“We’re all in this together”: A Mixed-Methods Study of Provider and Patient Perceptions of Emergency Care for Opioid Use Disorder

Abstract

Aims:

To compare attitudes and perceptions towards opioid use disorder among people with opioid use disorder and emergency providers, describe interactions between the two groups, and identify barriers to providing and receiving care.

Design:

Mixed methods observational study

Methods:

Participants were recruited from an academic, tertiary care hospital and a community-based harm reduction agency in New England. Emergency healthcare providers (nurses, physicians and paramedics) and adult people with opioid use disorder were enrolled. Electronic surveys were administered to providers, and semi-structured interviews were conducted with people with opioid use disorder and a subset of providers. Descriptive statistics were calculated for surveys and directed content analysis was used to analyze semi-structured interviews.

Results:

Sixty-eight providers completed the survey, 11 of whom also completed a semi-structured interview. Twenty-two people with opioid use disorder completed the semi-structured interview. Both providers and people with opioid use disorder agreed that addiction is a disease, however opinions differed on the extent to which personal choice played a role in the onset of opioid use disorder. Participants described how factors such as experiencing homelessness, alongside other personal or familial challenges, contributed to ongoing substance use and presented barriers to accessing healthcare. There was discordance in priorities between providers and people with opioid use disorder which often drove conflict and perceived stigma. Both groups described physical and emotional trauma from prior interactions, which shaped expectations of future interactions and biases toward each other.

Implications for the profession and/or patient care:

Educational initiatives should arm providers not only with clinical knowledge about opioid use disorder but with skills to recognize implicit biases, navigate unique barriers related to social determinants of health, and effectively deploy shared decision-making techniques. Healthcare organizations should provide support for trauma that emergency care providers are exposed to in caring for people with opioid use disorder.

Reporting Method:

Consolidated criteria for reporting qualitative studies (COREQ)-32 item checklist

Patient or Public Contribution.

This study did not include patient or public involvement in its design, conduct, or reporting.

INTRODUCTION

As opioid use and overdoses have escalated over the last 20 years both nationally and internationally¹, there has been an urgent push in medical and public health domains to improve the management of opioid use disorder (OUD). ² While the Centers for Disease Control and Prevention reported a slight decrease in drug overdose deaths in the US during the past year, approximately 6 million people in the nation still met criteria for OUD in 2024.³ Negative experiences in healthcare are associated with poor outcomes among people with OUD (PWOUD), including inconsistent primary care utilization, higher use of emergency services, and general distrust in the healthcare system.^4–9

Healthcare providers and PWOUD have differing opinions about drivers of negative experiences^10,11. PWOUD report a lack of provider understanding of their disease, poor care delivery, and stigma.^5,12–14 Providers express fears of being deceived by PWOUD and a lack of confidence in managing active substance use and OUD.^12,13,15 While some providers acknowledge the biases they have towards PWOUD, most also report feeling invested and motivated to help them but are uncertain how to effectively do so.^{12,13,16–18}

BACKGROUND

Prior work has demonstrated that dissatisfaction from both providers and PWOUD is particularly evident in the emergency care setting. Hawk et al found that stigma, minimization of pain, and lack of OUD specific knowledge were key drivers of negative Emergency Department (ED) experiences.¹⁹ Collins et al found that ED physicians had mixed perspectives about initiating medications for opioid use disorder (MOUD) and less than half felt prepared to do so.^20,21 Schoenfeld et al found that individual-level determinants driven by emotion (stigma) were notable barriers to initiation of MOUD by ED physicians.²² While the existing literature highlights ongoing patient concerns, to our knowledge no existing research has focused specifically on a direct comparison of patient and provider perspectives of OUD and how it impacts emergency healthcare interactions.

THE STUDY

The present study aimed to directly compare attitudes and perceptions towards OUD care among emergency healthcare providers (nurses, physicians and paramedics) and PWOUD and to identify barriers to providing/receiving care. Using a mixed methods design, we engaged emergency care providers and PWOUD to understand both groups’ perceptions on opioid use and health, perceptions and behaviors surrounding naloxone use, and finally how prior interactions with each other shape their current view of OUD care in the ED.

METHODS

Design

This was an observational mixed-methods study.

Study Setting and Sampling

Emergency healthcare providers working in a tertiary care academic medical center in New England were invited to participate by email. PWOUD were recruited in person from the ED at the same medical center and at a local community-based harm reduction agency, and those who completed an interview were compensated with a $50 retail gift card. Study participants were recruited for the interview until thematic saturation was reached in each group (PWOUD and providers).

Inclusion and Exclusion Criteria

All study participants were at least 18 years of age, able to communicate in English, and not under police custody. Additionally, all emergency healthcare providers were either a physician, advanced practice provider (physician assistant or nurse practitioner), registered nurse, or EMS provider (paramedic, dispatcher). PWOUD were included if they self-reported non-medical opioid use within the past five years and either presented to the ED for an opioid-use related complaint (e.g. overdose, abscess from injection drug use) OR presented to a local harm reduction agency for opioid related services (e.g. syringe exchange, naloxone).

