“Sobriety equals getting rid of hepatitis C”: A qualitative study exploring the interplay of substance use disorder and hepatitis C among hospitalized adults

Abstract

Background:

People who use drugs (PWUD) commonly experience complex illness, psychosocial stressors, housing insecurity, and stigma, which may play key roles in their struggles with addiction. In a study of hospitalized PWUD with hepatitis C virus infection (HCV), participants described treating HCV as “part of recovery.” These findings led us to explore how hospitalization and acute illness altered patients’ perceptions of substance use disorder (SUD) and HCV.

Methods:

Researchers audio recorded in-depth semi-structured individual interviews of 27 hospitalized adults with SUD and HCV seen by an addiction consult service (ACS) at an urban academic medical center between June and November 2019. Research staff transcribed interviews and dual coded them deductively and inductively at the semantic level. Researchers used a matrix visualization to discern relationships among codes and conducted a thematic analysis.

Results:

Many participants believed addictions treatment should precede an HCV cure for varying reasons. Some wanted to avoid reinfection; others believed “getting clean” afforded the mental clarity to address health issues, including HCV. Patients newly engaged in SUD treatment described HCV treatment as a “step towards recovery” and could serve as motivation to continue SUD treatment. Participants believed HCV cure could facilitate sobriety by “mentally putting drugs in the past” and was a future-oriented action toward “better health.” Many participants described the compounded stigma of having HCV infection and SUD by multiple groups, including friends/family who do not use drugs, other drug users, and health care workers.

Conclusion:

Hospitalized adults with SUD and HCV believed addictions engagement should precede HCV treatment and HCV cure could play an important role in their “recovery” journey. Discussing HCV treatment during hospitalization may be an opportunity to support engagement in SUD treatment and targets an untreated patient population critical for achieving HCV elimination.

1. Introduction

Substance-related hospitalizations are rising across the United States and people who use drugs (PWUD) have higher rates of hospitalization than the general population (Weiss, O’Malley, Barrett, Elixhauser, & Steiner, 2017). In the United States, hepatitis C virus (HCV) is the most common chronic bloodborne infection and presents significant preventable morbidity and mortality (Armstrong, Simard, McQuillan, Kuhnert, &Alter, 2006). Research has estimated HCV to be more prevalent among people who inject drugs and injection drug use is the leading HCV risk factor in high income countries (CDC, 2016; Degenhardt, Peacock, Colledge, et al., 2017). Promisingly, HCV treatment is widely available and highly effective, with a 99% cure rate (Burstow, Mohamed, Gomaa, et al., 2017). Substance use and HCV are intertwined public health crises; however, health system solutions to address these diseases are commonly siloed and PWUD are undertreated for HCV (Norton, Akiyama, Zamor, & Litwin, 2018). Additionally, HCV treatment settings tailored to the needs of PWUD are rare and continue to be a major barrier to HCV engagement (Bruggmann & Litwin, 2013).

Hospitalization can be a reachable moment to engage non–treatment seeking PWUD in addictions care (Englander, Weimer, Solotaroff, et al., 2017; Englander, Dobbertin, Lind, et al., 2019). Yet little is known from research about how hospitalization might engage PWUD in other aspects of care. The high burden of substance use disorder (SUD) among hospitalized adults coupled with a growing burden of unmet HCV treatment in this population raises the question of how hospitalization, HCV, and SUD interact. Research has provided little information about experiences or needs of people with HCV and SUD across care transitions. While many models of multidisciplinary integrated HCV care exist, the role of hospitalization in the HCV care continuum remains unclear (Bruggmann & Litwin, 2013; Scott, Doyle, Wilson, et al., 2017).

We performed a qualitative study to understand patients’ perceptions of SUD, HCV, and the relationship between HCV and SUD in the context of hospitalization for acute illness. Advancing our understanding of inpatients’ perceptions is a crucial step in tailoring care for people with HCV and SUD, and to assessing hospital systems’ role in the HCV care continuum and care transitions.

