Thread by @NanouTheNomad

Before I head to sleep: a #harmred22 tweetatorial on how to help hospitals be less harmful places for people who inject drugs & need treatment for serious infections (endocarditis, osteomyelitis)!

Hospitals are carceral, medicine is largely prohibitionist, and people who inject drugs are often treated very badly in medical settings. So many interventions aren't "traditional" harm reduction - but is about reducing harm medical system usually imposes on folks.

It's great if this can start before hospital & when worried, outreach teams or harm reduction programs can reach out to (and maybe introduce client to?) addiction medicine team at hospital, so patients have reason to trust us & we know they're on their way.

Otherwise, good for outreach teams to generally know when we are in hospital and to tell patients to ASK FOR an addiction medicine consult!

Important to remind teams & tell patients that our primary goal is for patients to be able to stay in hospital to get medical care they need & deserve. We are not the abstinence police! This often starts by aggressively treating both pain and withdrawal.

@DrMeganBuresh et al wrote a great paper on adapting methadone inductions to the fentanyl era, and Dr. Robert Kleinman and @DrSarahWakeman, as well as @especially_APT (separately) wrote papers about using short-acting opioids to treat withdrawal in hospital setting.

More aggressive methadone starts, using adequate doses of short-acting opioids to treat pain and withdrawal, and being able to offer low-dose initiation to buprenorphine (often later in hospitalization) (see paper by @ShawnCohen_MD, @DrMelissaWeimer and others) can all help!

Serious infections require at least 6 weeks of antibiotic treatment. Make the hospital stay as humane and carceral as possible. Avoid involvement of security (& police!) in room searches. Offer ear plugs, phone chargers, candy orders, books, fidget toys, etc. Visit.

Ideally there could be a way to make sure patients get outside sometimes or have smoke breaks but this is very difficult depending on hospital/floor policies. Offer adequate nicotine replacement!

Engage patient in decisions about orders as much as possible. For pain meds - scheduled or as needed. Ask- "do you want to be woken up?" Think about way order is put in (i.e. QID vs. q6h). If needed, consider extra dose for PT or dressing changes.

When it's time to taper, engage patient in how it's done (ie spacing vs. lowering dose, timing, etc.)

For methadone, split dosing while in hospital can sometimes help with pain but some patients don't find it makes much of a difference (or prefers to keep dose all in am).

Sometimes when methadone not yet therapeutic & patients having trouble sleeping, I would ask if they wanted me to "hold" 10 or 20mg of methadone for evening to help.

When bad interactions or very anxiety-provoking things happen in hospital it often happens in middle of night when patient/nurse cannot reach a provider familiar with the patient in time... & ends in premature ("AMA") discharge.

In some circumstances, having an emergency prn "in case of severe anxiety" order for something like diazepam available can a good idea for high risk person team is following closely.

When it comes to discharge plan: 6 weeks in hospital may not be feasible or bearable for patient. Is it possible they could go home w PICC? @AyeshaAppaMD & @jabarocas wrote a great review on this topic!

SNFs often reject pts w OUD put DOJ clear this is ADA violation. File complaints & encourage your state attorney generals to follow lead of MA in pursuing violations & settlements that will eventually, slowly help change this landscape. justice.gov/usao-ma/pr/ope…

Can patient who doesn't want to complete IV abx finish it with po antibiotics, or once weekly infusions? Check with ID for a "plan B." For endocarditis check out chart in this wonderful new guidelines by @LBaddour1, @DrMelissaWeimer and others!
ahajournals.org/doi/full/10.11…

MAKE SURE "PLAN B" (for antibiotics, as well as continuation of MOUD) is clearly documented in daily progress notes (not just consult notes). Often premature discharges happen in middle of night. Make sure patients know how to reach you & that you want to hear from them.

Again - it's impt that whole team (primary, specialists, nurses, PATIENT) are on board w idea that completion of tx is priority & that even if ideal 6 week IV antibiotic course can't be completed, we want to make Best Possible Plan happen.

Ideally patient would stay on MOUD into future, but usually I try to emphasize staying on it for course of antibiotic treatment. Make a follow-up plan as discharge approaches. Transition meds if desired/necessary. Direct referrals to methadone, last dose letters, etc.

Early in the stay if possible but DEFINITELY as discharge approaches, talk about patient goals. I say: "if you're interested in stopping use, using less, or using more safely, I'd love to help you with any of these goals"

Ask them about their injection practices, discuss safer techniques, alternatives (i.e. boofing) - @NEXTDistro has great resources (in English & Spanish) and @clairezagorski and @SessiBlanchard have great resources on boofing!

If patient doesn't know local outreach/harm reduction/SSP team, give them the number and have them put it in phone (and consider calling together the first time). Put @NeverUseAlone number in there too!

If you are not a clinician doing this work but want to advocate for someone: docs care about articles in medical journals. Here is a list of some of the (very new) articles I referred to in this thread. If you need a PDF reach out to me (or the authors!) docs.google.com/document/d/1hy…

So grateful to fellowship at @YaleADM, consult service director extraordinaire @DrMelissaWeimer, faculty, my co-fellows @CarolynAChan & @ShawnCohen_MD for teaching me so many of these tips & helping me love this work.

*non-carceral 🫣 Omg don’t do late night thread writing threads friends !!!!