‘The healthcare system was just trying to deal with me without really dealing with me’: exploring individual experiences of methamphetamine-related emergency department visits in Calgary – a qualitative study

Abstract

Introduction

Methamphetamine use has risen dramatically in North America, contributing to increased emergency department (ED) visits marked by agitation and complex psychosocial needs. While clinical consequences of methamphetamine use are well-documented, there is a paucity of research capturing the perspectives of people who use methamphetamines (PWUM) when accessing emergency care. This study aimed to explore the lived experiences of PWUM in ED settings to identify service gaps and inform patient-centered care strategies.

Methods

A qualitative exploratory study was conducted using semi-structured interviews with PWUM who accessed ED services in Calgary, Alberta within the past five years. Participants were recruited through community-based organizations and professional networks. Interviews were audio-recorded, transcribed, and analyzed using Braun and Clarke’s six-phase thematic analysis approach. A member-checking session was conducted with individuals with lived/living experience to validate findings.

Results

Five interviews were included in the final analysis. Three major themes emerged including: first, experiences of stigma in which participants described feeling judged, dehumanised and often received differential treatment following disclosure of methamphetamine use. This led to avoidance behaviours including leaving against medical advice and withholding substance use histories. Second, many highlighted the need for care beyond acute needs. While acute medical concerns were addressed, participants perceived a lack of attention to underlying psychosocial and addiction-related issues. Opportunities for deeper engagement and referral to supportive services were frequently missed. Lastly, participants provided recommendations for care delivery, namely enhanced integration of acute, mental health and community services; inclusion of peer support workers with lived experience; and creation of alternative care settings tailored to the needs of PWUM.

Conclusions

PWUM experience significant stigma and perceive ED care as focused solely on acute stabilisation rather than holistic, person-centred support. Their recommendations call for systemic changes that address both clinical and psychosocial dimensions of care. Integrating peer navigators, expanding service linkages and establishing alternate care environments may improve patient trust, engagement and health outcomes. Future work should incorporate these perspectives to develop more compassionate and effective emergency healthcare responses for PWUM.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Patient-centred perspective: The inclusion of participants with lived and living experience of methamphetamine use enabled the study to explore emergency care experiences directly from the perspectives of those most affected.

• Qualitative methodology: Our study implemented a rigorous qualitative methodology which aimed to elicit in-depth participant experiences. This was further cross referenced with a panel of people with lived/ living experience of methamphetamine use which improves the validity of our results.

• Limited participant panel: The limited participant panel and recruitment from a single urban center may restrict the generalizability of our study results.

• Selection and response bias: Recruitment through community networks and voluntary participation may result in selection, social desirability and recall biases which may have influenced the study results.

Background

Methamphetamine - related and methamphetamine - induced agitation is a growing challenge facing emergency services in North America. With 2.5 million individuals reporting the use of methamphetamines in the USA as of 2021,¹ and an additional 59 000 individuals reporting its use in Canada in 2018, methamphetamine consumption remains widespread.² In Alberta alone, methamphetamine use increased by 168% between 2010 and 2017.³ Similarly, the province of Manitoba, Canada has seen a 1700% increase in patients using methamphetamine between 2013 and 2017.^{2 4} As a result, these areas see greater interactions between individuals seeking assistance for methamphetamine use and emergency service providers. With a growing number of methamphetamine-related emergency department visits, it is critical to better understand the hospital experience from the perspective of the individual accessing care.

People use methamphetamine for a variety of reasons and the prevalence of use is higher among marginalised communities namely, individuals experiencing (or who have experienced) trauma, individuals with a history of polysubstance use, sexualised substance use (or using substances prior to sexual interactions), housing insecurity and other comorbid psychiatric disorders.^5–7 Furthermore, long-term use of amphetamines (including methamphetamine) is associated with increased rates of suicidality, psychosis, violence and depression.^8–10 In addition, mistrust of allied healthcare professionals and intense emotions resulting during emergency department visits serve to exacerbate this methamphetamine-induced-violent behaviour.¹¹ Taken together, managing methamphetamine-induced agitation and/or psychosis is clinically complex, making it challenging for healthcare providers and community-based front-line workers to deliver quality and timely care.¹²

Despite ample research outlining the short-term and long-term health effects associated with methamphetamine use,^{8 13 14} little is known about the clinical interactions for people who use methamphetamines (PWUM). Although patient medical records capture the incidence, prevalence and clinical details regarding methamphetamine-related emergency department interactions, to our knowledge there are no studies which examine the perspectives of people using methamphetamines accessing care. As such, to better identify service gaps and provide practical interventions to improve healthcare experiences among PWUM, we aim to assess their experiences in accessing emergency departments and receiving in-hospital care.

