Fostering Culture Change to Improve Care for Patients with Substance Use Disorders

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Fostering Culture Change to Improve Care for Patients with Substance Use Disorders

Understanding Substance Use Disorders (SUD) 

  • SUD affects millions of people in the U.S., including over 6 million people aged 12 or older with opioid use disorder in 2022.1
  • SUD is a treatable health condition. Effective, evidence-based treatment is available, but most people who need treatment do not receive it, and major disparities in access to evidence-based treatment persist.2,3,4
  • SUD is highly stigmatized. That stigma worsens SUD symptoms and outcomes.5
  • Psychological trauma and Adverse Childhood Experiences (ACEs) are major risk factors for SUD.6,7
  • Mental health concerns are highly prevalent among people with SUD.8 Substances may be used to cope with mental health symptoms, and mental health symptoms may be exacerbated by substance use.9

Addressing SUD Stigma

Why it matters

SUD affects millions of individuals, yet stigma remains a significant barrier to seeking and receiving effective treatment. Stigma can negatively impact patient care, staff satisfaction, and hospital culture, and put hospitals at risk of legal action. Addressing addiction stigma is crucial for several reasons:

  1. Compliance with regulations. Addressing SUD stigma by providing evidence-based SUD stabilization helps ensure hospitals comply with EMTALA and anti-discrimination laws, protecting the organization from legal and financial risks.
    1. EMTALA: EMTALA requires EDs to identify and stabilize medical emergencies. A patient whose SUD may seriously threaten their health may be deemed an emergency medical condition. EDs should screen for and stabilize SUD using evidence-based practices that reduce overdose risk and address cravings and withdrawal.
    2. ADA: Disability rights laws prohibit healthcare discrimination, including against people with SUD. Denial of evidence-based SUD treatment and policies that effectively deny services to people who use substance may be considered a disability rights violation.
    3. Title VI: Title VI of the Civil Rights Act prohibits discrimination on the basis of race. There are major disparities in SUD treatment access for people of color. Hospitals may be violating Title VI if white patients are more commonly offered SUD stabilization or evidence-based services for SUD in a hospital or community where patients of a certain race or ethnicity experience a higher rate of need for these services.10
  2. Improved patient outcomes. By reducing stigma and providing compassionate, evidence-based care, hospitals can improve health outcomes and reduce readmissions by enhancing patient engagement, uptake, and retention in SUD treatment.11,12,13,14
  3. Decreased costs. Improving SUD care in hospitals has been shown to reduce patient lengths of stay and readmissions, resulting in cost savings.15
  4. Increased access to care. Stigma is a significant barrier to seeking, receiving, and adhering to treatment, leading to delayed treatment and poorer health outcomes.16 By creating a welcoming, non-judgmental environment, hospitals can encourage more patients to access treatment and support. 
  5. Enhanced staff satisfaction and retention. When staff feel supported and equipped to provide high-quality care to patients with SUD, they are more likely to experience job satisfaction.
  6. Staff more likely to self-disclose SUD. Rates of SUD among healthcare providers is similar to the general population, at around 10-15%.17 A culture of SUD stigma contributes to staff reluctance to self-disclose, which increases risk of medical errors and injury, controlled substance diversion, staff absenteeism and turnover, and increased employee healthcare costs, and prevents treatment engagement and safe re-entry into the workplace.18,19, 20
  7. Community leadership. By taking a proactive stance against addiction stigma, hospitals can serve as leaders in the community, inspiring other organizations and driving broader social change.

What we can do

Individuals. Clinicians, staff, administrators, and leadership can all work to change organization culture and improve patient care by doing the following. 
Because of SUD stigma, patients expect to be treated poorly and will recognize even slight or perceived judgment. To provide the best care, we must actively work to show nonjudgment and support.

  • Actively learn about SUD and work to address personal biases. 
  • Lead with evidence and standards of care.
  • Model empathy, compassion, and respect in interactions with staff and patients.
  • Speak out against discrimination and encourage open, honest discussions about addiction and stigma.
  • Embrace a whole-person, trauma-informed approach to patient care and empower staff to meet patients where they are. 
  • Use "universal precautions" for trauma, as most patients with SUD have experienced ACEs and/or emotional trauma.
  • Talk to patients in a non-judgmental way, being mindful of tone and body language. 
  • Educate patients on strategies to reduce harms associated with substance use, such as never using alone, starting with a small dose (especially after periods of abstinence), and always having naloxone available.
  • Talk to colleagues about the impacts of stigma and what can be done to address it.
  • Have realistic expectations for the recovery process. It often takes multiple treatment attempts, and a return of symptoms is very common in early treatment.
  • Keep hope alive. Giving up on people does not help them get better.
  • Ensure all patients at risk of opioid overdose with naloxone and counsel on safer substance use and treatment options.