2. Methods

2.1. Setting and study design

We performed a qualitative study at an urban academic medical center in Portland, Oregon. An inpatient addiction consult service (ACS), called the Improving Addiction Care Team (IMPACT), saw all patients (Englander, Weimer, Solotaroff, et al., 2017; Englander, Collins, Perry, Rabinowitz, Phoutrides, & Nicolaidis, 2018). The ACS includes addiction medicine physicians, advanced-practice providers, social workers, and peer support specialists. Peers with lived recovery experience meet patients during hospitalization and can support patients in the community after discharge (Collins, Alla, Nicolaidis, et al., 2019; Englander, Gregg, Gullickson, et al., 2019). The ACS cares for adults with substance use disorders, including opioids, alcohol, and methamphetamine. The service also provides SUD assessments, medication, and behavioral treatment, access to peer support specialists, rapid pathways to community SUD treatment, and harm reduction support. Patients who the ACS sees are hospitalized for general medical and surgical conditions, and most are not seeking addictions care at time of admission (Englander, Weimer, Solotaroff, et al., 2017). Earlier work describes the ACS development, care model, and outcomes (Englander, Weimer, Solotaroff, et al., 2017; Englander, Dobbertin, Lind, et al., 2019; Englander, Collins, Perry, Rabinowitz, Phoutrides, & Nicolaidis, 2018; Collins, Alla, Nicolaidis, et al., 2019; Englander, Gregg, Gullickson, et al., 2019; Englander, Mahoney, Brandt, et al., 2019; Englander, King, Nicolaidis, et al., 2019). The Oregon Health and Science University Institutional Review Board approved this study.

2.2. Participants and data collection

We completed twenty-seven individual semi-structured in-person interviews between June 2019 and November 2019. The semi-structured interview guide included questions that explore patient’s understanding of HCV and its effect on health and life; patients’ perceptions of the interconnectedness of SUD and HCV; and how HCV related to patients’ overall health and psychosocial priorities. Experts in qualitative research and addiction medicine reviewed the semi-structured interview guide, including addiction medicine clinicians, researchers, and peer support specialists. We include the full interview guide in Supplement A. Two researchers (TV, XL) used purposive sampling to recruit subjects (Green & Thorogood, 2004). One member of the study team (XL) performed chart review to confirm a diagnosis of SUD (other than nicotine use disorder alone) and ongoing HCV infection. The interview and coding team included a female addiction medicine fellow physician (XL) and female medical student (TV), both with formal training in qualitative methods and interest in caring for patients with SUD. Researchers had no prior contact with potential participants before inviting them to participate in this study and obtaining informed consent. Researchers approached and completed 1:1 in-person interviews in patients’ rooms or conference rooms. The study recruited participants until the researchers (TV, XL, HE) identified thematic saturation and no new themes emerged from the data. The ACS discharged ten eligible participants before the research team could approach them; and twelve declined participation due to lack of interest, pain, or impending discharge. Interviewers did not record field notes and participants did not repeat interviews, review audio recordings/transcripts, or provide feedback on findings.

2.3. Data analysis

Two researchers (TV, XL) familiarized themselves with the data. The study team audio-recorded and transcribed the interviews verbatim. The study managed transcripts using Atlas.ti version 8.4. Researchers (XL, TV, HE) generated initial codes to organize data into meaningful groups, including hospital/systems level, outpatient level, individual patient, psychosocial, and support/community factors. Researchers (XL, TV) used one code book to dual-code all transcripts; met regularly to reconcile codes, identified emerging themes; and analyzed codes thematically using a semantic, mixed inductive-deductive and iterative approach (Braun & Clarke, 2006). Researchers (XL, TV) refined and reviewed themes via a matrix network display (Miles, Huberman, & Saldana, 2019). From this visualization, researchers drew connections across code groups and organized themes into categories. Researchers (XL, TV) then reviewed meaningful themes within these categories. The interview/coding team met monthly with one researcher (HE) to share emerging findings and seek input on coding and analysis.