Literature review

The authors completed a literature review with a focus on the qualitative experiences among PWUM and interactions with an emergency department or acute care setting. The authors considered peer-reviewed articles published between 2012 and 2022. The authors focused on literature reported from a North American context. Only publications in English were included. Inaccessible full-text studies, conference abstracts and article reviews were excluded. There was robust quantitative literature showcasing the incidence and prevalence of methamphetamine presentations to the emergency department; however, the authors discovered limited academic insight relating to the experience of receiving healthcare among patient populations who use methamphetamines.

Methods

Research design and framework

This research project uses a qualitative exploratory design with in-depth, semistructured interviews. Interview questions were developed and rooted in a framework that allowed the research team to explore the complexities associated with substance use and the biopsychosocial phenomena, and how these culminate and intersect with the emergency department system. People with lived experience reviewed the interview content to ensure it was appropriate and respectful. Inspired by the principles of trauma-informed care, the semistructured interview guide was designed by the research team, informed by past research and professional knowledge, to elicit information regarding the experiences of receiving clinical care due to methamphetamine intoxication (online supplemental appendix 1).

Data collection

Participants were recruited from community-based organisations and by word-of-mouth through existing professional networks. The research team contacted interested participants where the project was discussed in more detail, participants were screened for eligibility and an interview was scheduled. Inclusion criteria consisted of age greater than 18 years and had accessed a Calgary Zone Emergency Department for a methamphetamine-related concern within the past 5 years.

Data were collected over a 3-month period (May–August 2022) and participants were compensated with a CAD$50.00 prepaid VISA card and transit fare, if required. Prior to the interview, the research team reviewed the project details and consent forms and answered any questions. All interviews were audio-recorded, transcribed verbatim, anonymised and reviewed for accuracy.

Data analysis

Interviews were completed, transcribed and analysed by three researchers (CS, DV and BL) over 3 months. All three had experience with qualitative coding, with CS having master’s level training.

Transcripts were systematically reviewed by the research team using inductive thematic analysis, in alignment with a qualitative description framework. Following Braun and Clarke’s (2006) six-step thematic coding process, researchers manually analysed the transcripts line-by-line to generate 138 initial codes.^{15 16} The codes were collaboratively developed into 23 themes and subthemes until code saturation was reached.¹⁷ A member-checking session was completed with people with living and/or lived experience of methamphetamine use, as content experts, to determine the accuracy of the findings and to ensure the themes were trustworthy, authentic and credible. Themes were presented locally at a Tuesday Night version of narcotics anonymous known as ‘Tweaker Tuesdays’. The three most essential themes were collated for publication in this paper.

Results

Six participants completed qualitative interviews during the study period. Three interviews were completed in-person and three interviews were completed using the Zoom video conferencing platform. One participant’s experiences did not occur in Calgary and their information was excluded from the analysis. A total of five interviews were analysed. Although it was not a criterion, all participants disclosed they were not currently using methamphetamines around the time of the interview. Three major themes were identified within our analysis: (1) individuals’ experiences of stigma, (2) going beyond acute medical needs and (3) patient preferences for healthcare delivery. Additional supporting quotes for themes can be found in online supplemental appendix 2.

Individual experiences of stigma

One of the major highlighted themes discussed through the work was individuals’ experiences of stigma when interacting with healthcare workers. Individuals noted that disclosing their use of methamphetamines resulted in differences in treatment from staff members.

