and withdrawal. While several participantsattributed their continued drug use to the craving associated with cocaine use, the vastmajority indicated that drug use during their hospitalization was primarily motivated by theneed to manage pain and opiate withdrawal. Whereas some participants expressed that itMcNeil et al. Page 6Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptwas not “normal” to inject heroin or prescription opioids while hospitalized, in that itcontradicted the `curative' nature of hospital care, they nonetheless emphasized theanticipated relief from pain and opiate withdrawal. In some cases, participants articulatedhow pain and withdrawal symptoms directly interfered with treatment, and that only afteraddressing these immediate needs would they be `strong' enough to recover. As oneparticipant explained:I had to get out of there while I could move because I was losing so much weight…When I begged and begged to get some help [i.e., prescription opioids], theycouldn't, weren't gonna do anything and so I just said, “Fine, I'm leaving.” […] Iwas concerned [about the health consequences of leaving hospital]. You know, Igot this other thing [opiate dependency] and it's…it's like you're stuck between arock and a hard spot. I mean, how can I even fight off the infection if I can't stoppuking and shitting? [Participant #15, Caucasian Female, 47 years old]At its most extreme, one participant articulated how his transition to heroin injection was theconsequence of inadequate pain management in hospital settings, and represented this as theonly means to address the extreme pain associated with osteomyelitis (i.e., an infection ofthe bone or bone marrow).I started using heroin when I had that osteomyelitis. I was in so much pain andmorphine wasn't cutting it… [The reason why] I started using the heroin actuallywas to kill the pain. […] The pain and the osteomyelitis…it was so crippling I felt,like, so stiff… If they [hospital staff] had given me the right dose, I probablywouldn't even be using heroin… [The morphine] wasn't enough and they weren'tgiving it into my I.V. They were shooting it into my muscle and that wasn't killingmy pain…The heroin I was using, I'd do right into my bloodstream and it wouldkill the pain. [Participant #5, Aboriginal Male, 44 years old]“Like I was in jail” – Surveillance, regulation, and in-hospital drug useWhereas the social-structural context of pain management practices in hospitals perpetuatedthe need to inject drugs, participant accounts underscored how larger structural-environmental context of hospital settings was shaped by the enforcement of abstinence-only drug policies (macro-structural environmental factor). Participants characterizedhospitals as “jails” or “prisons”, and viewed hospital staff as playing the role of “cop” inenforcing abstinence-only drug policies. Nearly all participants described how some nursesand security guards subjected them to surveillance and regulation by “policing” their druguse. Many participants reported that some nurses closely monitored their behavior foroutward signs that they were injecting drugs in hospital. Other participants reported that theywere subjected to physical searches by security guards when suspected of possessing drugs.As one participant explained:[Security guards] yell and scream at you…When there's nobody around, [they say],“You fucking junkie.” […] A few times, I've been shaken down [searched] by[security guards] even though [I had] nothing to get high [i.e., had no drugs in herpossession]. They search you, destroy your property, cause a scene, and make sureeverybody there knows that you're a drug addict. […]They use their authority topull power trips more or less. It's not right. [Participant #12, Aboriginal Female, 29years old]These forms of surveillance reinforced participants' marginal status as `drug addicts'.Participants expressed dissatisfaction with these forms of surveillance and regulation, withone participant describing that they made her feel “like I was in jail.”McNeil et al. Page 7Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptRather than preventing drug use, this surveillance and regulation produced structuralvulnerability to drug and health harms. Most participants continued to use drugs during theperiod of their hospitalization to cope with pain and opiate withdrawal or due to cravingassociated with cocaine use, and half of our participants reported in-hospital drug use. Thestrategies enacted to avoid detection by nurses and security guards compromisedparticipants' ability to practice harm reduction. Many participants expressed that they couldnot request syringes without attracting suspicion or risking involuntary discharge. Someparticipants subsequently reused syringes that they had snuck into hospital and hidden intheir personal belongings, and which were potentially contaminated with bacteria whichcould further cause osteomyelitis or cellulitis (i.e., a bacterial skin infection). As oneparticipant with recurring injection-related infections explained, “I always try to have a rigon me… [The nurses] don't know I have them. [I keep it] in my coat, a bag or whatever Ibrought”. Other participants relied on visitors to bring injecting equipment, andsubsequently injected with syringes of an unknown origin. One participant explained thechallenges and risks associated with accessing syringes in hospitals:They [i.e. nurses] don't give rigs [i.e. syringes] to us…I think that they should. Ifnot, we're reusing our rigs or we're having to risk getting kicked out for stealingthem or people'll be sharing them. […] I know one girl was using her same rig fordays to the point where it was tearing and she was suffering every time she'd do herfix. She