3. Results

3.1. Participant characteristics

Participant characteristics (n=27) are described in Table I. The mean age was 41 years (range: 23–64); most participants identified as male (67%), were Caucasian (85%), and primarily used opioids (78%). The majority of participants lived in a metro area (81.5%) and had been diagnosed with HCV more than 1 year ago (81.5%). Interviews lasted, on average, 38 minutes. The average length of hospital stay was 21 days (range 3–57 days). Most patients were admitted with infections (84%), including endocarditis, skin and soft tissue infections (SSTI), epidural abscesses, osteomyelitis, and bacteremia. We organize resultant themes into three main categories: 1) Experiences of SUD, 2) Experiences of HCV, and 3) Interplay of SUD and HCV.

Table I.

Participant characteristics.

Demographic Categories	Number of Participants (%)
Age:
Mean Age:	41 years old (SD: 10)
18–34	7 (25.5%)
35–44	11(41%)
45–64	9(33.5%)
Gender:
Female	8 (30%)
Male	18 (66%)
Non-Binary	1 (4%)
Primary Substance:
Heroin/Opioids	21 (78%)
Alcohol	3 (11%)
Methamphetamine/stimulants	3 (11%)
Time Since HCV Diagnosis:
Diagnosed during this hospitalization	1(4%)
Within the last year	4 (15%)
Over a year or more ago	22 (81%)
Ethnicity/Race:
Caucasian/White	23 (85%)
Hispanic or Latinx	1 (4%)
American Indian/Alaska Native	1(4%)
More than once race	2(7%)
Geographic Location:
Urban	22 (81.5%)
Suburban area	2 (7.5%)
Rural community	3 (11%)
Marital status:
Never married	15 (55.5%)
Married or living like married/partnered	4(15%)
Separated or Divorced	8 (29.5%)
Average Length of Hospitalization (days)	21 (range: 2–57)
Primary Hospital Problem
Infection:	23 (84%)
Endocarditis	8 (29%)
Skin and Soft Tissue Infection	6 (22%)
Epidural Abscess	5 (18%)
Osteomyelitis	3 (11%)
Bacteremia	1( 4%)
Musculoskeletal trauma	2 (8%)
Nephrotic Syndrome	1 (4%)
Hepatic encephalopathy	1(4%)

3.2. Experiences of SUD

3.2.1. Motivations and initiation of addictions treatment

For many participants, hospitalization provided a pivotal opportunity to address their addiction. Participants described getting sick as an “eye-opener” that motivated many to be “done with using.” Most participants took steps to address SUD during hospitalization; for example, starting medication for addiction treatment (MAT). Specifically, MAT and sobriety afforded participants the opportunity to “think clearly.” One participant stated:

This whole heart thing ended up in one way being kind of a good thing ‘cause this is the first time since [the] seventh grade [that] I think that I’ve been sober. It feels good. … Being able to be clear minded and remember things. I can tell you what I did yesterday…what I did the day before.

−38 y/o male with opioid use disorder

The combination of engaging with ACS, starting MAT, disrupting active use, and recognizing severe medical complications as directly related to substance use led many participants to prioritize addiction as a “number one” health concern. However, a few participants did not want to reduce or stop substance use. As one described: “I don’t have time for anything but that [drug use].”

3.2.2. Dynamic life challenges

Nearly all participants—regardless of interest in addictions care—described many challenges to their health and primary needs outside of the hospital. Some participants worried about “living on the streets” or in unstable environments. As one participant described: “I can’t survive like this on the streets, not at this age, and not with this leg being gone.” Most participants worried about returning to substance use after hospitalization, and cited concerns over potential triggers—persistent untreated pain, peripherally inserted central catheters for ongoing antibiotic delivery, or returning to familiar environments where they previously used substances. One participant stated: “Just being out there [on the streets]…[it’s] easy to go back out and use…people aren’t exactly out there trying to uplift one another when you’re down and out on the street” (48 y/o male with opioid use disorder). A few also noted that they might go to jail, which could disrupt their continued engagement in addictions treatment.