Just like the treatment from the nurses and…it was just…I felt like I wasn’t worthy enough to be there…they just wanted nothing to do with me. And I could feel that. (P_05)

In many cases, and in an attempt to counteract the aforementioned experiences, individuals using methamphetamines would choose to omit this information from their medical history or from discussions with their healthcare providers.

When I was with people who were actively using with me and had to go to hospital… all of us collectively agreed to not admit to drug use or you will not receive the same kind of care. (P_04)

These experiences of likely both overt and perceived stigma and mistreatment between healthcare staff and people using methamphetamines resulted in many participants expressing a desire to leave against medical advice.

I just wanted to get out of there at that point… I went there cause I thought I was in need of medical attention but then when they sat me in the hallway… I felt like people were judging me, that was the last place I wanted to be. (P_06)

Overall, interview participants expressed a desire to be treated similarly to others accessing care within emergency departments.

Even though I’m…actively using…I’m still a person. I still have needs or wants. And that they matter. Just because I’m homeless or on drugs, doesn’t mean I’m any less of a person. (P_05)

Individual experiences of stigmatisation and mistreatment due to disclosure of their substance use were pervasive across interviews impacting both perceived and actual quality of care received within Calgary emergency departments.

Going beyond acute medical needs

Participants reflected on the core functions, expectations and responsibilities of an emergency department within the context of providing physically acute and psychosocial care for PWUM. Participants perceived that their healthcare management was often strictly focused on their acute needs, with no focus on further preventative, harm reduction or treatment measures for their substance use. While participants’ presenting symptoms were treated, they reported that there was insufficient dialogue about the broader experiences of their methamphetamine use.

I ended up there twice…the staff were good at giving… me the liquids I needed to come back to life again but there was never any questioning about what was going on… it was good that they were able to diagnose that symptom. But again, they didn’t go any further. (P_02)

In many cases, participants reported that healthcare providers often neglected to ask about the circumstances leading up to their hospitalisation or to begin to build relationships with those they interact with.

At the same time, it just felt like the healthcare system was just trying to deal with me without really dealing with me. (P_04)

And I’m thinking back on this now but wouldn’t have that been the perfect opportunity to maybe ask what happened? And I’m not saying if they had asked me if I was a drug user [that] I would have necessarily been honest, but I think there was a missed opportunity there to have a conversation… (P_02)

One participant perceived that these shared experiences could be in part due to lack of specialised training in addictions within emergency departments or the desire to understand the stressors faced by individuals using methamphetamines accessing care.

I think for the most part, they did a good a job for treating me medically for what was wrong with me. I don’t think they understood…how addiction works or like meth…medically they did a great job because my infection was treated, but…they don’t specialize in addictions and…having as much empathy or understanding for what a person…is actually going through behind just the addiction itself. (P_06)

Patient recommendations for improving healthcare delivery

Participants identified several missed opportunities for patient engagement and medical support. They also offered three tangible strategies to enhance healthcare delivery to PWUM in the prehospital, emergency department and in-hospital environments. They include enhanced service integration, peer-based supports and the potential for an alternative care environment (eg, sobering centre). They also noted the need for tangible and practical resources on discharge.

To begin, participants identified that more holistic service integration including acute care, psychological services and other community support was lacking within emergency departments resulting in missed opportunities to access these services.

So when I was in the hospital it was an opportunity to engage with potential other care. So there could have been an opportunity to refer me to detox or treatment…but that didn’t happen, so… I ended up back in the cycle of addiction. (P_01)

Furthermore, participants noted that presenting these services as an option to individuals accessing care may increase their visibility and assist individuals in making better informed healthcare decisions.

Even just knowing that there was support, that I could access, would have helped. (P_05)

Improving service integration, visibility and accessibility was a key area of improvement identified by study participants to potentially address their addictions or other underlying social or mental health concerns.

Second participants discussed peer based navigation services (or emergency department support by individuals with lived/living experience of substance use) would improve access to services and shared patient advocacy among peers and patients.

You know it would be really great if, you know, if in that circumstance there needs to be some sort of peer advocate who is there to ensure the experience of the patient. (P_04)

Participants highlight that these types of peer-based supports would help to facilitate meaningful and non-judgemental discussions surrounding substance use supports. In some cases, participants had already experienced peer support programmes within healthcare settings and noted that the trust within individuals provided a grounding presence which aided them to be more calm and comfortable within stressful emergency department settings.