Data collection

Using a mixed methods approach we assessed five major domains: 1) perceptions on opioid use and health, 2) perceptions and behaviors surrounding naloxone, 3) treatment for OUD, 4) interaction with the healthcare system/PWOUD, and 5) memorable experiences. Due to differences in the two study populations’ levels of healthcare literacy and availability, data collection methodology differed.

Healthcare providers were administered an electronic survey containing multiple choice, Likert scale, and two open-ended questions (Appendix). Prior to deployment, the survey was pilot tested by five physicians not affiliated with the study and revisions were made based on feedback. Upon completion of the survey, providers were also invited to participate in a semi-structured interview to explore the same topics in-depth (Appendix). PWOUD completed semi-structured interviews only (Appendix).

Semi-structured interviews took place via secure video conference or in-person in a private room. Each interview included two study team members (an interviewer and notetaker) and were conducted by SC (MD, PhD, cis white female physician), BC (BS, cis white female research coordinator), AM (BS, cis white female medical student at the time of the interviews), and MT (BS, RN, cis white female research coordinator at the time of the interviews). All interviewers underwent qualitative research training via formal coursework (SC) and/or training sessions conducted by an experienced qualitative researcher (SC, BC, AM, and MT). Study staff had no prior personal or professional relationships with any of the PWOUD participants. SC had professional relationships with some of the providers and therefore did not participate in any of these interviews and was masked to their identities. The remaining research staff had no personal or professional relationships with any of the provider participants. All participants were provided with the name of the principal investigator during the consent process and were informed that she is an emergency physician at the medical center.

A Research Electronic Data Capture (REDCap) database was used for all demographic and survey data collection.²³ All interviews were audio recorded, transcribed, and scrubbed of identifiers in a HIPAA- compliant fashion. Transcripts were not returned to participants for review, nor did participants provide guidance on the findings.

Data analysis

Surveys > 50% complete were included in the analysis. Descriptive statistics were calculated for all variables: frequencies and percentages for categorical data, medians and interquartile ranges for ordinal data, and means and standard deviations for continuous data.

Likert scale responses were treated as categorical data for descriptive purposes and analyzed as ordinal data using non-parametric tests. Categorical data were analyzed using Chi-square test or Fisher’s exact test, depending on expected cell frequencies. Ordinal data were analyzed using the Wilcoxon rank-sum test (for comparisons between two groups) or Kruskal-Wallis test (for comparisons among more than two groups). For statistically significant results involving more than two groups, post hoc pairwise comparisons were conducted using Wilcoxon rank-sum or Chi-square tests with Bonferroni correction. All statistical analyses were conducted using R (Version 4.4.1, Vienna, Austria).²⁴

Semi-structured interview data were analyzed using directed content analysis to explore the five main interview domains noted above.²⁵ The coding structure was developed by the study team (BC, SC, LC, RDM, and AM) and was based on deductive codes from the core domains and additional codes that emerged from review of the transcripts. Once the coding scheme was developed, the first five interview transcripts were coded independently by two coders (AM and LC) who met to review and update the codebook for clarification and consistency. New codes were created when novel topics were introduced in subsequently coded transcripts. Previously coded transcripts were re-coded to accommodate the updated coding structure. The remaining transcripts were then double coded using the final codebook and compared for agreement. Any discrepancies were discussed with a third reviewer (BC) until agreement was reached. Agreed-upon codes were entered into NVivo qualitative data analysis software (Version 12). Coded data was analyzed and reviewed by study staff (SC, BC, AM, LC) to identify recurrent themes and draft topic summaries for each domain.

Ethical Considerations

The study was approved by the UMass Chan Medical School Institutional Review Board (docket number H00015590). Informed consent was obtained from all participants prior to participation. Methods and reporting followed the consolidated criteria for reporting qualitative studies (COREQ)-32 item checklist.²⁶

RESULTS

Characteristics of the Sample

Of the 388 providers invited to participate, 100 responded, and 68 completed > 50% of the survey (Table 1). The majority of providers identified as white (76.9%) and non-Hispanic (86.8%). Approximately half of the interviewees had 10+ years of experience working in emergency medicine/EMS and nearly all (95.8%) had administered naloxone for an opioid overdose. Eleven of the 68 providers also completed the semi-structured interview.

Table 1:

Sample Demographics

Healthcare Provider Demographics (N=68)			PWOUD Participant Demographics (N=22)
	N	% of Total		N	% of Total
Age (years)
less than 25	1	1.5%	less than 25	1	4.5%
25–34	26	38.2%	25–34	9	40.9%
35–44	19	27.9%	35–44	7	31.8%
45–54	13	19.1%	45–54	2	9.1%
55–64	7	10.3%	55–64	2	9.1%
65+	1	1.5%	65+	0	0.0%
Unreported	1	1.5%	Unreported	1	4.5%
Sex
Male	37	54.4%	Male	15	68.2%
Female	31	45.6%	Female	7	31.8%
Race
White	50	76.9%	White	14	63.6%
Black/African American	3	4.6%	Black/African American	0	0.0%
Asian	6	9.2%	Asian	0	0.0%
Other	3	4.6%	Other	5	22.7%
Mixed	3	4.6%	Mixed	2	9.1%
Unreported	0	0.0%	Unreported	1	4.5%
Ethnicity
Hispanic/Latino	2	2.9%	Hispanic/Latino	6	27.3%
Unreported	7	10.3%	Employment Status
Occupation			Unable to Work/Unemployed	15	68.2%
Physician	26	38.2%	Employed (Part-time/Full-time)	5	22.7%
Nurse Practitioner/Physician Assistant	3	4.4%	Homemaker	1	4.5%
Registered Nurse	20	29.4%	Unreported	1	4.5%
Emergency Medical Technician/Paramedic	16	23.5%	Highest Degree or Level of School Completed
Other	3	4.4%	High School Education or Less	16	72.7%
Years of Experience in Emergency Medicine/EMS			Higher Education	2	9.1%
6 months-1 year	4	5.9%	Trade, Technical, or Vocational Training	3	13.6%
1–5 years	14	20.6%	Unreported	1	4.5%
5–10 years	18	26.5%	Current Housing Situation
10+ years	31	45.6%	Unhoused	14	63.6%
Unreported	1	1.5%	Apartment/House	6	22.7%

Semi-structured interviews were conducted with 22 PWOUD (Table 1). The majority identified as white (63.6%), non-Hispanic (72.7%), male (68.2%), and had a high school diploma or less as their highest level of education (72.7%).

Of note, interview data collected about the “treatment for OUD” (specifically, MOUD) was extensive and exceeded the scope of this paper, thus it will be reported separately: the following results report on the other four domains. Table 2 shows the final codebook and code frequency for the four included domains.

Table 2:

Applied Thematic Analysis Codebook and Code Frequency

Code	Description	N (%) Mentioning Code
Domain 1: General perception on opioid use and health
Utilization of healthcare services	Includes both appropriate and inappropriate use; dental care.	21 (63.6)
Facilitators and barriers of healthcare	Includes access, etc. Excludes MOUD-based treatment for OUD.	31 (93.9)
Opioid use	Includes provider "othering" comments (i.e., what providers think about PWUD's opioid use). Excludes initiation of opioid use.	11 (33%)
Perceptions	Includes safety of use; addiction as a disease; stigma surrounding opioid use; etc.; patient perceptions regarding themselves (i.e., I think my fentanyl use is bad.); patient perceptions on what others think about them (i.e., My mom thinks my fentanyl use is bad.); othering (i.e., Other PWUD think their fentanyl use is bad.). Excludes desire to stop using/ continue using.	32 (97.0)
Adverse health effects	Includes treatment of cellulitis, HCV, endocarditis, etc.; utilization of services; opioid overdoses; the null. Excludes treatment for OUD.	27 (81.8)
Reasons for opioid use
For continuing use	Includes desire to stop/ continue use.	15 (45.5)
Transition to 'regular' use	Includes timeframe; use patterns (i.e., motivation to use, 'risky' transitions).	26 (78.0)
Domain 2: Perceptions and behaviors surrounding naloxone use
Physical and emotional feeling	Includes actual; perceived; signs and symptoms surrounding opioid withdrawal.	78.8)
Perceptions	Includes impact in the community; impact on the participant personally.	29 (87.9)
Past experiences	Includes receiving; administering; circumstances surrounding the event (e.g., if they have ever been administered naloxone for reversal of a suspected opioid OD, if they were transported to the ED or not, etc.); the null.	33 (100)
Impact on behavior and usage	Includes the null.	29 (87.9)
Access and availability	Includes perceptions on availability; actual availability; comments about carrying naloxone (i.e., if they/ someone they know does/ does not carry it); the null.	33 (100)
Domain 3: Interaction with the healthcare system (PWOUD) or with PWOUD (for providers)
Interaction with healthcare system	Includes interpersonal relationships; how the situation played out. Excludes comments about the pathology that brought them to the ED.	6 (18.2)
Public health efforts	Includes efforts targeted at prevention, treatment of OUD; hospital-based efforts, training. Includes the null.	29 (87.9)
Domain 4: Memorable experienes and knowledge sharing
Positive experiences	Includes the null.	23 (69.7)
Negative experiences	Includes the null.	31 (93.9)
Pearls	Includes things that they wish the other group knew.	30 (90.9)

Survey Data (Providers) & Semi-Structured Interview Data (PWOUD and Providers)

For each domain, provider survey results are presented first, followed by qualitative interview summaries from both participant groups.

Domain 1: General perception on opioid use and health

When queried about their agreement with the statement “Addiction is a Disease”, 75% of providers agree to some extent (Figure 1). There were no statistically significant differences in responses across age or sex. However, when compared by occupation, physicians were significantly more likely to respond affirmatively than nurses (95% vs 76%, p = 0.01). Just over half of providers (63%) felt that most PWOUD want to stop using opioids.

Figure 1:

Provider responses regarding addiction as a disease.

Providers noted that PWOUD were at higher risk for adverse health effects, as many left the hospital prematurely via self-directed discharge (i.e. “against medical advice”) or declined care due to fear of opioid withdrawal. Providers noted that while PWOUD recognized death as a possibility of their substance use, they overlooked other serious complications (e.g. brain injury). Non-medical-related determinants—such as legal troubles, financial strain, lack of social support, and safety concerns— were often cited by providers as perceived drivers of ongoing opioid use and/or barriers to treatment and recovery.