Organizations. Leadership can foster positive culture change within their organizations with the following:

  • Foster a culture of continuous learning and growth
    •  Allocate time and resources for training on SUD and stigma.21 Free online training resources for healthcare workers include:
      • University of Washington’s Learn About Treatment.22
      • University of Texas at Austin Dell Medical School’s Reducing Stigma Education Tools (ReSET).23
      • Providers Clinical Support System’s SUD 101 Core Curriculum.24
    •  Support ongoing training and practice in de-escalation and motivational interviewing.
    •  Celebrate successes in increased MOUD initiation and reduced readmissions for substance-use related diagnoses. 
    •  Set clear expectations for person-centered care, using respectful, non-stigmatizing language, and demonstrating non-judgment.
    •  Emphasize the importance of treating all patients with respect and positive regard.
  • Implement evidence-based practices and protocols 
    •  Establish organization-wide use of evidence-based protocols for treating patients with SUD, including providing MOUD and harm reduction.
    •  Implement a hospital-wide naloxone distribution program; ensure that all patients at risk of opioid overdose leave with naloxone in hand. Hospitals must do this to comply with SB 5195.25
    •  Utilize clinical champions to facilitate adoption of evidence-based practice.26
    •  Hire peers and individuals with lived experience to provide valuable insights and support.27
  • Engage in continuous quality improvement 
    •  Establish a quality improvement team to identify and address areas for growth.28
    •  Facilitate effective collaboration between departments and disciplines to provide comprehensive, integrated care. 
    •  Encourage use of an addiction consult service.29
    •  Establish a substance use intervention team that can be called upon to support patients during their stay and facilitate transitions of care.30, 31 
      Resources for implementing this work include:
    •  Foster a non-judgmental environment where patients feel comfortable discussing their substance use and seeking help.
  • Support staff well-being34, 35
    •  Prioritize staff well-being and address burnout through adequate staffing and initiatives such as wellness programs and mental health support.
    •  Provide ongoing support and resources to help staff manage the emotional challenges of caring for patients.
    •  Foster a culture of open communication and encourage staff to share their experiences and concerns.36
    •  Keep staff informed and involved in decision making for organizational change.37
  • Collaborate with community partners 
    •  Partner with addiction medicine providers and harm reduction programs to support effective linkage to ongoing care and services.38

With these actions, hospitals can work toward reducing SUD stigma, improving patient care and outcomes, and fostering a supportive environment for both patients and staff.

Resources

  1. Harm Reduction Coalition, 2021. Respect to Connect: Undoing Stigma. 
  2. California Bridge, 2023. People First: A Team Approach to Stigma Reduction: An innovative, stigma reduction training
  3. National Institute for Drug Abuse, 2021. Words Matter - Terms to Use and Avoid When Talking About Addiction.

References

  • Substance Abuse and Mental Health Services Administration. (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/report/2022-nsduh-annual-national-report

  • Ibid.

  • Hollander, M. A. G., Chang, C. H., Douaihy, A. B., Hulsey, E., & Donohue, J. M. (2021). Racial inequity in medication treatment for opioid use disorder: Exploring potential facilitators and barriers to use. Drug and alcohol dependence, 227, 108927. https://doi.org/10.1016/j.drugalcdep.2021.108927

  • Oldfield, B. J., Chen, K., Joudrey, P. J., Biegacki, E. T., & Fiellin, D. A. (2023). Availability of Specific Programs and Medications for Addiction Treatment to Vulnerable Populations: Results from the Addiction Treatment Locator, Assessment, and Standards (ATLAS) Survey. Journal of addiction medicine, 17(4), 477–480. https://doi.org/10.1097/ADM.0000000000001158

  • Room, R., Rehm, J., Trotter II, R. T., Paglia, A., & Üstün, T. B. (2001). Cross-cultural views on stigma, valuation, parity, and societal values towards disability. In Disability and culture : universalism and diversity. (pp. 247–297). Retrieved from https://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-56761

