Understanding why Patients with Substance use Disorders Leave the Hospital against Medical Advice: A Qualitative Study

Abstract

Background Hospital discharges against medical advice (AMA) is associated with negative health outcomes and re-admissions. Patients with substance use disorders (SUD) are up to three times more likely to be discharged AMA as compared to those without SUD. Studies suggest that undertreated withdrawal and a perception of stigma may increase the risk, however, to date, there are no published qualitative studies exploring the specific reasons why patients with SUD leave prematurely. Methods Semi-structured interviews with patients ( n = 15) with SUD with documented AMA discharges from our hospital between 9/2017 and 9/2018. Maximum variation sampling was employed to display diversity across gender, race, age, and type of substance use disorder (alcohol vs opioids). Patients were interviewed until no new concepts emerged from additional interviews. Two coders separately coded all transcripts and reconciled code assignments. Results Four core issues were identified as patients’ reasons for leaving the hospital prematurely: undertreated withdrawal and ongoing craving to use drugs, uncontrolled acute and chronic pain, stigma and discrimination by hospital staff about their SUD, and hospital restrictions, including not being allowed to intermittently leave the hospital floor. For patients with histories of criminal involvement, being hospitalized reminded them of being incarcerated. Conclusion These findings shed light on the reasons patients with SUD are discharged from the hospital AMA, an event that is associated with increased thirty-day mortality and hospital re-admission. AMA discharges represent missed opportunities for the health care system to engage with patients struggling with a SUD. Our findings support the need for inpatient addiction treatment, particularly for management of withdrawal and co-occurring pain, and the need to address health care provider associated stigma surrounding addiction.

A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs

“…Another strategy to enhance patient sense of control is to provide a safe, nonjudgmental space to discuss and provide needed resources, including overdose prevention education, naloxone, and referrals to resources for other unmet needs including housing. Several participants described experiencing stigma en route to and while receiving care in the ED, which is consistent with previous studies and highlights a critical need to educate and train ED and other health care providers about the negative impact of prior demoralizing, stigmatizing, and traumatic health care interactions experienced by individuals who use drugs 50–53 …”

“…Several participants described experiencing stigma en route to and while receiving care in the ED, which is consistent with previous studies and highlights a critical need to educate and train ED and other health care providers about the negative impact of prior demoralizing, stigmatizing, and traumatic health care interactions experienced by individuals who use drugs. [50][51][52][53] Our findings highlight a tension between what clinical experts believe is the most important factor in improving patient outcomes Several studies have demonstrated an improved quality of life for patients with OUD engaged with MOUD, who often have complex unmet needs including health, housing, and employment. 48,[54][55][56][57] Although the existence of complex needs of patients following an opioid overdose is not a novel finding, the degree to which unmet housing and employment needs outweigh the perceived need of SUD treatment, even in the aftermaths of an overdose, has not previously been demonstrated in ED patients.…”

Substance Use Disorders and COVID-19: Multi-Faceted Problems Which Require Multi-Pronged Solutions

“…People with SUD may be further affected as the COVID-19 impact worsens. This group already faces stigma and discrimination from the general public (52), policy makers (53,54) and healthcare workers (14,(55)(56)(57)(58). Resource allocation and clinical practice with embedded stigma and discrimination has a prohibitive effect on healthcare utilization by individuals with SUD (14).…”

Hospital admissions and mortality due to complications of injection drug use in two hospitals in Regina, Canada: retrospective chart review

“…Studies have shown that patients who leave prior to treatment completion have higher rates of readmission and higher mortality [ 31 – 33 ]. Stigma, discrimination by hospital staff, and hospital restrictions are commonly cited reasons for PDD [ 34 , 35 ]. We also speculate that in our hospitals, the lack of access to supervised consumption sites (SCSs), needle syringe programs (NSPs), and inpatient opioid agonist therapy (OAT) contribute to patients leaving before treatment completion.…”