Abstract
Study objective
We described the experiences and preferences of people with opioid use disorder who access emergency department (ED) services regarding ED care and ED-based interventions.
Methods
Between June and September 2020, we conducted phone or in-person semistructured qualitative interviews with patients recently discharged from 2 urban EDs in Vancouver, BC, Canada, to explore experiences and preferences of ED care and ED-based opioid use disorder interventions. We recruited participants from a cohort of adults with opioid use disorder who were participating in an ED-initiated outreach program. We transcribed audio recordings verbatim. We iteratively developed a thematic coding structure, with interim analyses to assess for thematic saturation. Two team members with lived experience of opioid use provided feedback on content, wording, and analysis throughout the study.
Results
We interviewed 19 participants. Participants felt discriminated against for their drug use, which led to poorer perceived health care and downstream ED avoidance. Participants desired to be treated like ED patients who do not use drugs and to be more involved in their ED care. Participants nevertheless felt comfortable discussing their substance use with ED staff and valued continuous ED operating hours. Regarding opioid use disorder treatment, participants supported ED-based buprenorphine/naloxone programs but also suggested additional options (eg, different initiation regimens and settings and other opioid agonist therapies) to facilitate further treatment uptake.
Conclusion
Based on participant experiences, we recommend addressing potentially stigmatizing practices, increasing patient involvement in their care during ED visits, and increasing access to various opioid use disorder-related treatments and community support.
INTRODUCTION
As opioid-related deaths rise worldwide,1 improved health care services for people who use drugs are essential. People who use drugs visit emergency departments (EDs) frequently2,3 and often visit EDs in the year prior to experiencing an overdose.4 Therefore, ED encounters represent time-critical opportunities to offer point-of-care, evidence-based opioid use disorder interventions. These interventions include initiating opioid agonist therapy5 (eg, buprenorphine/naloxone, methadone) and addiction or primary care referrals. Buprenorphine/naloxone has a favorable safety profile, and its initiation in EDs can increase engagement in future treatment.6,7 As such, offering buprenorphine/naloxone during ED visits to eligible patients is recommended.7,8 To increase the effectiveness and uptake of buprenorphine/naloxone programs and other substance use-related interventions, EDs should involve people who use drugs in their own clinical decision-making and in overall service planning.9–11
ED patients with opioid use disorder have reported drug-related stigma,12 requested accessible opioid treatment,12 and felt that post-opioid overdose ED care was degrading or lacked sufficient resources,13,14 but the ED experiences of people with opioid use disorder remain incompletely described. In addition, prior studies are limited by a narrow focus on opioid agonist therapy, particularly buprenorphine/naloxone, or ED experiences post-overdose. We aimed to understand better the experiences of people with opioid use disorder who access EDs by focusing on general opinions of ED care, experiences with ED staff, and specific opinions of ED opioid use disorder-related interventions, including buprenorphine/naloxone initiation. Accounts of these experiences will assist health care providers and administrators in shaping ED care, ultimately improving services for people with opioid use disorder visiting EDs.
MATERIALS AND METHODS
Study Design and Setting
This qualitative study consisted of semi-structured telephone and in-person interviews with people with opioid use disorder who accessed ED services. We developed the interview guide (Appendix E1, available at http://www.annemergmed.com) with expert input as previously described.15 The interviewer pilot-tested the guide with 2 individuals with lived experience of opioid use (SG and DT) by conducting a full mock interview and incorporating the resulting feedback. We used the COREQ (Consolidated Criteria for Reporting Qualitative Research) to report our methods and results16 and adhered to Lincoln and Guba’s recommendations for qualitative rigor (Appendix E2, available at http://www.annemergmed.com).17
The University of British Columbia Providence Health Care Research ethics board approved the study (H19-02203).
Study candidates had all sought care at 2 urban EDs in Vancouver, BC, Canada, that provide take-home naloxone, buprenorphine/naloxone initiation, and outreach referrals as part of routine care for opioid use disorder patients.