Lastly, due to the adverse events occurring within emergency departments, participants expressed a desire to access alternative care settings which are either situated within, in close proximity to or even completely separate from emergency departments.

Here’s a bigger picture, and let’s get into this now…the emergency room is not the best place for people coming in using meth. Right now the emergency room is the only option because there really are no other services. (P_01).

Overall, participants highlight both previous and ongoing experiences of stigma when discussing their experiences within emergency department settings and when interacting with healthcare workers. Participants felt as though only their acute medical needs were attended to, while their substance use and social situations were often overlooked. Lastly, participants suggested three strategies to address the ongoing mistrust with the healthcare system including holistic service integration, peer navigators or advocates and alternate care settings.

Discussion

To our knowledge, this is the first study to examine the perspectives of PWUM and their interactions with acute care systems. Indeed, while there is significant literature which examines the perspectives of healthcare workers regarding the management of individuals using methamphetamines^{12 18–20} as well as long-term patient outcomes from its use⁸ patient perspectives remain limited. Participants were homogeneous in the sense that they all used the same type of drug (methamphetamine) in the same geographic location (City of Calgary) and participants offered rich narratives of their experience in interviews that last well over 45 min in most cases.

Stigma and its impact on healthcare interactions

Stigma surrounding substance use (including methamphetamines) is pervasive within healthcare settings,²¹ and continues to be a central theme within our research. Individuals often felt dehumanised and judged when interacting with healthcare staff, resulting in both increasing rates of leaving against medical advice and hiding their substance use and other harmful behaviours. Our findings are in line with previous research which demonstrates similar avoidance behaviours and further including delaying presentation to emergency services, downplaying pain and seeking healthcare elsewhere²²

Evidently, stigma plays a large role in both perceived and actual quality of care received. Previous research describes stigma for substance use as common²³ and may play an indirect role in substance use outcomes.²⁴ Furthermore, while methamphetamine psychosis and agitation can lead to healthcare worker-associated violence,¹² it also leads to high rates of restrictive interventions among this population.²⁵ Overall, both stigma and the nature of the substance used result in modified treatment for PWUM, likely further contributing to perceptions of mistreatment.

Importantly, these findings are consistent with a broader body of literature examining healthcare interactions among individuals with other substance use disorders, particularly opioid use disorder. Studies of patients receiving treatment for opioid use disorder have similarly documented experiences of stigma within healthcare settings, including perceptions of judgement, discrimination and reduced quality of care.²⁶ These experiences can influence healthcare-seeking behaviours, with some patients concealing substance use or avoiding care altogether due to concerns about stigmatisation.²⁷ Emergency departments in particular represent critical points of contact with the healthcare system for individuals with substance use disorders, yet structural barriers remain.

To address this common issue, diverse strategies may be enacted. Specifically, training on trauma-informed care principles and exposure to the lived experiences of PWUM and substance use more broadly demonstrate impacts on reducing stigma within healthcare workers.²⁸ Overall, continued efforts are needed to address substance use stigma among healthcare workers with aims of improving healthcare outcomes and sense of comfort for individuals with substance use disorders accessing care.

Going beyond acute medical needs

One major challenge that individuals using methamphetamines accessing acute care facilities identified was the lack of interdisciplinary and multispecialty healthcare present within emergency departments. As stated by participants, emergency departments and other acute care settings present both a unique and valuable opportunity to engage with individuals experiencing addictions who may otherwise not engage with the healthcare system.^{29 30} Indeed, many patients with substance use disorders, including methamphetamines, experience delays when accessing emergency care,³¹ which may lead to increased rates of leaving against medical advice. Thus, a more focused approach to management may support individuals’ access to quality care within these facilities.³⁰

Undoubtedly, managing multiple health and social concerns within an acute care setting and for healthcare workers presents a challenge, particularly within facilities which are overburdened, understaffed and underfunded. Addressing these gaps, however, may help to address recurring cycles of addiction and higher rates of returning to the emergency department, as seen within individuals who use methamphetamines.³² Indeed, one service which promoted ‘early and assertive treatment for methamphetamine psychosis’ resulted in a threefold increase in attendance to outpatient methamphetamine management programmes.³³