3.3. Experiences of HCV

3.3.1. Emotions associated with HCV

Participants described a variety of emotions associated with HCV. Most felt HCV was “really embarrassing” and many expressed “disappointment” after HCV diagnosis. As one participant stated, “[I felt] pretty lousy, disappointed. I felt like I had failed myself ‘cause I thought I was smarter than that.” Some felt “angry” and “betrayed” by others who may have knowingly infected them. Reciprocally, many felt “guilty” knowing they may have infected others. As one participant described:

I had a pan of all my dirty needles, and I said, “No one use these no matter how desperate you are. I have Hep C”. Come to find out, two of my friends [were] desperate to get high, and they both got Hep C. It made me feel guilty, even though I gave them a fair warning. I just thought it was dumb of them.

−27 y/o female with opioid use disorder

Some participants described feeling “sad” or “depressed” having to grapple with infection and disclose their HCV status to friends, sexual partners, or close family. As one participant described, “[I felt] kind of depressed... because I would have to tell my mom...[and] come to grips with it.” A few participants described that in addition to negative emotions, HCV limited their behaviors. For example, a few participants identified HCV as a romantic roadblock. As one participant described, “I don’t date anymore. I’m not trying to give it to someone else. … I don’t want that guilt on my conscience.”

Other participants described feeling “normal” since HCV was common, almost ubiquitous, among their social circles, families, or communities. One participant reported:

For me, it’s been really normal. Both my parents had it, and it didn’t seem to affect them at all. My sisters, I believe both of them have it. Most of my friends have it. It’s never been a big deal to me.

−41 y/o female with opioid use disorder

3.3.2. Delayed health consequences of HCV infection

Despite the many negative emotions around being HCV positive, nearly all participants said HCV did not affect their physical health or present an “immediate danger”. One young participant described their mother’s experience with HCV, “She lived with it her whole life and it’s just now starting to affect her and she’s 50.” For most, the lack of acute physical reminders and delayed onset of HCV complications made it a “low priority”, especially compared to acute medical issues and addiction. As one participant described:

[HCV] kind of receded into the background, and I don’t think of it as much anymore. It’s not until I’m in a situation, like being in the hospital, and I have to divulge that [I have HCV] or even think about it.

−26 y/o male with opioid use disorder

Some participants described the link between alcohol use and HCV, and reported alcohol abstinence as a way to reduce HCV health effects. A male participant with opioid use disorder stated, “I’m not too concerned about [HCV]… I feel like I’m pretty healthy. As long as I don’t drink alcohol and do other things, then I’ll be fine.”

3.3.3. Misunderstanding HCV

Many participants described a general lack of HCV knowledge. One participant stated, “I don’t really know what to expect with having Hep C” and another said, “To be honest, I’m pretty ignorant about the full details of hep C. I know that it attacks your liver.” Some participants acknowledged previous HCV misconceptions. As one participant stated, “It’s way easier to catch than I first understood. … I thought you had to share a traditional blood-to-blood transaction, whereas you could just use somebody else’s utensils and get it—which was the way that I got it.”

Some participants reported feeling confused about how they got HCV and how it is transmitted. As one participant shared, “I feel stupid, cuz, I’m messin’ around with all that stuff and I’m not even aware how I got it.” Most reported learning about HCV from other PWUD or harm reductive services. Some described hearing HCV misinformation among PWUDs. One participant stated:

[Many] don’t seem to understand completely how you get [HCV]. Some of them actually believe that you can give it to yourself. Which I’ve tried to explain to them that it doesn’t work that way. It doesn’t just spontaneously appear. But they believe that. It blows me away. Or they don’t realize there[are] different strands. [Some PWUD] they think they’re impervious to it.

−36 y/o male with opioid use disorder

Universally, participants commented on the unknown future consequences of HCV infection. As one participant said, “I’m sick with something I don’t even know what it is or how to get rid of it or how it’s going to be for the long term.” Another participant stated, “I don’t know what [HCV is] doing to me but I know it’s not good.”