Selection of Participants
We contacted candidates from June 2020 to September 2020 using purposive sampling to achieve diversity among participants. All candidates belonged to an 84-member cohort of individuals who had been enrolled in a 1-year intensive community outreach program and had been offered buprenorphine/naloxone initiation packs during an ED visit between October 2019 and March 2020. Original eligibility for the 1-year intensive community outreach program required: age 18 or greater, an opioid use disorder diagnosis according to Rapid Opioid Dependence Screen criteria,18 residence within Vancouver city limits, absence of opioid agonist therapy at the time of ED screening, and discharge from the ED. During the 1-year intensive outreach program, participants who had consented to further research contact were reached by phone. Being on opioid agonist therapy at the time of contact was not an exclusion criterion for the qualitative interview. Potential interview participants received qualitative study details (study activities, objectives, and interviewer credentials and experience) prior to providing written informed consent in person. We offered participants a Canadian (CAD) $50 honorarium for their time and expertise.
Research Team
We describe the research team in Box, which included people with lived experience of opioid use, public health and medical students, an outreach team worker, and a physician.
Data Collection
We used closed-ended questions to initiate discussion and then followed up with open-ended questions with prompts as needed to facilitate comprehensive responses. Interviews lasted 45 to 90 minutes. We transcribed audio recordings of interviews verbatim using Otter transcription software (Otter.ai, version 2.3.75, Los Altos, CA).19 We removed all identifiers and verified accuracy by reading transcripts while listening to the audio.
One interviewer (LRG) conducted all interviews to maintain consistency. We performed interviews in parks, in approved outreach offices, or in participants’ residences. An outreach worker (JH) was in-person with participants for all telephone interviews to assist with obtaining informed consent, supporting communications (eg, providing participants with a cellphone), and providing psychological support if needed; aside from the interviewer, no other nonparticipant was present during the interviews. The interviewer took field notes on observations, including body language where appropriate. This information was not coded and did not form part of the data set per se, but rather used to clarify any nonverbal/ambiguous answers (eg, a participant nodding their head). In addition, we obtained participants’ contact information and verbal consent to be contacted for follow-up questions, if needed.
Primary Data Analysis
Because of the budget and time constraints, we decided a priori to continue interviews until reaching thematic saturation or completing 20 interviews, whichever came first. We analyzed our data using Braun and Clarke’s theoretical thematic analytic framework.20 All codes and themes arose from data and not prior hypotheses.
The primary coder (LRG) used NVivo 12 (QSR International, Doncaster, Australia)21 to group answers to open-ended questions into emerging themes. The primary coder also quantified answers to closed-ended questions where appropriate (eg, number of lifetime ED visits). The secondary coder (ZRO) independently reviewed uncoded transcripts and then compared codes with the primary coder until consensus was reached. Using a planned trigger of suspected thematic saturation or new concepts requiring interview guide adjustments, we conducted preliminary analyses after 12, 16, and 19 interviews. After analyses of 12 and 16 transcripts, we slightly adjusted the interview guide to elicit more in-depth answers, clarify questions, and probe emerging concepts. We assessed for thematic saturation during all interim analyses and added or revised codes to best describe the data.
After analysis, we iteratively developed a codebook (Appendix E3, available at http://www.annemergmed.com) in collaboration with team members with lived experience of opioid use (DT and SG). On consensus on codes, the primary coder coded all transcripts. As 10% to 20% of the full sample is commonly recommended for checking internal coding consistency,22 the secondary coder analyzed 4 transcripts selected randomly, and we then calculated Cohen’s Kappa statistic to assess the level of agreement between both coders’ analyses. We did not specifically seek participants’ feedback on transcripts or codes. Instead, an author with lived experience of opioid use (DT) reviewed emerging codes and themes and the final manuscript for content and wording.