just didn't have it in her to go and try and steal clean rigs. Whereas for me,my friend that I was with had no problem. She would just sneak in and grab somefor both of us. [Participant #30, Aboriginal Female, 28 years old]The most common strategy to avoid detection when injecting was to use drugs in lockedhospital washrooms. Very few of our participants had been assigned private rooms, andinstead shared rooms with up to five other patients. Participants indicated that washroomswere one of the only spaces over which they could exert control and thus evade surveillance.Despite widespread awareness among local PWID of the overdose risks associated withinjecting alone, the situated risk perceptions of our participants elevated other concerns (e.g.,pain management, avoiding detection) above the need to mitigate these risks. For example:If you're sharing a room with somebody, there's always that threat that somebody'sjust gonna come in and not realize you're in there [the bathroom] and open [thedoor]. […] I think they pretty much have zero tolerance in [the hospital]. I wasworried about getting kicked out and then not getting the proper health care that Ineeded to get better. […] I'd turn the tap so, if they came in my room to check tosee if I was okay, then they'd hear the water running so they'd figure oh she's just inthe bathroom. [Participant #25, Caucasian Female, 44 years old]“I'll just run out” – Well-intentioned departures from hospitalApproximately half of our participants reported that they left hospital altogether when usingdrugs. Some participants “snuck out” of the hospital in the hope that they would returnbefore nurses discovered they had gone. Other participants had been admitted to hospitalwards that regularly issue “day passes”, which allow patients to leave hospital for a specifiedamount of time (typically up to six hours) at the discretion of nurses or physicians withoutbeing discharged. Day passes were used by some wards to accommodate ongoing drug use,in that it was expected that participants would consume drugs off-site and not return tohospital until the immediate effects of intoxication had subsided. Most homeless or unstablyhoused participants stayed close to the hospital and used drugs in nearby public settings(e.g., parks, alleyways), while housed participants returned to their residence. For example:I only had a pass so my plan was just to go grab some dope and then go back to thehospital. [I] stopped a couple of blocks away from there to do some dope. [I] justMcNeil et al. Page 8Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptended up staying in that one little spot in the park there and getting high for the dayand then went and checked back in. [Participant #9, Caucasian Male, 48 years old]While nearly all participants intended to return to hospital, most did not return until aftertheir passes had expired (resulting in discharge) and many did not return at all. Severalparticipants emphasized how their health deteriorated after leaving hospital. For example:The first time it was just, “OK, I'll just run out. They won't know I'm gone.” Andthen, I got stuck out there. Like, I was to a point where I wouldn't stop [bingecocaine use]. And then, I finally came back the next day `cause I was afraid oflosing my leg [due to a soft tissue infection]. […] And then, the second time [I lefthospital], I couldn't walk at all and my leg swelled up twice the size and there waspus draining out of it. [Participant #13, Caucasian Female, 44 years old]Some participants later returned to the same hospital to resume treatment and werereadmitted through the emergency department. These participants reported that, subsequentto returning to hospital, they were subjected to greater scrutiny by some nurses, with severalnoting that they were denied day passes.`Get the fuck out' – Involuntary discharge for in-hospital drug useWhereas all participants indicated that they had been admitted to hospital for complex healthproblems, and required extensive treatment, approximately one third of our participantsreported that they were involuntarily discharged for in-hospital drug use. Participantaccounts underscored how, while many injected in locked bathrooms in an attempt toconceal their drug use, these were highly-regulated spaces that were actively monitored bynurses and security guards. In turn, most participants reported that they had beeninvoluntarily discharged after they were caught, or suspected of, injecting drugs inbathrooms. For example:I went to use the bathroom, and they sent the police in the bathroom. They said Iwas taking too long and they thought I was using drugs in there. I was on the toilet,and the cop walks in with the key. […] He says, “You're taking too long. Get thefuck out.” He's swearing at me. He's standing there with the security guards, andcouple of the staff from the hospital. […] They physically escorted me out. Theytold me they were going to arrest me if I step back on the property. They said I wascreating a disturbance. […] I was just using the bathroom. [Participant #1,Aboriginal Male, 39 years old]Some participants acknowledged that they were disruptive during these encounters (e.g.,swearing at hospital staff), which likely discouraged nurses and security guards fromexercising discretion (i.e., seizing and disposing of the drugs but stopping short ofinvoluntary discharge). However, these participants did not wish to discontinue treatmentand expressed concern regarding the potential health consequences of involuntary discharge,and nearly all were later re-hospitalized.DISCUSSIONIn summary, our findings highlight how abstinence-only drug policies, together withinadequate pain management fuelled by narcotics control and negative