Recognizing and reducing the impact of trauma of hospitalization: Considerations for persons who use drugs

Abstract

Amidst the ongoing opioid crisis, the number of individuals with substance use disorders being hospitalized for acute medical illnesses has increased. There is now a growing recognition that these events may be psychologically traumatic, leading to the development of acute stress reactions and post-traumatic stress disorder. Patients who use drugs may be particularly susceptible to being traumatized due to their underlying psychiatric comorbidities, prior trauma histories, inadequate treatment of the underlying substance use disorders, and stigmatization. Interventions such as early identification and screening, trauma-informed care, and specialized addiction services may help to mitigate the risks of trauma amongst this population. More research is needed to better guide hospitals to ensure people who use drugs receive optimal care.

One pertinent repercussion of the ongoing opioid epidemic is the drastic increase in hospitalization for patients with substance use disorder (SUD). For some patients, substance use may directly contribute to their need for medical care, demonstrated by an increasing number of hospitalizations for infectious complications of injection drug use (endocarditis, skin and soft tissue infections, osteomyelitis, etc.)¹ and rising rates of alcoholic liver disease.² For others, substance use will be incidental to a range of different medical conditions requiring acute hospital care, as prevalence of SUD continues to rise in our communities.

The increased rate of hospitalization amongst this population is particularly noteworthy as persons who use drugs (PWUD) have poor outcomes both during and following hospitalization. Studies have found that individuals hospitalized for injection related infection were at a higher risk of readmission, recurrent infection, overdose, and death following discharge.^3,4 Such findings have sparked an investigation of the causes of poor outcomes amongst hospitalized populations of PWUD.

One potentially influential factor in determining outcomes is the impact of the psychological trauma associated with hospitalizations. Detsky and Krumholz first addressed the stressful, depersonalizing nature of hospitals and described a “posthospital syndrome” that predicts worse patient outcomes.⁵ After recognition of the effects related to trauma of hospitalization, Davydow and Katon acknowledged the important role of prehospitalization psychiatric conditions as significant risk factors for posthospital psychological morbidity.⁶

Continued awareness of the stressful experience of acute medical illnesses has led to studies demonstrating a link between hospitalization and the later development of post-traumatic stress disorder (PTSD). The DSM 5 defines a traumatic event as an individual’s exposure to threatened death or serious injury, and acute medical illnesses certainly fulfills this criterion. A meta-analysis of studies assessing patients with critical illness found that one-fifth of survivors had symptoms of trauma at one-year follow-up,⁷ which suggests that the risk of developing PTSD after hospitalization may be similar to that of traumatic events such as traffic accidents or war.⁸

The consistently poor posthospital outcomes of PWUD and potential role of traumatization during hospitalization in portending these outcomes warrants further investigation. In this commentary, we identify aspects of hospitalization that are particularly distressing for PWUD and may contribute to an increased risk of traumatization and subsequent PTSD for this population. In addition, we propose potential interventions to address these issues amongst PWUD.

Predisposing Factors for Trauma in Persons Who Use Drugs

In the hospital, PWUD frequently receive suboptimal care for their underlying SUD. One study of patients with opioid use disorder (OUD) seen at Veteran’s Affairs Hospitals across the United States found that only 2% received medications for OUD during their hospitalization.⁹ Another study demonstrated that only 20% of individuals screening positive for alcohol use disorder (AUD) during hospitalization received interventions related to their substance use.¹⁰ Failure to properly treat underlying SUDs can lead to worsening cravings and withdrawal symptoms. For certain substances, such as alcohol and benzodiazepines, withdrawal can lead to life threatening symptoms. Craving and withdrawal may be particularly difficult to tolerate in the hospital as these symptoms often receive little attention and patients are unable to access coping mechanisms, such as social supports, time outdoors, and smoking cigarettes.

The hospital environment can also be profoundly distressing due to the very nature of acute care settings. Patients often share rooms, have little privacy, and may receive limited information regarding their treatment plans. The loss of autonomy and freedom of movement can further exacerbate this distress, as patients may either be discouraged or completely prevented from leaving their floor. Moreover, patients frequently lack adequate understanding of their condition and may not be included in shared decision-making regarding their care. Adding to the difficulty of the situation, patients are inundated with beeping of machines, frequent testing, painful procedures, and more.⁵ The end result is often a stressful and dehumanizing experience at a time when patients are least able to cope.