RESULTS
Interviews and Transcripts
We attempted to contact 26 individuals from June 2020 to September 2020: 3 did not respond, and 4 did not attend their interviews. Of all the study candidates who were successfully reached, no individual refused to participate. We conducted 19 interviews (10 telephone and 9 in-person) prior to achieving thematic saturation. We attempted unsuccessfully to contact one participant for follow-up questions; no other participant required follow-up. All participants answered all questions asked related to ED care and ED-based interventions. One participant requested a copy of their transcript but provided no corrections. No repeat interviews were conducted. We identified 76 codes relating to ED care and ED-based interventions for opioid use disorder (Appendix E3, available at http://www.annemergmed.com). A minority of codes were changed during interim analysis for clarification, minimization of overlap, and optimization of fit into the overall coding structure. In assigning codes to transcripts, Cohen’s Kappa statistic (ie, interrater agreement) was 0.91. The coders assessed areas of disagreement as internally consistent and logical and reached a consensus on the final coding.
Participant Characteristics
Participants included 13 men and 6 women, with a median age of 34 years (Table 1). Twelve participants were housed at the time of their interview, and 13 reported visiting EDs for any reason more than 20 times in their lifetime. In addition, participants reported a variety of drug use and opioid agonist therapy use at the time of the interview.
Table 1.
Baseline characteristics of study participants reported at the time of the interview. N=19.
| Characteristic | n (%) |
|---|---|
| Self-reported sex | |
| Man | 13 (68) |
| Woman | 6 (32) |
| Age (y) | |
| Median age | 34 |
| Age range | 23 to 59 |
| Self-reported ethnicity | |
| White | 13 (68) |
| Indigenous (or mixed ethnicity including Indigenous) | 6 (32) |
| Housing | |
| Housed | 12 (63) |
| Not housed (ie, no fixed address, sheltered, transitioning into housing, and housed in treatment) | 7 (37) |
| Preferred method of opioid consumption | |
| Injection | 15 (79) |
| Method of consumption other than injection | 4 (21) |
| Substances consumed (other than opioids) in the preceding 7 days prior to intake | |
| Alcohol | 4 (21) |
| Amphetamine | 17 (89) |
| Benzodiazepines | 5 (26) |
| Cannabis | 7 (37) |
| Cocaine | 0 (0) |
| Number of self-reported ED encounters in a lifetime for any reason | |
| 1 to 19 | 5 (26) |
| 20+ | 13 (68) |
| Does not know | 1 (5) |
Varied Experiences of Discrimination, Comfort, and Respect in EDs
While coding, we categorized participant-reported “stigma” and “discrimination” together as our participants used both terms interchangeably. See Table 2 for further examples of quotes pertaining to select themes below.
Table 2.
Examples of select themes and quotes used during the qualitative analysis of participants’ transcripts.
| Theme | Example Quotes from Participant Transcripts |
|---|---|
| Feeling stigmatized or discriminated against in emergency departments |
“As soon as [ED staff] find out I’m a drug user, it’s like instant stigma. Instant stigma. Like, I don’t know what it is, but immediately they start like treating me different than other people.” (Participant 9) “I was in pain from getting these IVs because I was dehydrated… And [the ED staff administering the IV] got pissed off at one point. They’re like, ‘Well, why don’t you just do it yourself? Show us … where you would inject.’ … and I’m like puking, like projectile vomiting like that’s why they needed to put the IV in me so I could get Gravol IV, and … one of the nurses or whoever it was kind of just blurted that out.” (Participant 13) |
| Feeling respected or comfortable in emergency departments |
“They give us like warm blankets, food, whatever, trying to make the wait like as fast as possible, like that type of thing. I think it’s been alright.” (Participant 13) “I guess when they … see I was having problems with … drug use and then they got like somebody to actually help me. Like to come in from the like the [addiction clinic] or whatever.” (Participant 8) |
| Preferring participatory ED care |
“It’s the people that actually took their time to hear what I was saying that made the biggest difference in my life.” (Participant 10) “[Discussing opioid agonist therapies] No, it’s always good to have options, and one I don’t think is better than the other. (Participant 6) “I’m always grateful when, when my doctors willing to engage with me.” (Participant 2) |
Feeling stigmatized or discriminated against in EDs
Discrimination was a frequent theme in interviews. Most participants reported substance-use-related discrimination during ED visits. Some participants felt discriminated against for other reasons, such as homelessness or past criminal activity. Participants felt discrimination, and the resulting influence on their treatment was not always uniform across different EDs or within EDs depending on staff roles.