stereotypes, framehospital care, and produce structural vulnerability to harm among PWID. Diverse forms ofsocial control that function to regulate drug use in hospitals (i.e., surveillance andregulation) increase the potential for drug-related harm and discharges against medicaladvice. Our findings demonstrate that hospitals constitute not just a setting to receivetreatment and care for PWID, but a `risk environment' where social and structural conditionsMcNeil et al. Page 9Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptproduce discharges against medical advice and, in turn, more complicated and protractedmedical treatment.Conceptualizing hospitals as `risk environments' allows us to better appreciate howcontextual forces operating within hospitals shape diverse harms, including dischargesagainst medical advice, and advance beyond individualized approaches that associate riskwith moral culpability and lack of awareness of potential consequences (Rhodes, 2002).Consistent with research in drug scene milieus (Rhodes et al., 2007; Small et al., 2007), ourfindings demonstrate the role of the criminalization of drug use in perpetuating systems ofsocial control that render PWID vulnerable to harm. Previous research on public injectionsettings has described how street policing, together with the stigma associated with injectiondrug use, leads to a sense of urgency when injecting that compromises PWID's ability tofollow harm reduction practices (Rhodes et al., 2007; Small et al., 2007). Although hospitalsare distinct from typical public injection settings in many ways, these same social andstructural forces shape hospital care, and similarly constrain PWID's ability to practice harmreduction. Notably, we found that PWID went to extreme measures to conceal in-hospitaldrug use, and thereby minimize their likelihood of being caught and involuntarilydischarged. Several of these measures (e.g., injecting alone in locked washrooms, injectingwith syringes of an unknown origin) dramatically increase the risk of fatal overdose or HIV/HCV transmission. In this regard, our findings highlight the importance of considering howdiverse settings constitute risk environments for injection drug-using populations, and howdrug criminalization frames the structural vulnerability of PWID in these settings.Although it has been widely reported that complex co-morbidities, along with inadequatepain management, contribute to high levels of unmanaged pain among PWID (Neighbor etal., 2011; Passik et al., 2006), only limited attention has been paid to how untreated andundertreated pain shapes experiences in hospital settings (Merrill et al., 2002; Neale et al.,2008). Previous research has underscored the complexities of pain management amongPWID, and emphasized how physician's perceptions of people who use drugs shapeprescribing practices (Berg et al., 2009; Merrill et al., 2002). In a qualitative study ofphysician experiences treating chronic pain among PWID, Berg and colleagues (2009)found considerable variation in prescribing practices, and explored how this was influencedby larger discourses that characterize PWID as `drug-seeking'. Many physicians consciouslyundertreated pain because they were concerned about promoting continued drug use (Berg etal., 2009).Our findings build upon this research by demonstrating how this powerful culturalstereotype shapes hospital care for PWID and possibly leads to treatment decisions thatincrease the likelihood of discharges against medical advice. Furthermore, by documentinghow the stereotype of the `drug-seeking addict' intersected with institutionalized racism, ourfindings in part explain previous epidemiological findings indicating that Aboriginalancestry increases the likelihood of discharge from hospital against medical advice amongdrug-using populations (Anis et al., 2002; Chan et al., 2004). Importantly, our participantsdescribed how inadequate pain management was normalized within hospital settings, andcharacterized their treatment by nurses and physicians as complicit in perpetuating suffering.This approach to pain management may be understood as a manifestation of the `everydayviolence' endured by PWID and underscores the urgent need to rethink pain managementpractices for drug-using populations and reorient them toward alleviating suffering. Whilefurther reforms may be needed to accommodate this, including changes to legal andprofessional regulations regarding the prescribing of prescription opioids, it is important toconsider the high potential for negative outcomes if these changes are not made.Furthermore, given the central role of discrimination in shaping pain management practices,McNeil et al. Page 10Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripteducation and training programs aimed at improving cultural competency among hospitalstaff are likely needed.Greater acknowledgement that contextual forces operating within hospital settings producesuffering, and contribute to discharges against medical advice, necessarily begs the questionof whether changes to the environmental contexts of hospital settings can improve care fordrug-using populations. Our findings illustrate how injection drug-using populationsundergo a vicious cycle of emergency department visits, hospitalizations, and departures thatrepeats itself to both increase the risk of death and the overall burden on the health caresystem. Certainly, there is an urgent need to integrate evidence-based approaches that showpromise in disrupting this cycle. Methadone maintenance treatment has shown somepromise in mitigating departures from hospital prior to completing treatment among PWID(Chan et al., 2004), and efforts to increase access to opiate substitution therapies