Finally, PWUD are often subjected to damaging stigma. One systematic review found that healthcare providers felt overwhelmingly negative about PWUD and that these negative attitudes diminished patients’ feelings of empowerment and reduced treatment completion, leading to worse outcomes.¹¹ Further studies have suggested that the impact of stigma may be particularly damaging in the setting of acute hospital care, where patients are particularly vulnerable and reliant on healthcare providers for treatment.¹²

Implications for Hospital Care for Persons Who Use Drugs

As discussed by Davydow and Katon, it may turn out that pre-morbid psychiatric conditions could be one of the greatest risk factors for in-hospital traumatization and post-hospital PTSD.⁶ This may be particularly relevant for PWUD as they are more likely to have comorbid psychiatric conditions at baseline, and more likely to have a history of trauma predating their hospitalization.¹³ These findings may indicate PWUD are at a greater risk for new or worsening traumatization during and after hospitalization with severe infections. Further evidence of this theory comes from studies showing that patients with SUD are up to three times more likely to be discharged against medical advice (AMA) as compared those without SUD, which may be indicative of these patients’ need to escape an overwhelmingly intolerable situation.¹⁴

The risk of PTSD amongst PWUD is particularly troubling as it may prognosticate worse treatment follow up and adherence following hospitalization. One meta-analysis found that patients with PTSD were more likely to be nonadherent to medications prescribed for chronic medical conditions.¹⁵ This effect may be most significant for trauma related to a medical event, as treatment may serve as an aversive reminder of acute medical events.¹⁵ Losing patients to follow up in this manner is worrisome, as the number of PWUD needing treatment for their SUD that actually receive it is already notoriously low.

Reducing the Trauma of Hospitalization for Persons Who Use Drugs

Interventions to reduce the trauma of hospitalization for PWUD should focus on addressing a range of issues experienced by PWUD. Implementation of universal, sensitive screening through one of many validated tools allows for identification of patients in need of specific intervention.¹⁶ Ensuring adequate pain management for PWUD appears to be of particular importance, as poor pain control is frequently cited amongst patients with SUD leaving AMA.¹⁴ Although pain management for PWUD can be difficult, particularly for those requiring opioid analgesics, providers should focus on legitimizing patient experience and following one of many frameworks that exist to guide treatment.¹⁷ A variety of setting specific guidelines exist for patients presenting to medical care for indications other than substance use, such as pregnancy.^18,19

In addition to improving treatment of the SUD, interventions may need to target identification, prevention, and treatment of trauma and its associated symptoms. One study of patients hospitalized following an assault or motor vehicle accident found that patients demonstrating acute stress symptoms (intrusive thoughts, avoidant behaviors, etc.) while hospitalized were at greater risk for PTSD 1 year later.²⁰ Identification of acute stress symptoms during inpatient treatment may help guide early interventions to address the risk of development of PTSD. Interventions should focus on early linkage to treatments with known efficacy for PTSD, such as cognitive-behavioral and exposure therapy.²¹

Given the high prevalence of lifetime trauma among PWUD¹³, one means of prevention for re-traumatization is the adoption of trauma-informed care (TIC) approaches. TIC recognizes the pervasive nature of trauma and its impact on health and attempts to provide sensitive care in a manner that avoids re-traumatization. Some tangible TIC strategies would include screening for prior trauma histories, involving patients in treatment decisions, provision of peer support, and training the hospital staff in TIC approaches. Incorporating TIC into health systems has been effective in demonstrating changes in attitudes and confidence amongst providers.²² However, few if any studies have assessed the effects of TIC on outcomes related to hospitalizations of PWUD.

Although resource intensive, addiction consult services (ACSs) can facilitate many of the interventions described to improve care for PWUD. ACSs are often comprised of multidisciplinary teams of caregivers with expertise in addiction treatment who can provide an overall assessment, enhance engagement, manage withdrawal and pain, recommend the initiation of medication treatment such as buprenorphine, and provide linkage to ongoing specialty SUD care following discharge.²³ By comprehensively addressing common issues faced by PWUD in the hospital, ACSs may help to reduce the bias and mistrust that PWUD experience. However, more research is needed to assess the impact of ACSs on the experience of hospitalization and risk of traumatization amongst PWUD.

Conclusion

The increasing rates of SUD and ongoing opioid epidemic have contributed to an increasing population of PWUD that require acute hospital care.¹ Traumatization during acute hospital care may be a largely neglected consideration in predicting patient outcomes.⁵ There is reason to suspect that PWUD may be more susceptible to traumatization and adverse outcomes during and after hospitalization for serious infections.⁶ We propose that hospitals adopt practices to improve care for PWUD, implement TIC to minimize re-traumatization, and utilize ACSs when resources allow. More research is clearly needed to better guide hospitals to ensure PWUD receive optimal care.