“I distinctly remember a patient with an abscess from shooting up heroin… It was extensive, and needed IV antibiotics. Clearly she was very actively using, and was upfront about it….she said “… I’m not gonna be able to use while I’m in the hospital”. And.. she’s not set up for methadone or Suboxone… She really wasn’t in that place. She’s like “I’m gonna go into withdrawal, and I’m gonna feel like garbage. I hear you, I see what I need, and I can’t do that.”... [She was] honest and upfront and was trying to work at a plan that both kept her safe and met her needs because anything else, she wasn’t going to comply”

- Female physician, 45–54 years old

“They are nobody’s favorite patients.... even their chronic medical issues are much harder [to treat] because they have opioid addiction”

- Female Physician 45–54 years old

PWOUD agreed with providers that addiction is a disease, but their opinions on the role of choice in first use and return to use varied. Both groups recognized a blurry line between choice and compulsion, with many PWOUD describing addiction and opioids as powerful forces that “take hold” and must be escaped from. While PWOUD often express a desire to quit, they feel powerless, fearing their addiction is “too strong.” Opioid use is viewed as a coping mechanism to manage physical and/or emotional pain and maintain “normalcy”.

“[with experience]... you start realizing that there [are] very few people out there that got themselves into this situation ‘cause they wanted to, and they’re just as much of a human being as you are. When you start putting [PWOUD] in that category rather than some other category, it becomes a lot easier to empathize and see the difficulties they have with people that were just like me who were looking at them as something less than a person.”

- Male physician, 25–34 years old

“...waking up with [opioids] being your automatic first thought with you know, no say or control over that, that makes your whole day revolve around it.”

- Male with OUD 25–34 years old

“It’s not living, it’s’ just existing”

- Male with OUD 25–34 years old

Participants describe their environment as an important influence on their experience of addiction. Many mentioned feeing less judged and more comfortable around others who use opioids, and their social circles, where substance use is common, often reinforce and drive continued use. Experiences of homelessness and family history of addiction were also discussed: some participants reported that addiction affected multiple close family members, while others described being estranged from family members who did not have opioid use disorder. These perceptions highlight the complex social and familial contexts shaping participants’ experiences.

“It used to be a joke ..I’d say “Oh, yeah. A family that smokes together stays together.” But it’s not funny. ‘Cause my kids are addicts. My grandmother is an addict. My sisters and brothers are addicts. My mother’s an addict. I say, it’s not funny. We’re all addicts.”

- Female with OUD 45–54 years old

“If you’re in the streets and you’re homeless and you’re walking down…[STREET NAME], all there is everyone out walking and if that’s all you’re around, how are you going to get clean? You know? You can’t get clean unless you change your whole lifestyle completely, everyone around you, your cell phone number, you know.”

- Male with OUD 25–34 years old

“I’m outside, it’s so cold right now. If I do dope, I’m warm for five hours. Last night, I had no blankets. … If I didn’t get high, I wouldn’t be able to take it, I would probably kill myself.”

- Male with OUD 35–44 years old

Regarding health conditions, PWOUD were particularly concerned about infectious diseases from intravenous drug use (e.g. HIV and Hepatitis C), psychiatric issues, and exposure to trauma. Their perception of health often hinged on the absence of bloodborne infections. Untreated pain accounted for a significant portion of reported adverse health events. PWOUD often believed they could manage their pain independently. While they acknowledged the risk of death from opioid use, many were ambivalent, viewing death as more peaceful than the suffering associated with withdrawal and OUD.

“Don’t automatically assume we’re looking for Percs or pills just to get high because if we want to get high we can get it cheaper on the street. We come to the hospital because there is something really wrong. We don’t come there because we want to get high.”

- Female with OUD 45–54 years old

Domain 2: Perceptions and behaviors surrounding naloxone use

Providers were split in their opinions on naloxone’s impact on behavior: 48% felt that naloxone changes the way people use opioids while 50% did not. There were no differences by age, sex or occupation. Seventy-one percent felt that community naloxone availability has had a positive impact on the opioid crisis, with no difference by age or sex. However, when compared by occupation, physicians were more likely to opine that naloxone availability had a positive impact on the opioid crisis when compared to nurses (96% to 50%, p = 0.00). Fifty-nine percent of providers thought that PWOUD would be “likely” or “extremely likely” to administer naloxone to someone if available (Figure 2), with no statistically significant differences in provider responses across age or occupation. However, male providers were more likely to respond affirmatively to this question than females (73% to 42%, P = 0.00).

Figure 2:

Provider responses regarding likelihood of PWOUD to administer bystander naloxone

Providers saw naloxone as a necessary but uncomfortable intervention, sometimes resulting in aggressive wakeups; because of this, they tend to brace themselves for potential violence afterward. Providers focused on the physical effects, believing PWOUD should value life over temporary discomfort.

“ You use caution… you only have to be assaulted once. It’s like you don’t give Narcan to someone without putting a knee over their arm so they can’t reach out to strike you with it…you cross your legs and cross their legs and control their legs so you don’t get kicked.”