3.4. Experiences at the interplay of HCV and SUD

3.4.1. Compounded HCV and SUD stigma

Nearly all participants reported experiencing SUD, HCV, and inter-related stigma. Notably, participants described stigma from family/friends who are nonusers, other PWUD, health care workers, and they even mentioned internalized stigma.

Participants expressed having HCV and SUD meant people “looked down on [me] so horrendously.” As one participant stated:

Every time if someone finds out you have Hep C, it’s automatic, “Oh, you must have used drugs.” I hate everything being linked back to my drug use. When I came in the hospital, my whole family was all like, “Oh, because you are a drug addict”.

−31 y/o female with opioid use disorder

Participants also recalled feeling stigmatized for having HCV among other PWUD. As one participant stated, “Even in groups of addicts, sometimes us with hep C… can feel like we’re ostracized.” Another participant described: “The people that don’t have [HCV]—even addicts or users—they act like you’re definitely dirtier than them, or something’s wrong with you, or whatever, maybe they don’t want to be around you.”

Many participants also described feeling HCV and SUD stigma from health care workers. As one participant stated, “It’s embarrassing the way [health care providers] say it…like I’m tainted, ‘hey, watch out [for HCV].” Another participant described lengths to keep their HCV status private among visitors and providers during hospitalization, “I actually wrote it down [HCV status] and handed the [addition medicine physician] a note… I didn’t want no one else around to hear and they came back and talked to me privately about [HCV].”

Finally, a few participants internalized HCV and SUD stigma. As one participant shared, “My view of people who had [HCV] were careless and junkies … now that I have it, it makes me feel like I’m a junky … and tainted.”

3.4.2. Addiction engagement comes before HCV treatment

Many participants thought stopping substance use should precede HCV curative treatment for multiple reasons. Some believed this was important to avoid reinfection after an HCV cure. As one participant said:

[I] want to be sober when I do [HCV curative treatment] because what’s the point of getting rid of it if I’m going to give it right back to myself? … To tell myself that I wouldn’t [use substances] just because I got rid of HCV is a lie.

−34 y/o male with opioid use disorder

For some participants, stopping substance use allowed them to get their “priorities straight” and address ongoing medical concerns, including HCV. One participant expressed: “This is the first time I’ve been clean for four or five years … This is my time to get all these [health issues] taken care of.”

Participants identified the lack of future-oriented thinking associated with active substance use as a major barrier to addressing nonimmediate medical issues. One participant stated, “You put the health aside because you have to have your drug. I was preferring to be high and not be concerned about my health.” Another participant described, “[When you are] active in your addiction and you need [substances] to get well [you aren’t concerned] if it might affect you in the future.” For many, engaging with the ACS opened a window not only to engaging in SUD care, but also to start thinking about HCV and other medical needs.

Among those who were not ready to stop using substances, most acknowledged active use as a barrier to health care engagement. One participant described, “I’m not clean at all, and I can’t get a handle on any of my medical conditions.”

3.4.3. Transformative potential of HCV cure

Many participants believed “being free” of HCV would support their ongoing engagement in addictions care and desire to move “forward”. One participant stated that treating HCV, “would be an extra motivator, once I cleared [HCV] out, an extra motivator to stay that way.” Another participant identified both MAT and HCV cure as recovery supports:

Now, I’m taking Suboxone, and I feel like, now, I’m finally, actually steps towards not doing it again. I feel like every other time I’ve tried to quit, I’ve deep down had the intentions of, “Oh, this isn’t gonna be my last time”. I feel like being completely Hep C free, being on a preventative, I feel like I’d actually be taking all the steps to be moving forward and not have any recurring drug-related things.

−26 y/o female with opioid use disorder

Some participants commented that being cured of HCV would change their self-perception. One participant stated, “I would feel a lot cleaner and less like a gross drug addict… more presentable to society, more accepted.” Another participant described HCV as “a symbol of me using [substances], it’s part of my old life” and HCV curative treatment would allow her to “leave another part of my addict self behind.”

Many participants described “relief” that HCV can be cured. One participant described how being cured of HCV would allow HCV to “not be another consequence I have to carry on my back from mistakes that I made coming to this point … I don’t have to keep being punished beyond the lesson I’ve been taught here.”