Participants frequently mentioned being labeled or stereotyped during unfavorable ED experiences. Participants felt that being labeled and judged as “addicts” or “drug users” contributed to poorer care or disrespectful ED staff attitudes (eg, using insensitive language). Many participants expressed a desire to be treated as well as others who do not use drugs, reporting that they felt ED patients who did not use drugs received faster or better care.
“They will give you treatment that is not par to someone that’s going in … with [an] injury or something or an ailment that’s not related to drugs.”
(Participant 6)
Participants reported feeling frustrated or angered in EDs because they felt discriminated against. Some participants felt patronized by the tone or word choice of ED staff. Many participants felt ignored by ED staff.
“… they were kind of almost condescending, like, they were talking down to me, like, I was stupid.”
(Participant 13)
“I always felt every time I was going [to an ED] that they would take one look at you and … you know, ‘Oh, this is just another addict,’ and I never really had anybody in the emerge take the time to really assess me.”
(Participant 7)
Some participants wished that staff would not “follow [people] to the washroom” (Participant 7) as they perceived this was a result of discrimination.
Feeling respected or comfortable in EDs
The theme of respect and comfort in the ED at times coexisted with feelings of discrimination. Many participants reported feeling completely comfortable discussing their substance use with ED staff, and several reported generally feeling respected by ED staff. Participants felt supported when they received the care they were seeking, were correctly diagnosed, and were given adequate mental health support. Many favorable ED experiences involved attentiveness or personalized care from ED staff. For example, participants appreciated when ED staff checked in on them frequently or brought them blankets or food.
Some participants associated positive emotions with EDs, such as feeling gratitude, respect, validation, and happiness.
“Well, the doctors [were] …pretty much understanding and did their job well. You know, that made me feel respected.”
(Participant 6)
Of note, some participants reported decreased discrimination or judgment over time and felt EDs are improving by providing more holistic care.
“I think the way … that they’ve been trained over like more recently over the years is a lot different. The type of care that they’re … taught to give, you know, is more holistic … and more open-minded.”
(Participant 13)
Struggling with the chaotic nature of EDs
Participants attributed some challenging or unpleasant ED visits to the hectic nature of EDs. They felt that some ED staff were overworked, misdiagnosing people, or were not communicating effectively with each other. Some participants felt EDs could be unwelcoming and preferred their regular physicians or clinics that were seen as calmer and more welcoming.
“I didn’t know that I was supposed to feel [welcome] in the emergency department. I thought everyone was supposed to feel crammed and uncomfortable.”
(Participant 18)
Other participants also preferred their regular providers as they felt their regular physicians seemed more personable, less judgmental, or more familiar with people’s histories.
“I’d rather be able to just go and talk to a doctor and a doctor that I know … then he knows who I am and what’s going on with me. Rather than every time we go into emergency, you got to tell your story over, and you got to start from scratch.”
(Participant 11)
Some participants felt that their ED care had been rushed, with some unaddressed issues.
“… there’s a few times I felt really rushed out of there before I was ready. It was just like, ‘Okay, see you, get out of here.’”
(Participant 13)
Participants requested more privacy in EDs by staff lowering their voice or providing private rooms for substance use-related visits or health issues of a more personal nature.
Of note, some participants saw ED disorder as unavoidable and understood why ED staff may not always be extremely welcoming or quick to help as they deal with high work stress.
Avoiding or Prematurely Leaving ED Care
Another theme consisted of leaving EDs prematurely—either without being assessed or prior to completion of medical treatment—or avoiding them altogether because of negative experiences. Many participants valued prompt ED care, and some had left EDs early because of long wait times.
“… the nurses weren’t helping me … when I’d ring the bell [and] ask them for help, they wouldn’t come to see me, so I just ended up leaving.”
