Harm Reduction in
Hospitals: Is it Time?
Beth S. Rachlis, omas Kerr, Julio S. G. Montaner
and Evan Wood
ABSTRACT
Among persons who inject drugs (IDU), illicit drug use often occurs in hospi-
tals and contributes to patient expulsion and/or high rates of leaving against
medical advice (AMA) when withdrawal is inadequately managed. Resul-
tant disruptions in medical care may increase the likelihood of several harms
including drug resistance to antibiotics as well as costly readmissions and in-
creased patient morbidity. In this context, there remains a clear need for the
evaluation of harm reduction strategies versus abstinence-based strategies with
respect to addressing ongoing issues related to substance use among addicted
hospitalized patients. While hospitalization can be used to stabilize addicted
patients as they recover from their acute illness and help them to achieve ab-
stinence, patients unable to maintain abstinence should not be penalized for
failing to do so at the expense of their health. is article describes harm re-
duction activities within hospitals and areas for future investigation.
H R  H: I  T 225
Introduction
Soft-tissue infections and other injection-related infections are among the main
contributors to health service use among people who inject drugs (IDU) [1-6]. In
many settings, the two most common reasons for emergency department (ED)
visits relate to soft-tissue infections, and problems related directly to drug use
(e.g., overdose)[1,2,4,6]. Not-surprisingly, many IDU use EDs as a regular point
of care; IDU are generally less likely to use outpatient services compared to non-
IDU[4] and generally face poor access to prevention programs and addiction
treatment services [7-9].
As a result, IDU often present to EDs later in the course of their illness, and
this in turn increases the likelihood for hospital admission [2,4,5]. Drug-related
infections are often painful and may progress to more serious life- and limb-
threatening conditions [10]. More complicated infections such as endocarditis
require extended periods of treatment with intravenous antibiotics and thus may
require even longer hospital stays.
However, IDU are more likely than other patients to discharge from hospitals
against medical advice (AMA) [11,12]. A 2002 study noted that IDU were over
four times more likely to leave AMA compared to non-IDU [12] and leaving
AMA is a strong predictor for frequent readmission [11-13]; Moreover, repeated
admissions for chronic medical problems are generally more costly for total days
of stay than single, cost-intensive stays [13].
In addition to the high costs associated with increased health utilization, these
ndings also suggest that patients are not fully recovering from their illness the
rst time they are treated. Incomplete therapy or treatment failure may also in-
crease the likelihood for drug resistance to antibiotics [11,13,14]. As such, uncov-
ering why IDU are more likely to leave AMA is a necessary rst step in order to
improve health outcomes, although incidentally this may also decrease the high
costs associated with elevated rates of health service utilization.
Discussion
Harm Reduction
While an abstinence-based approach to drug use generally requires that complete
cessation from all non-prescribed drugs is a pre-requisite for eective addiction
treatment [15], harm reduction emphasizes that eorts to improve health and
social outcomes should begin with ‘where a person is at’ in terms of their drug use
[16]. Strategies need to be maximized, both in terms of types of services oered
and where they operate. Furthermore, abstinence-based programs are generally

Get Social Work in Public Health and Hospitals now with O’Reilly online learning.

O’Reilly members experience live online training, plus books, videos, and digital content from 200+ publishers.