3.4.4. Shared SUD/HCV risk factors with peer support specialists

Some participants described the importance of the ACS peer support specialists in their addiction treatment engagement. For some, the shared experience of drug use as a health risk factor was one of the most important qualities in connecting with a peer support specialist. Many described this shared experience with a peer as beneficial to treating HCV even if the peer never had HCV or had not gone through HCV treatment themselves. One participant stated, “As smart as doctors are, and as smart as the research makes people, you haven’t been stuck on a bed where I’m at. You haven’t been stuck in a trap house with a needle in your arm.”

4. Discussion

Our study describes the unique experiences and interplay of HCV and SUD among hospitalized adult PWUD with HCV infection seen by an ACS. Many participants believed hospitalization was pivotal to addressing their substance use. Participants described HCV treatment engagement and cure of infection as an important support to their addictions treatment. However, despite interest in an HCV cure, most identified SUD and acute medical issues as their immediate priorities. Furthermore, participants perceived compounded stigma of HCV and SUD—from friends and family, other PWUD, health care workers, and within themselves—as barriers to treatment engagement.

Our findings highlight the need for hospital providers to better understand priorities of PWUD and work collaboratively with inpatients to lay the foundation for future health care engagement. Many participants wanted to prioritize addictions treatment before engaging in HCV care. Current U.S. guidelines advocate for treating HCV in PWUD regardless of ongoing substance use—a critical step to reducing HCV treatment barriers and stigma of PWUD(AASLD-IDSA, 2020; Edlin, Carden, & Ferrando, 2007; Bruggmann, 2013). This approach may also be key to reaching patients who continue using substances and highlights the need for multiple HCV elimination strategies (Edlin, Carden, & Ferrando, 2007). For some patients, hospitalization for a life-threatening illness is a reachable moment for initiating addictions care; and simultaneous HCV discourse may be synergistic in initiating or sustaining outpatient engagement. Successful models in the HIV care cascade—an inpatient multidisciplinary HIV consult team—could be adapted for HCV or incorporated as part of existing hospital ACS and merit further exploration (Nijhawan, Bhattatiry, Chansard, Zhang, & Halm, 2020). Inpatient HCV discourse and expanded care transition resources may augment posthospital HCV engagement by connecting patients to tailored ambulatory HCV treatment models (Litwin, Jost, Wagner, et al., 2019; Akiyama, Norton, Arnsten, Agyemang, Heo, & Litwin, 2019). Tailoring hospital-based interventions to meet the needs of inpatient PWUD with HCV—including HCV education on transmission, long-term HCV outcomes, treatment options, as well as in-hospital addictions care, care transition coordinators, and peer support specialists—may be key to reaching a population who is historically undertreated and difficult to reach (Terrault, 2019; Critchley, Carrico, Gukasyan, et al., 2020). To support patients in achieving successful HCV treatment, providers and patients need to collaboratively prioritize health care goals while contextualizing structural and health vulnerabilities including housing, socioeconomics, and environmental SUD triggers. Furthermore, many participants viewed HCV engagement as an important step toward “recovery”, mirroring previous work in the outpatient setting (Williams, Nelons, Seaman, et al., 2019; Brooke Severe, Madden, Heimer, 2020; Bourgois, Holmes, Sue, & Quesada, 2017). This suggests hospitalization may be an important opportunity to disrupt the cycle of addiction; and that discussing HCV during hospitalization may support sustained addictions treatment engagement as an outpatient. Future research should look at hospitalization’s role in aligning SUD and HCV treatment goals among patients, providers, and within our current health system (Høj, Jacka, Minoyan, Artenie, & Bruneau, 2019).