(Participant 5)
Participants also mentioned ED encounters where they felt they received no care at all and subsequently experienced worsening health problems. Past poor experiences had led some participants to avoid seeking ED care entirely or defer ED care until they were very sick.
“… and when I went back for the checkup, that’s when I was like treated really harsh and they … sent me away, and then I ended up having to go back with multiple problems … Instead of like resolving one of the problems.”
(Participant 16)
“I went [to the ED] because I knew I was on my last leg and if I didn’t go that the infection could become fatal.”
(Participant 6)
Most participants reported voluntarily seeking ED care at times; however, several reported at times being brought to EDs against their will or without awareness.
Preferring Participatory ED Care
Many responses evoked the theme of choice and participation in care, with active participation reported during favorable ED experiences. Participants greatly appreciated feeling heard and believed by ED staff as well as when they received adequate explanations of their condition and care.
“They allowed me to feel like [I] was part of my own care and understand what was going on with my body and what we were doing to Lix it.”
(Participant 2)
On the other hand, participants reported that a lack of participation in their own care contributed strongly to negative ED experiences. Participants described times when they felt ED staff did not include them in their care or listen to their needs.
“Nobody told me what happened, what [my medication] was for. Nobody told me anything, and then I was released.”
(Participant 13)
“Them just going through the motions, right, but not really hearing you.”
(Participant 10)
Participants requested options in their ED care, such as choices regarding opioid agonist therapy. Participants discussed that options allowed them to feel more involved in their care and would increase the likelihood of treatment uptake and adherence.
“It’s good to have options. Yeah, and I found having the options that I felt like … my opinion matters.”
(Participant 2)
Valuing Accessible Care
Interviews touched on the theme of accessibility of care, both within and outside of the ED. Participants valued the 24-hour availability of ED care as opposed to clinics or other services that are only open during standard operating hours and discussed challenges in accessing services outside those times.
“I wish I was just able to walk into a facility and be accepted into a treatment program on 24 hours a day, seven days a week.”
(Participant 9)
Of note, one participant highlighted accessibility challenges when ED staff make referrals for ongoing care, with appointments at times and locations “all over the place” (Participant 18) (ie, requiring substantial time and travel).
Views on ED-Related Services That Support People With Opioid Use Disorder
ED-initiated buprenorphine/naloxone
Most participants knew about buprenorphine/naloxone prior to enrolment, and all believed most of their peers also knew about buprenorphine/naloxone. However, participant experiences demonstrated a potential lack of specific education or awareness around buprenorphine/naloxone. For example, several felt they had received insufficient information from care providers regarding precipitated withdrawal upon receiving a buprenorphine/naloxone prescription. Additionally, many participants noted that ED-based buprenorphine/naloxone was not well known among their peers and suggested wider promotion of such programs.
“Educate people, so they know besides, like, just ending up at emergency and Linding out. I think it should be advertised more.”
(Participant 16)
Most participants have previously tried buprenorphine/naloxone, and many reported positive buprenorphine/naloxone experiences (eg, increased productivity/feelings of normalcy and reduced drug use/cravings). However, others reported negative buprenorphine/naloxone experiences (eg, precipitated withdrawal or an inability to reduce cravings or withdrawal symptoms effectively) or described deterrents of buprenorphine/naloxone (eg, inability to sleep, induction process, and risk of precipitated withdrawal). Many participants recommended that opioid withdrawal symptom management medications (eg, ibuprofen for pain and dimenhydrinate for nausea) be provided with buprenorphine/naloxone.
Despite variable buprenorphine/naloxone experiences, most participants thought offering ED-based buprenorphine/naloxone was a good idea; however, only a few participants felt EDs should observe patients until they achieve withdrawal sufficient to initiate buprenorphine/naloxone. Although some participants favored ED-based initiation and others preferred take-home buprenorphine/naloxone packs, most felt the choice of initiation site should be up to the patient, which highlighted an appreciation for shared decision-making to find the best care plan. Evoking the accessibility theme again, participants appreciated the convenience of ED-dispensed take-home buprenorphine/naloxone packs and felt that buprenorphine/naloxone prescriptions requiring a trip to the pharmacy would likely go unfilled.