andappropriate pain management among hospitalized PWID are needed. To achieve this goal,increased addictions and pain management training among physicians and nurses will benecessary (Miller et al., 2001).Over the past decade, considerable evidence has mounted highlighting the role of `saferenvironment' interventions (e.g., syringe exchange programs, supervised drug consumptionfacilities) in reshaping the `risk environment' of people who use drugs (Rhodes et al., 2006).Within this context, supervised drug consumption facilities have been found to beparticularly effective in creating social, structural, and environmental conditions that enableharm reduction practices and facilitate access to health care services (Kerr et al., 2007; Krusiet al., 2009; Small et al., 2009; Small et al., 2008). Moreover, preliminary evidence suggeststhat this harm reduction strategy has significant potential to reshape the social and structural-environmental contexts within health care settings (Krusi et al., 2009). However, hospitalpolicies, including those existing where the present research was conducted, continue to beprimarily oriented toward promoting and, in some cases, enforcing drug abstinence. Againstthis backdrop, our findings lend support to the argument for integrating comprehensive harmreduction approaches, including supervised drug consumption services, into hospitals(Rachlis et al., 2009). While this approach is by no means a panacea, our findings suggestthat this has the potential to reduce the deleterious effects of efforts to deter and limit druguse within hospital settings, and thus drug-related risks (e.g., injecting alone) and dischargesfrom hospital against medical advice. This approach would allow hospital staff to shift theirattention from policing drug use to more pressing patient concerns, and also minimize theconflicts occurring in hospitals.We acknowledge that this approach may encounter opposition among health careprofessionals who view harm reduction as counter to `curative' approaches to care (Pauly,2008). In addition, drug legislation may preclude the adoption of comprehensive harmreduction approaches in some jurisdictions (Beletsky et al., 2008). It may, therefore, beinstructive to position harm reduction as an `ethical approach' intended to minimize harm aspart of a broader strategy to ensure equitable access to hospital care (Pauly, 2008), andthereby locate it within the scope of health care practice. This approach has previously beenused by an HIV/AIDS care facility in a Canadian setting to reposition supervised injectionservices as an issue of ethical health care practice (Wood et al., 2003). Furthermore,involving PWID in the development and implementation of hospital-based harm reductionservices may serve to increase the acceptability of such services while promoting agencyamong PWID, and thus an opportunity to work in a productive fashion with hospital staff.This study has limitations that should be taken into consideration. Because our participantshad been discharged against medical advice, their experiences in hospital may be negativelybiased, and may not be representative of those who completed treatment. Our findings areMcNeil et al. Page 11Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptalso specific to hospitals in the Vancouver area and, although they generate insights thatmay be relevant to other settings where hospital care is shaped by similar contextual forces,they cannot fully account for PWID's experiences in hospitals. Whereas our participantswere covered by universal, publicly-funded health care insurance, PWID in other settingsmay face additional financial barriers to care that have an additional impact on hospital care.Finally, because we did not interview hospital staff, our findings represent only theperspectives of PWID. It is, therefore, possible that we overlooked some of the contextualforces that shaped specific aspects of care. Further research into the perspectives of hospitalstaff regarding the care of injection drug-using populations, and the potential integration ofharm reduction services into hospitals, is urgently needed.In conclusion, this study documents how hospitals constitute a `risk environment' for PWID.Our findings demonstrate that contextual forces operating within hospital settings fosterconditions that increase the potential for drug and health harms, including discharges againstmedical advice. Optimizing evidence-based drug and pain treatment services, augmented bycomprehensive harm reduction services, have significant potential to promote health equityby reshaping the environmental context of hospital care, and thereby reducing the enormoushealth and fiscal impacts resulting from discharges against medical advice.AcknowledgmentsThe authors thank the study participants for their contribution to the research, as well as current and pastresearchers and staff with the British Columbia Centre for Excellence in HIV/AIDS. Tricia Collingham, CameronDilworth, Ivan Fletcher, Jennifer Matthews and Aaron McKinney provided research support and assistance. Thisstudy was supported by the Canadian Institutes of Health Research (MOP-81171) and the US National Institutes ofHealth (R01DA033147). This research was undertaken, in part, thanks to funding from the Canada Research Chairsprogram through a Tier 1 Canada Research Chair in Inner City Medicine which supports Dr. Evan Wood. 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Points to a need for evidence-based pain management augmented by harmreduction approaches.McNeil et al. Page 16Soc Sci Med. Author manuscript; available in PMC 2015 March 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript


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