- Male paramedic, 55–64 years old

PWOUD expressed internal conflict over the pros and cons of naloxone. While they expressed pride in their ability to save others with naloxone, most resented receiving it themselves, viewing it as painful and disruptive. Some avoided using it on peers, resorting to alternatives like cocaine or physical force, fearing arrest or retribution from the affected individual if naloxone was their first tool. PWOUD described naloxone as aversive, contrasting it with the peacefulness of overdose, and described shame, anxiety, and an intense desire for more opioids after reversal. Most acknowledged naloxone’s benefits but preferred death over receiving it. They carried it for themselves and others, seeing it as a symbol of care, especially because they felt outsiders (EMS, police) were often slow to respond to overdose calls

“It [naloxone being available] makes me feel like we are all in this together”

- Female with OUD 45–54 years old

“It comes with the territory. If you are getting high you might OD and get narcan’d”

- Male with OUD 35–44 years old

“It feels like your guts are coming out of your mouth and you get really cold, your stomach tightens up, like you are dope sick. Then you get hot and you are just like puking everything up even if you have nothing in your stomach, you’re puking straight bile. It’s the worst feeling in the world. Every time I get Narcan, I would love to break someone’s neck.”

- Female with OUD 45–54 years old

“I get violent on [narcan]...like I’m gonna kill anyone”

- Male with OUD, 35–44 years old

“At first, she looked like she was sleeping and she had the needle in her arm still. And then she wasn’t breathing… I was wondering where the Narcan was… I was so scared, I didn’t know how to use it.. I don’t know how much to give. I just did one half up one nostril and one up the other. In the meantime I was trying to do CPR. Her jaws were like stuck closed and I couldn’t open her mouth. I was so pissed because if she were to die, the fact that I probably would’ve gotten into trouble because I’m on probation. And then she woke up and was not like “Thank you for saving me” but was like “ You better buy me a bag because you just Narcan’d me.”

- Male with OUD, 35–44 years old

Providers were divided on whether naloxone availability influenced drug use behaviors. PWOUD reported that naloxone did not increase their own opioid use but provided a sense of safety. Some worried it may make others reckless, but most agreed people don’t intentionally overdose as it was highly undesirable to need naloxone.

“..some people think of it [naloxone] as a little bit of a safety net. But I don’t know that it changes their behavior. I think addiction is addiction, and the drug is running their life, not so much a safety net. I don’t think the safety net is really much of a consideration for someone who’s primary concern on a day-to-day basis is “Where and I gonna get the money for the drugs and am I gonna be able to not feel sick today?”

- Male paramedic, 35–44 years old

PWOUD primarily obtained naloxone from harm reduction programs or peers, not pharmacies or prescriptions. Providers were less likely than PWOUD to carry it regularly, citing cost, liability, and low perceived need outside of work, though some suggested storing naloxone in public spaces in a similar fashion to automated external defibrillators (AEDs).

Domain 3: Interaction with the healthcare system (PWOUD) or with PWOUD (for providers)

When asked an open-ended question about difficult interactions treating PWOUD, provider responses generally focused on person-specific difficulties. Person-specific difficulties mentioned aggression (N=14), chronic pain (N=13), dishonesty about opioid use (N=14), difficult encounters (N=8), issues with accessing MOUD treatment options (N=1), and ambivalence towards health (N=1). Process specific difficulties that were mentioned included lack of adequate analgesic options (N=1).

Honesty was a concern, with 43% of providers reporting they thought PWOUD were never or rarely honest about their opioid use with healthcare providers, and another 48% answered neutral (“sometimes honest”): no one in the sample selected “always honest” (Figure 3). There were no statistically significant differences in responses across age, occupation or sex.

Figure 3:

Provider responses regarding honest of PWOUD, their own knowledge, and likelihood of initiation conversation about OUD treatment.

Regarding the current effort of the healthcare system to address the opioid crisis, the consensus is that the efforts are well-intentioned but poorly executed, and that there is substantial room for improvement. The majority of participants felt that providers in general were not being adequately educated to treat PWOUD (61.8%), with only 55.9% feeling that they personally were adequately trained (Figure 3). While there was no difference by age or sex, there was a difference when compared by occupation– significantly more EMS providers felt they were adequately trained than nurses (75% vs 20%, p = 0.02).

Only 31% of providers felt they were “very knowledgeable” about treatment options for OUD, with 46% of providers being neutral and “somewhat knowledgeable” on the topic. Sixty-two percent of providers reported they were “likely” or “extremely likely” to initiate a conversation about OUD with their patients (Figure 3). There were no statistically significant differences in responses to either question across age, occupation, or sex.

Providers acknowledged the existence of stigma and expressed frustration with their inability to address the systemic issues and behaviors associated with treating PWOUD. They often feel helpless, wishing for more resources to treat pain and other symptoms. Many criticized the focus on acute rather than chronic treatment, describing a “spin-dry” culture where PWOUD are detoxed but returned to the same environment without adequate long-term support, leading to rapid relapse.

