How to develop compassionate, nonpunitive, in-hospital substance use policies

More than 40% of people with substance use disorders use substances during hospital stays to avoid withdrawal, undertreated pain, negative feelings, and stigma. Although it’s linked to poor outcomes, there isn’t a lot of research to guide institutional policies on in-hospital substance use. Without those policies, healthcare workers use personal beliefs about addition when responding. Those beliefs may be rooted in stigma and result in harmful responses, including surveilling and punishing patients and calling security. They can view addiction as a personal choice and moral failing. Responses like this are unsurprising since healthcare workers are historically undertrained to care for people with substance use disorders.

Policies that focus on punitive measures are also harmful. They might result in riskier in-hospital substance use, overdose, patients leaving, reduced trust, and increased stigma. People with substance use disorders see hospitals as risky places. They avoid or delay care because of stigmatizing and traumatizing healthcare experiences, making their health worse. Punitive policies also align with criminalization promoted by the War on Drugs, compounding systemic racism.

In a new commentary, authors from San Francisco General Hospital argue that hospital policies should facilitate therapeutic responses instead of leaving healthcare workers to apply potentially stigmatizing beliefs about addictions. They share the revised policy they developed and call for policies that are person-centered, stigma-free, evidence-based, nonpunitive, and coupled with addiction education for the healthcare workforce.

Based on evidence and their experience revising the policy, the authors make these recommendations for nonpunitive policies:

Convene an interprofessional group that includes patients to create or review the policy.
Ensure the policy is patient-centered and does not include punitive measures, including security as a first responder. If security is included, confirm they are a last resort.
Evaluate the policy with an equity lens to determine who will be disproportionately affected and how, based on policy implementation trends across race/ethnicity and substance use.
Obtain legal, security, regulatory, nursing, and leadership sponsorship of the policy to ensure consistent messaging and support.
Educate health care workers about the policy, evidence-based addiction care, harms of stigma, and SUD-related inequities, especially around race/ethnicity. Provide best-practice scripts of how to respond to in-hospital substance use concerns.
Involve health care workers in policy implementation and a continual improvement process.
Inform all patients, regardless of substance use history, of the policy on
Offer patients adequate pain control, evidence-based addiction treatment, and supportive care that helps them tolerate hospitalization.

With increased rates of substance-related hospitalizations and persistent gaps in addiction treatment, in-hospital substance use will continue. Criminalization of substance use has fueled racial and ethnic inequities and hasn’t reduced addiction-related deaths. Healthcare systems can promote health and advance equity and antiracism by revising or developing in-hospital substance use policies. These policies must dismantle stigma and punitive practices and facilitate compassionate evidence-based care.