“I Have to Quit, the Doctor Told Me I Will Die If I Don't" Substance Use and Hospitalized Patients' Perspectives on Readiness to Change

Background

Adults with substance use disorders (SUD) have high rates of hospitalization, readmission, and complex chronic illness.  Despite this, many are not engaged in addiction treatment. Hospitalization may be a ‘reachable moment’ to initiate and coordinate addiction care. We hoped to better understand patient perspectives on readiness to change and interest in drug treatment, and to understand how people struggling with SUD derive meaning from an acute hospitalization.

Methods

We performed a qualitative study of hospitalized adults with SUD at a large, urban, academic medical center.  Participants were recruited from a larger mixed methods study targeting a convenience sample of adults screening positive for high-risk alcohol and/or drug use. We conducted semi structured qualitative interviews in patient rooms, which were later transcribed. We used a thematic analysis approach to identify emergent themes and guide analysis.  Using an iterative process, team members individually coded transcripts and met regularly to discuss and analyze data.

Results

We completed 26 qualitative interviews from September 2014 through April 2015.  Among those interviewed, 10/26 (39%) reported moderate-high risk alcohol use, 9/26 methamphetamine use (35%), and 10/26 opioid (38%) use. Qualitative analyses identified the following major themes: (1) some patients described perceived stigma and internalized shame about substance use, (2) some patients felt that hospitalization was a wake up call as to the severity of their substance use; this recognition was motivating for change, and (3) hospitalization may be an appropriate time to initiate addiction treatment.

Some patients described feeling stigma and shame within hospital settings, as one patient stated, ‘I don’t like ER’s because they don’t help . . . they think, oh she’s not gonna get help, she’s a heroin addict . . .this is what we see in all of the addicts, just put her on the list with everybody else, she’ll figure it out, give her a list of resources.’  Several patients felt that the severity of their medical conditions was directly related to using, as one patient stated:  ‘an abscess, it almost got into my bone, I almost lost a limb.’ Hospitalization presented a shift in perception of drug use severity, and for some, precipitated a sense of urgency for drug treatment: ‘I got sick where they’re telling me, you know, if I don’t give up the drugs I’m not going to be around for a while.’ Some patients stated that being near death motivated a desire to cut back/quit using, as one patient stated, ‘its to the point I almost died the other day and you know I have a three year old little boy and its nowhere I wanna be.’ 

Conclusion

Our findings suggest that hospitalization may a ‘reachable moment.’ Medical social workers’ unique skills can support patients in moving towards readiness and engaging in addiction treatment. Although much is known about addiction care in outpatient settings, many hospitals do not currently have a standard of care for supporting people with SUD. More research is needed in the treatment and care of medically complex patients admitted to hospitals with SUD.