“People are willing in that moment and then get [buprenorphine/naloxone] in their hands right then … it’s a good thing to get in their hands … when they’re vulnerable and open to it. And that’s when they’re in the [ED].”
(Participant 2)
In keeping with the participatory care/collaboration theme, participants felt that EDs should offer other opioid agonist therapy modalities to those declining buprenorphine/naloxone, as well as offer management programs for drugs other than opioids.
“No one is more right than the other … it all comes down to what the individual is going to use, right? … [Buprenorphine/naloxone] works for me, but like, I would never want it included at the expense of another form.”
(Participant 2)
Other ED-related services
Most participants valued linkages between EDs and community services (eg, referrals to clinics or outreach teams), and some participants advocated for outreach workers to be present in EDs. Of note, some participants were unaware that linkages between EDs and community services existed, and many felt these could be better promoted.
Most participants felt that having addiction specialists in EDs would be helpful, and several said they would meet with one if they were available. Participants also believed a peer (ie, someone with lived experience of drug use) in EDs could be beneficial by helping to fill out forms or explain people’s experiences to ED staff.
“You don’t know unless you’ve been there. You can see it, and we can tell you as much as we can, you know, [precipitated withdrawal is] like 10 times worse than opioid withdrawal, but how do you know what opioid withdrawal is? … I think there should be some people who have like been there that are also working in the hospital … that can come out and like translate.”
(Participant 18)
LIMITATIONS
Because we conducted this study in urban settings in Vancouver, BC, Canada, which has publicly funded single-payer health care and direct ED-to-outreach linkages, our findings may not apply in all settings. Our participants initially accessed care in an ED, were willing to participate in an intensive outreach program, and were available for follow-up interviews; they may, therefore, not represent all people with opioid use disorder who visit EDs. Our participants felt sufficiently physically and emotionally well post-ED discharge to participate in lengthy interviews; ED-based interviews might have yielded different answers. Any responses may be subject to availability and social desirability biases; although the direction and magnitude of these influences cannot be ascertained, the involvement of coauthors with lived experience of opioid use may mitigate some of these concerns.
DISCUSSION
Our study presents the experiences of people with opioid use disorder who access ED services. Common themes included discrimination, valuing care that is accessible and participatory (eg, being listened to and being offered care options), and valuing ED-based services (eg, buprenorphine/naloxone initiation and ED linkages to additional community support). This enhances the understanding of issues facing ED patients with opioid use disorder and should help EDs plan service improvements for this population.
Many participants experienced discrimination related to their drug use while in the ED and felt it resulted in inferior care and poorer outcomes. These findings are consistent with other research in Canada, the United States, and Australia demonstrating drug-use-related stigma in EDs and outpatient settings12,23–26 and reporting subsequent lower-quality care for people who use drugs.25,26 Experiences of ED-based discrimination are corroborated by ED staff acknowledging being at risk of biases, frustration, and lack of empathy when interacting with people who use drugs.14,27 Among our participants, experiences of discrimination were balanced by overall comfort in discussing substance use in the ED, and a perceived temporal trend toward improved ED care, also noted in previous ED research.13 To address ongoing discrimination against people who use drugs, ED leaders should consider making trauma-informed and culturally safe care training more accessible to ED staff (eg, paid training, accommodating times/formats). This training should emphasize avoiding stigmatizing terms (eg, “addict”),8,28 keeping language person-centered,28 learning de-escalation skills, and checking internal biases.