“I feel like we don’t support the mental health aspect of things as much as I think we should. We tend to treat very physical [symptoms]...”

- Female RN 35–44 years old

“Traumas [cases] are easy. They’re very straightforward. This kind of population isn’t straightforward. It isn’t so easy. It takes a lot of experience, and it does take a lot of training. We just don’t have that.”

- Male physician, 25–24 years old

PWOUD often viewed emergency services, including EMS and EDs, as “last resorts” and generally perceived hospitals as unsafe spaces, making significant efforts to avoid them. Once labeled as “drug users,” PWOUD felt that providers stop caring about their overall health. In hospital settings, their substance use often became the primary focus, leading to defensiveness about follow-up questions related to opioids, which they saw as irrelevant to their main concerns. PWOUD preferred to receive care at community outreach programs and homeless shelters where they felt less judged.

“I didn’t tell them [about my opioid use] at the hospital either because I feel like whenever you say something all of a sudden you go from patient to peasant…. Next thing you know they are looking at you like a completely different person”

- Male with OUD 25–34 years old

“They go out of their way to help someone that’s not an addict, cause I feel like they think that we’re a waste of time, that we’re just gonna - whatever they help us with, we’re just going to go back and use again “

- Female with OUD 25–34 years old

PWOUD differentiated between trustworthy and untrustworthy providers and were generally distrustful of “nosey” clinicians that asked too many questions. They felt their SUD was irrelevant to most medical care and disliked questions about it and perceived such inquiries as invasive. PWOUD felt that providers focused on addiction at the expense of overlooking co-occurring conditions and admitted to concealing details about their opioid use for fear of judgment and inadequate care. This highlights a significant disconnect between PWOUD and providers, as PWOUD often saw discussions about SUD as unnecessary while providers felt they needed this information to deliver care. Both PWOUD and providers had concerns about each other’s honesty.

“Let’s say I went to the hospital and said “Okay, I have a cold.” They tell you…”Take off your jacket and let’s take your blood pressure.” If they see tracks on my arm…that cold is gonna go out the window… Now they are gonna think that I am sick because I haven’t shot up.”

- Male with OUD, 35–44 years old

“ I wish they would be more upfront oftentimes ... .don’t know if they are ashamed or if they are scared… I’m not asking questions to judge you, I’m asking so I can figure out what is going on and relay that to the hospital. I don’t care what you’ve done. I’m not asking it to get you in trouble or to make you feel dumb… If you tell me what’s going on, then I can help.”

- Male paramedic, 35–44 years old

Providers cited expected barriers to care for PWOUD which included stigma, lack of insurance, homelessness, and incarceration. Access to healthcare can be complicated by conflicts with providers. PWOUD often had strong opinions about effective medications and may have “fired” providers who disagreed, interpreting inflexible rules as personal insults. They felt their complaints were not taken seriously and believed providers hesitated to prescribe needed medications due to fear. PWOUD perceived various factors as evidence of stigma, such as inconsistencies in care, rigid policies, and refusal to provide necessary therapies. Economic hardship further complicated compliance with treatment plans, as high medication costs and transportation issues hindered access, and unstable housing made it difficult to follow many nonpharmacologic treatment plans (e.g. bed rest).

“You get sick and tired of hearing the doctor say “Stay off your feet.” Well that’s kinda hard when you are homeless and you gotta walk all day. Unless someone gives you a wheelchair, you got no choice but to be on your feet.”

- Male with OUD 35–44 years old

Domain 4: Memorable experiences and knowledge sharing

When asked about memorable experiences, both providers and PWOUD overwhelmingly highlighted positive moments, which were seen as rare. PWOUD appreciated experiences where they felt they were treated with dignity, had their pain properly addressed, and felt respected without judgment. Providers recalled grateful patients who were ready to change and noted that interactions with families were often more positive than those with the PWOUD. Both groups viewed successful naloxone rescues as empowering, with PWOUD feeling especially valued when actively involved in resuscitations.

“There have been a couple of memorable [occasions] that really stood out. Like when people took the time to treat me like a human being and not a piece of s**t.”

- Female with OUD 25–34 years old

“Some judge you because you are OD’ing, you know they think “God I have to deal with another overdose again.”... But then you get some EMTs that are so nice and go out of their way to help you and make you comfortable.”

- Male with OUD 35–44 years old

“One particular patient I saw for 20 or 30 years in different places around the state…He actually ended up getting clean when he finally got into a methadone program. He is still sober, got his own job. I look at him and go “That’s why I got into this job.” …. He did it so it can be done…. Anytime I get a little upset about my job, I think “Alright, so I did do one good thing.”

- Female paramedic 45–54 years old

Negative experiences, however, were more common, discussed in broader terms, and seen as the norm. PWOUD often felt dismissed or “red-flagged,” leading them to hide details of overdoses and opioid use. They resented being blamed for their addiction and being given care recommendations that didn’t consider social barriers. Withdrawal and pain after overdoses further clouded their experiences.

“I know at this hospital I was red flagged. And hey you can’t get any pain meds whatsoever…. The wouldn’t give it to me, so I had to go to another hospital for a second opinion….. And there they treated me perfectly normal because I wasn’t flagged.”