  • Brady, K. T., Back, S. E., & Coffey, S. F. (2004). Substance abuse and posttraumatic stress disorder. Current Directions in Psychological Science, 13(5), 206-209. https://doi.org/10.1111/j.0963-7214.2004.00309

  • Dube, S. R., Felitti, V. J., Dong, M., Chapman, D. P., Giles, W. H., & Anda, R. F. (2003). Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the adverse childhood experiences study. Pediatrics, 111(3), 564–572. https://doi.org/10.1542/peds.111.3.564

  • Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of general psychiatry, 62(6), 617–627. https://doi.org/10.1001/archpsyc.62.6.617

  • Quello, S. B., Brady, K. T., & Sonne, S. C. (2005). Mood disorders and substance use disorder: a complex comorbidity. Science & practice perspectives, 3(1), 13–21. https://doi.org/10.1151/spp053113

  • Legal Action Center. 2022. Hospital administrator guide: Addressing substance use disorder in emergency departments. Retrieved September 24, 2024, from https://www.lac.org/assets/files/Hospital-Administrator-Guide_v3.pdf

  • AMA Journal of Ethics. (2020). Ethical imperatives to overcome stigma against people with substance use disorders. AMA Journal of Ethics, 22(8), E702-708. https://doi.org/10.1001/amajethics.2020.702

  • Aronowitz S, Meisel ZF. Addressing Stigma to Provide Quality Care to People Who Use Drugs. JAMA Netw Open. 2022;5(2):e2146980. doi:10.1001/jamanetworkopen.2021.46980

  • Cochrane, B. S., Ritchie, D., Lockhard, D., Picciano, G., King, J. A., & Nelson, B. (2019). A culture of compassion: How timeless principles of kindness and empathy become powerful tools for confronting today's most pressing healthcare challenges. Healthcare management forum, 32(3), 120–127. https://doi.org/10.1177/0840470419836240

  • Anderson, E. S., Rusoja, E., Luftig, J., Ullal, M., Shardha, R., Schwimmer, H., Friedman, A., Hailozian, C., & Herring, A. A. (2023). Effectiveness of Substance Use Navigation for Emergency Department Patients With Substance Use Disorders: An Implementation Study. Annals of emergency medicine, 81(3), 297–308. https://doi.org/10.1016/j.annemergmed.2022.09.025

  • Englander, H., Weimer, M., Solotaroff, R., Nicolaidis, C., Chan, B., Velez, C., Noice, A., Hartnett, T., Blackburn, E., Barnes, P., & Korthuis, P. T. (2017). Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder. Journal of hospital medicine, 12(5), 339–342. https://doi.org/10.12788/jhm.2736

  • Simon, R., Snow, R., & Wakeman, S. (2020). Understanding why patients with substance use disorders leave the hospital against medical advice: A qualitative study. Substance abuse, 41(4), 519–525. https://doi.org/10.1080/08897077.2019.1671942

  • Geuijen, P. M., van den Broek, S. J. M., Dijkstra, B. A. G., Kuppens, J. M., de Haan, H. A., de Jong, C. A. J., Schene, A. H., Atsma, F., & Schellekens, A. F. A. (2021). Success Rates of Monitoring for Healthcare Professionals with a Substance Use Disorder: A Meta-Analysis. Journal of clinical medicine, 10(2), 264. https://doi.org/10.3390/jcm10020264

  • American Nurse Journal. (2021). Addressing substance use disorder and diversion in the healthcare environment. Retrieved September 24, 2024, from https://www.myamericannurse.com/addressing-substance-use-disorder-and-diversion-in-the-healthcare-environment/

  • Brohan, E., Henderson, C., Wheat, K. et al. Systematic review of beliefs, behaviours and influencing factors associated with disclosure of a mental health problem in the workplace. BMC Psychiatry 12, 11 (2012). https://doi.org/10.1186/1471-244X-12-11

  • Livingston, J. D., Milne, T., Fang, M. L., & Amari, E. (2012). The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction (Abingdon, England), 107(1), 39–50. https://doi.org/10.1111/j.1360-0443.2011.03601.x