Our participants reported favoring when ED providers considered their opinions during decision-making (eg, treatment choice and initiation site). This is consistent with previous research suggesting that shared decision-making between people who use drugs and providers may lead to better engagement, informed decision-making, and outcomes regarding care plans29–31 and that insufficient shared decision-making may weaken patient-provider relations.31,32 EDs should, therefore, foster shared decision-making processes for patients with opioid use disorder by providing evidence-based information on care options, providing decision support/counseling to clarify options, and ensuring patients communicate their preferences.33
Participants supported ED-based buprenorphine/naloxone programs while noting that buprenorphine/naloxone would not be universally preferred. Many recommended expanding ED-based treatment options. Previous studies report varying opioid treatment preferences outside of ED settings in a number of American cities.34–38 Resulting recommendations include offering more opioid agonist therapy options34,38 and more individually tailored ED-based opioid use disorder interventions.38 ED administrators and physicians may therefore consider: (1) expanding treatment options to include treatments other than buprenorphine/naloxone (eg, methadone and slow-release oral morphine); (2) offering more induction method choices, including buprenorphine/naloxone microdosing (where people do not need to abstain from using opioids prior to induction); and (3) providing a variety of initiation site choices (eg, EDs, treatment centers, and at-home with to-go packs). Even if EDs do not have the immediate capacity to increase treatment options, EDs can ensure clear transitions of care (eg, well-defined referral pathways) to various community-based substance use services.
In addition to buprenorphine/naloxone initiation, participants appreciated other opioid use disorder-related ED resources (eg, addiction specialists, peer support) and linkages to community resources (eg, outreach support and referrals to clinics), though they felt all resources could be expanded and better promoted. Positive participant feedback on community linkages supports previous research describing EDs as a “gateway” to services that might otherwise be difficult for people who use drugs to access.23 EDs can undertake various measures, such as hiring navigators and engaging outreach workers, to strengthen community linkages and maximize the chances of referral success. When possible, in-person handovers have been suggested to increase the uptake of the referral process.39
Of note, we identified themes that people without opioid use disorder often express regarding care in EDs and other settings: desiring involvement in one’s care (eg, clear communication and active participation), preferring familiar care providers, and accessing EDs only as a last resort.40–42 These commonalities remind us that despite having unique experiences, people with opioid use disorder have similar aspirations for their care as people without opioid use disorder.
In conclusion, our findings are an opportunity to learn from the experiences and preferences of people with opioid use disorder who visit EDs. Based on our findings, EDs should take steps to reduce opioid use disorder-related discrimination, involve patients with opioid use disorder in shared decision-making, increase access to a variety of treatment options, and increase linkages to community support.
Supplementary Material
SUMMARY.
What is already known on this topic?
Emergency department (ED) patients with opioid use disorder need emergency care and then can start a reduction intervention.
What question this study addressed?
How do ED patients with opioid use disorder see their care and treatment opportunities?
What this study adds to our knowledge?
In 19 patients recently seen in two urban EDs, structured interviews uncovered negative perceptions of their care, the challenges they face, and their willingness to engage in treatment planning.
How this is relevant to clinical practice?
Awareness of perceived barriers and the patients’ desire for care can aid starting therapies for opioid use disorder.
Funding and support:
All authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Funded by a grant from the Canadian Institutes of Health Research to the Canadian Research Initiative in Substance Misuse and by the Providence Health Care and Vancouver Coastal Health Research Institutes.
Footnotes
Authorship:
All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Description of the research team responsible for collecting and analyzing study data.
Research Team
The interviewer was a female Master of Public Health student (LRG) who had no prior relationship with the participants. A male community outreach worker (JH) who was also a Master of Social Work student assisted with participant recruitment as he had prior working relationships with some of the participants. LRG received training in interviewing and qualitative software. LRG and ZRO, the latter, a female medical student, served as the primary and secondary coders, respectively, and both had preexisting interests in substance use and harm reduction and received training in qualitative analysis. The principal investigator (AK), a male emergency physician with experience in public health, research, and health care management, oversaw data collection and coding. SG and DT, both women with lived experience of opioid use and coauthors of our study were involved in multiple steps of our study, contributing to the: interview guide design, data collection processes, analytic framework, and the codebook and manuscript drafts by performing face validity checks on codes. SG and DT also provided feedback regarding content and wording at multiple stages of the study.
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