- Male with OUD 35–44 years old

“ They don’t look at us like humans… I just don’t get treated with respect”

- Male with OUD 25–34 years old

“If they come in defensive, it can be really difficult not to meet that with your own defensiveness.”

- Female physician, 45–54 years old

“I woke a guy up [with naloxone] and as soon as he was awake, I got shoved….I’ve had to basically fight. You get assaulted by these people who wake up”

- Male paramedic 55–64 years old

“I remember going on a run for this 16-year-old kid who had just been released from the hospital...As soon as he got home he used again and the parents heard him hit the floor, and the father did mouth to mouth … We got there, kid was blue…We gave him Narcan and woke him up. Thekid was an absolute jerk and straight up was like “you take me wherever you want as long as you want and I’m not gonna quit. I like this.” And you know you are looking at the family and they are just devastated.”

- Male paramedic 55–64 years old

Providers cited verbal and physical abuse from PWOUD as a source of fear and frustration, and many felt compassion fatigue from frequent ED recidivism. They also expressed a sense of personal failure when unable to connect PWOUD with treatment resources, though even small successes had a significant impact on their morale.

When asked what they wanted the other group to know, PWOUD and providers both emphasized understanding each other’s intentions and motivations.

The most common theme in provider answers to this question was that they “actually care” and genuinely want to help them without judgment (N=37). They clarified that questions about substance use are not meant to be judgmental but are necessary to provide appropriate care.

“ That we are there to help them and would look to help them in any was possible. Sometimes the offer or the presentation of the help is poor, and sometimes its poorly received. I think there can be miscommunication in both directions. But we are not looking to get them in trouble.”

- Male Paramedic 45–54 years old

“The emergency department is here to help anymore and I’m certainly going to do everything that I feel is necessarily to help anybody I see. I don’t intentionally treat opiate users any differently and I sort of hope their community understands that”.

- Male physician, 25–34 years old

PWOUD wanted providers to recognize that seeking care, especially in the ED, is often a last resort and not always driven by drug-seeking behavior. They stressed that addiction is a disease, not a choice, and urged providers to understand that not all PWOUD are the same, nor were they always “addicts.”

“That every single case is different. Everyone is their own individual. And that even if you know addiction is part of their medical history, still thoroughly examine and see what this prison needs.”

- Male with OUD 25–34 years old

“That they weren’t always an opioid addict and that’s not all they are. They have a family, have a life, and maybe they can get better. People don’t choose to be addicts. No one does. No one would choose this life.”

- Female with OUD 55–64 years old

DISCUSSION

In this mixed-methods study of emergency health care providers and PWOUD, we highlight many perceptual disconnects that impact the way these key stakeholders interact, but also some areas of common experience. Both groups agree with the notion that addiction is a disease. However, there was discordance between the motivations and priorities of PWOUD and what providers thought PWOUD should prioritize. Both providers and PWOUD described being traumatized by prior interactions and explained how these profound experiences shape future interactions. Both providers and PWOUD desire to be understood, to be treated with respect, and to be assumed to have good intentions.

This discrepancy between the priorities articulated by PWOUD and those anticipated by providers reflects a fundamental misalignment in perspectives. For example, both agree naloxone is aversive: but providers felt that it was worth the discomfort to stay alive, while PWOUD sometimes stated they would rather die than experience the pain of withdrawal. Although providers have their own perception of health and wellness (and perhaps what is “right”), imposing those standards onto patients is not only poor practice but yields poorer health outcomes.^27,28 The alternative strategy, patient centered care- which considers the PWOUD’s values, needs, and preferences in care decisions- has repeatedly been demonstrated to increase patient and provider satisfaction, improve engagement and improve outcomes.^29–31 This may be counterintuitive to healthcare providers who have experience and knowledge, but may be lacking in time, resources, and facilitation skills to implement.

There was also alignment between the results in our study and prior literature. Previous research has shown mixed provider perceptions of providing naloxone for opioid use, with a prior study expressing that 55% of all nurses in the sample reported naloxone kits as “a little” or “somewhat” effective. Similarly, in our study, we found that only about 50% of nurses viewed naloxone as a positive impact on the opioid crisis¹⁸. Similar to prior work in PWOUD receiving care in the ED, they describe receiving naloxone as highly aversive and deny any personal change in drug taking behavior based on naloxone’s availability³².

Fundamental attribution error is a cognitive bias that causes people to overemphasize an individual’s personality traits and underestimate external factors when explaining their behavior. For example, providers attributed dishonesty about opioid use to ambivalence about one’s own health and lack of integrity, whereas PWOUD reported prior experiences and fear of being denied proper treatment driving their decision to not to disclose substance use. PWOUD expressed a feeling that providers were immediately judgmental about PWOUD, whereas providers described these reactions as driven by prior traumatic experiences and feelings of helplessness. Fundamental attribution error is one of several cognitive biases that drive bias in medicine (both implicit and explicit),³³ and to which those in fast-paced environments with high cognitive load are particularly prone. Educational initiatives such as implicit bias training or perspective-taking exercises for healthcare providers with a focus on PWOUD as a use case can prime providers to recognize (and temporize) their own tendencies toward fundamental attribution error.