Our study builds on existing work describing the stigma and psychological burden of HCV and SUD, and adds perspectives of hospitalized adults. Participants not only internalized feelings of disappointment due to HCV, but many felt ostracized by their own community of PWUD (Dowsett, Coward, Lorenzetti, MacKean, & Clement, 2017; Tsai, Kiang, Barnett, et al., 2019). Additionally, most participants perceived HCV and SUD stigma in our health care systems and described subsequent challenges accessing healthcare as a PWUD. Some described feeling misjudged due to their history of drug use, while others commented on the stigmatizing language that health care providers used. Some participants also described experiencing assumptions—from nonsubstance using family, friends, or providers—around substance use due to chronic HCV infection. This cyclical reinforcement of stigma may lead to worse health outcomes due to disengagement from care, psychological distress, or reduced engagement in substance use treatment (Tsai, Kiang, Barnett, et al., 2019; Paquette, Syvertsen, & Pollini, 2018). It also highlights the potential benefits of integrated SUD and HCV care as part of an ACS and in outpatient settings.³⁴ PWUD may be more likely to engage with teams who specialize in addiction medicine, harm reduction services, or opioid agonist therapy (OAT) clinics (Akiyama, Norton, Arnsten, Agyemang, Heo, Litwin, 2019; Norton, Bachhuber, Singh, et al., 2019).

Last, our findings demonstrate the transformative potential of an HCV cure. Some participants described HCV engagement as a path “forward” and possible shifts in self-perception as a PWUD once cured. Others described an HCV cure as an opportunity to erase a “mistake” of past drug use and expressed “relief” in the ability cure HCV. These findings highlight the nuanced internalization of SUD and HCV. Recognizing how an HCV cure reshapes personal narratives may be important when designing tailored HCV interventions in inpatient and outpatient settings (Whiteley, Whittaker, Elliott, Cunningham-Burley, 2018). Many participants also believed an HCV cure had the potential to support, motivate, and sustain ongoing addiction treatment. The synergistic relationship among sustained addiction treatment, HCV cure, and forging of recovery narratives is an important area for future research (Llewellyn-Beardsley, Rennick-Egglestone, Callard, et al., 2019).

Our study has limitations. First, we performed our study at a single, academic medical center with a well-established ACS. While ACSs are an emerging hospital intervention, how our findings transfer to hospitals without specialized inpatient addiction services is unclear (Priest & McCarty, 2019). Furthermore, participants had limited racial, ethnic, and geographic diversity, perhaps limiting transferability. We recruited hospitalized participants, and while participants acknowledged that their priorities might change after discharge (particularly around engaging in SUD care), we did not follow participants over time. Future research should elicit patients’ perspectives after discharge as well as after completing HCV treatment. Though it is a strength that we included patients with multiple SUDs, most participants in our sample primarily had opioid use disorder. The availability of MAT for opioid use disorder, unlike stimulant disorders, may impact the SUD/HCV treatment trajectory. Notably, some participants also endorsed using multiple substances, but our sample size did not allow comparisons between groups. Given the adverse health effects of alcohol on the liver, people with alcohol use disorder may have different HCV experiences and face different stigmas compared to people with opioid or methamphetamine use disorder. Future research should examine the difference between those with alcohol use disorder and opioid use disorder.

5. Conclusion

Our findings have important implications for providers and health systems. Our findings highlight the opportunity for hospital providers to explore patients’ priorities relating to HCV and their long-term health goals. For ambulatory providers assuming the care of recently hospitalized patients, understanding patients’ goals and priorities can also support timing of and engagement in HCV care. Further, providers who care for adults with HCV and SUD should acknowledge the compounded stigma of the two diagnoses. Our findings underscore the need for health systems to integrate HCV and SUD care, even at a hospital level. Ultimately, hospitalization may be an important opportunity to engage patients in a discussion of HCV treatment engagement, which could in turn, support their addictions treatment and future health goals.

Highlights.

• Hospitalized adults with substance use disorder (SUD) and hepatitis C (HCV) expressed a desire to engage in addictions treatment prior to hepatitis C cure.

• Hospitalized adults described HCV cure as an important support in their “recovery” journey

• Those with SUD and HCV described a compounded stigma from multiple groups of people including family/friends who do not use drugs, other drug users and healthcare workers

• Discussing HCV and HCV cure during hospitalization may be an important opportunity to support SUD treatment