  • Biancarelli, D. L., Biello, K. B., Childs, E., Drainoni, M., Salhaney, P., Edeza, A., Mimiaga, M. J., Saitz, R., & Bazzi, A. R. (2019). Strategies used by people who inject drugs to avoid stigma in healthcare settings. Drug and alcohol dependence, 198, 80–86. https://doi.org/10.1016/j.drugalcdep.2019.01.037

  • https://www.learnabouttreatment.org/for-professionals/

  • https://vbhc.dellmed.utexas.edu/courses/course-v1:ut+cn01+2020-21/about

  • https://pcssnow.org/education-training/sud-core-curriculum/

  • Washington State Health Care Authority. (n.d.). Distributing opioid overdose reversal medications (2SSB 5195). Retrieved July 23, 2024, from https://www.hca.wa.gov/about-hca/programs-and-initiatives/behavioral-health-and-recovery/distributing-opioid-overdose-reversal-medications-2ssb-5195#education-materials

  • Wood, K., Giannopoulos, V., Louie, E., Baillie, A., Uribe, G., Lee, K. S., Haber, P. S., & Morley, K. C. (2020). The role of clinical champions in facilitating the use of evidence-based practice in drug and alcohol and mental health settings: A systematic review. Implementation research and practice, 1, 2633489520959072. https://doi.org/10.1177/2633489520959072

  • Substance Abuse and Mental Health Services Administration. (2017). Peers supporting recovery from substance use disorders (Publication No. SMA-17-5009).

  • Linnander, E., McNatt, Z., Boehmer, K., Cherlin, E., Bradley, E., & Curry, L. (2021). Changing hospital organisational culture for improved patient outcomes: developing and implementing the leadership saves lives intervention. BMJ quality & safety, 30(6), 475–483. https://doi.org/10.1136/bmjqs-2019-010734

  • Tatangelo, M., Landry, R., Beaulieu, D., Watson, C., Knowlan, S., Anawati, A., … & Morin, K. A. (2024). Association of hospital-based substance use supports on emergency department revisits: A retrospective cohort study in Sudbury, Canada from 2018 to 2022. Harm Reduction Journal, 21(1), 71. doi.: 10.1186/s12954-024-00985-0

  • Tran, T. H., Swoboda, H., Perticone, K., Ramsey, E., Thompson, H., Hill, K., & Karnik, N. S. (2021). The substance use intervention team: A hospital-based intervention and outpatient clinic to improve care for patients with substance use disorders. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 78(4), 345–353. https://doi.org/10.1093/ajhp/zxaa408

  • Ober, A. J., Osilla, K. C., Klein, D. J., Burgette, L. F., Leamon, I., Mazer, M. W., Messineo, G., Collier, S., Korouri, S., Watkins, K. E., Ishak, W., Nuckols, T., & Danovitch, I. (2023). Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care. Journal of substance use and addiction treatment, 150, 209063. https://doi.org/10.1016/j.josat.2023.209063

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  • Oros, M., Smith, S., Davis, Y., Higgins, F., & Masog, M. (2024, February 1). Emergency department-based substance use response: A toolkit for developing, planning, and implementing a peer recovery coach led program. NACCHO.

  • Horner, G., Daddona, J., Burke, D. J., Cullinane, J., Skeer, M., & Wurcel, A. G. (2019). "You're kind of at war with yourself as a nurse": Perspectives of inpatient nurses on treating people who present with a comorbid opioid use disorder. PloS one, 14(10), e0224335. https://doi.org/10.1371/journal.pone.0224335

  • Sederer, L.I., Marino, L.A. Ending the Opioid Epidemic by Changing the Culture. Psychiatr Q 89, 891–895 (2018). https://doi-org.offcampus.lib.washington.edu/10.1007/s11126-018-9589-0

  • Ellis, L. A., Tran, Y., Pomare, C., Long, J. C., Churruca, K., Saba, M., & Braithwaite, J. (2023). Hospital organizational change: The importance of teamwork culture, communication, and change readiness. Frontiers in public health, 11, 1089252. https://doi.org/10.3389/fpubh.2023.1089252

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  • Biancarelli, D. L., Biello, K. B., Childs, E., Drainoni, M., Salhaney, P., Edeza, A., Mimiaga, M. J., Saitz, R., & Bazzi, A. R. (2019). Strategies used by people who inject drugs to avoid stigma in healthcare settings. Drug and alcohol dependence, 198, 80–86. https://doi.org/10.1016/j.drugalcdep.2019.01.037

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