Lastly, as highlighted by participants, emergency departments may lack access to specialised addictions care resources. While this issue is likely systemic in nature, redistribution of healthcare resources to not only provide acute interventions and prevent access to more comprehensive and preventative care practices may reduce healthcare burdens overall. Programmes such as addiction medicine consult teams have recently been established to address this need^{34 35} and should be considered for more comprehensive management of people using substances accessing acute care. Future studies should more comprehensively examine the impacts of more comprehensive care and management programmes beyond the acute presentation for individuals with methamphetamine use disorders and resulting impacts on healthcare resource utilisation.

Patient recommendations for improving healthcare delivery

Lastly, participants suggested a few different strategies to enhance service navigation and patient healthcare advocacy. First and foremost, peer-based navigational and support services, which integrate individuals with lived experience of substance use themselves (peers), to help to support patient healthcare access have gained momentum within recent literature.^{36 37} These services can potentially enhance trust, empower patients and improve communication between patients and healthcare providers and improve treatment uptake.^{37 38} Emergency departments should therefore continue to consider these programmes to improve health outcomes and delivery for individuals who use substances.

One additional proposed strategy was the use of alternative care environments such as sobering centres that are separate from traditional emergency departments. While these facilities may support access to specialised addictions care and help to provide a safe, non-judgemental space for individuals to receive care; funding and spacing challenges may hamper efforts to establish these services. While programmes such as in-hospital supervised consumption sites have been established, the perspectives of clients accessing these sites remain mixed.^{39 40} Taken together, these diverse strategies present valuable opportunities to address patient concerns with acute care management of PWUM.

These findings align with emerging Canadian policy priorities emphasising stigma reduction, integration of addiction services into acute care and the expansion of peer-led harm reduction programmes. Canada’s national drug policy framework, the Canadian Drugs and Substances Strategy, emphasises improving access to evidence-based treatment, harm reduction services and trauma-informed supports for people who use substances while recognising that substance use disorders require a continuum of care that includes peer support and community-based services.⁴¹ Recent federal investments have also prioritised peer-led navigation and recovery coach programmes that support individuals with substance use concerns in transitioning between emergency departments and community care, reflecting growing recognition of the value of lived experience in service delivery.³⁷ As stimulant-related harms continue to increase across Canada and pharmacologic treatment options for stimulant use disorder remain limited, health systems have increasingly focused on service delivery innovations such as integrated addiction medicine teams, peer navigation programmes and multidisciplinary care models to improve engagement and continuity of care⁴² . In this context, the patient-informed strategies identified in our study including trauma-informed care, addiction medicine consult services and peer support integration may represent important approaches to improving healthcare engagement and outcomes for individuals using methamphetamines.

Strengths and Limitations

Interpreting the results of our study should be done in the context of a few limitations. First and foremost, there were significant challenges in recruitment of participants due to the demographics of our study sample. While we reached thematic saturation, the study sample may limit the validity and generalizability of our findings. With 5 participants, saturation was defined by examining the frequency and repetition of core experiences rath than the absence of new information. Participants were also at risk of recall and social desirability biases which may influence the study results. Lastly, data was collected from one specific city (Calgary, Alberta, Canada) and thus the results of this study may not be generalizable to other settings. Despite these limitations, this study is one of the first to examine the perspectives of individuals using methamphetamines who have recently accessed emergency departments, providing novel insights into strategies to build patient report and improve healthcare outcomes for this population.

Conclusions

To our knowledge, this is the first study to qualitatively examine the perspectives of PWUM and access care in the ED. They identified the need to address current gaps in services which historically have led to delays in accessing care, mistrust in the healthcare system and associated morbidity and mortality. Understanding the context of stigma within healthcare settings, prioritising comprehensive care for patients and providing more supportive spaces for individuals to access care (including peer support professionals and multidisciplinary healthcare teams) are some strategies PWUM recommend to better support individuals using methamphetamines to access care.

Data availability statement

Data are available on reasonable request.