Both healthcare providers and PWOUD describe trauma from prior interactions with one another. This can include physical trauma (e.g. providers getting assaulted, PWOUD getting violently ill during a disorienting overdose reversal) or mental/emotional trauma (e.g. perception of discrimination for PWOUD, or providers not seeing “success stories”). In addition, our data and participant experiences suggest that both groups may also be impacted by “masked trauma”—trauma that is present but not immediately visible or formally recognized, such as underlying psychological distress or cumulative stress from repeated negative encounters. These experiences shape future interactions and set healthcare providers and PWOUD up for a vicious cycle of poor interactions that confirm pre-existing biases. Unrecognized (or masked) trauma may contribute to emotional reactions and reinforce stereotypes among providers, as well as mistrust and avoidance among PWOUD. This finding is consistent with prior literature, which describes the incidence of verbal or physical abuse of emergency healthcare providers to be as high as 70–100%,^34–37 and shows that workplace violence leads to burnout, job dissatisfaction, decreased productivity and compassion fatigue.^37–42 Trauma-informed care, a theoretical framework rooted in social work literature, provides guiding principles for how to care for people who have experienced trauma including trauma-informed care guiding principles (safety, trust, choice, collaboration, and empowerment) in the care of PWOUD and in training and/or support initiatives for healthcare providers could facilitate critical self-reflection, help address unconscious biases and stereotypes, and empower providers to recognize their own needs for support. This would provide a mechanism to both acknowledge this trauma and support providers and PWOUD to mitigate its downstream effects and is an important area for future research.

Limitations of the Work

Our study has a few important limitations. Social desirability bias, or the tendency of respondents to provide answers that they think will be viewed favorably by others, may have impacted responses. We attempted to minimize this by collecting complementary data through an online survey (for providers), ensuring the interviewer was not someone the participant had a pre-existing relationship with (providers and PWOUD), and conducting interviews away from the hospital, in a community-based organization (PWOUD). Our sample also had limited racial and ethnic diversity: while it was representative of the local community, we serve it may not be representative of the larger population. Finally, as in all qualitative studies, participants (including PWOUD and providers) generally only see one side of the larger picture: so, accusations of bias must be carefully considered in the context of other evidence.

This study was conducted in an urban New England location which has some important implications to consider when applying the data to a more general population. Urban locations in the United States have been demonstrated to have more access to OUD treatment and overall less stigma for OUD compared to rural locations^43,44. New England states specifically have been shown to be among the highest in the US on rates of MOUD treatment for people with OUD⁴⁵. Internationally, access to MOUD and harm reduction services also varies, with many Western European countries offering more comprehensive programs and lower stigma than the US, while countries with more restrictive policies or limited resources may face even greater challenges⁴⁶. Future research should continue to explore how local and national contexts shape the experience of PWOUD and healthcare providers.

Recommendations for Further Research

Future research in this area should focus on expanding our knowledge of how these factors differ among diverse populations, how they impact key outcomes, and what interventions result in effective changes. Geographic and individual diversity should be studied to understand how perspectives are different across providers and patients with varying racial/ethnic, gender and socioeconomic backgrounds. Work to elucidate the impact of such biases on clinical outcomes, patient-oriented outcomes, provider career satisfaction and burnout will provide more concrete evidence of the importance of change. Finally, studies to understand the impact of educational and other interventions on cognitive biases and provider/patient outcomes will help us understand how to improve the quality of the experience for both providers and patients.

Implications for policy and practice

Irrespective of some limitations, these data provide valuable insight into the experiences and relationships of PWOUD when they engage with emergency care. The disease of OUD creates incredible challenges for both the people who live with it and those who strive to care for them. It is critical to recognize that these challenges generally are reflective of external factors (part of the disease process and its complications) as opposed to character flaws of the people involved. Educational initiatives should aim to arm providers not only with clinical knowledge about OUD but with the skills to recognize implicit biases and to seek (and respect) PWOUD’s perspective when making care decisions even if those decisions differ from their own. Healthcare organizations should also recognize and provide support for the potential for trauma that emergency care providers are exposed to in caring for PWOUD.

CONCLUSION

Disconnects between the perception of PWOUD and emergency healthcare providers impact the way these key stakeholders interact. Both groups have experienced trauma through these interactions and are vulnerable to fundamental attribution error. Both providers and PWOUD desire to be understood, to be treated with respect, and to be assumed to have good intentions. Knowledge of the similarities and discordances in perspectives of both healthcare providers and PWOUD can be leveraged in future efforts to inform provider- and patient-facing education/outreach initiatives, to improve patient-provider relationships, and to improve health outcomes for PWOUD.

Statement on Statistics:

There is a statistician on the authorship team (Nirzari Kapadia). The authors have checked to make sure that our submission conforms as applicable to the Journal’s statistical guidelines. The author(s) affirm that the methods used in the data analyses are suitably applied to their data within their study design and context, and the statistical findings have been implemented and interpreted correctly. The author(s) agrees to take responsibility for ensuring that the choice of statistical approach is appropriate and is conducted and interpreted correctly as a condition to submit to the Journal.