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      Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada

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          Abstract

          Aims

          Many people who use drugs (PWUD) have multiple health and social needs, and research suggests that this population is increasingly accessing emergency departments (EDs) and shelters for health care and housing. This qualitative study explored the practices of those working in EDs and shelters when providing services to PWUD, with a particular focus on key challenges in service provision.

          Methods

          EDs and shelters were conceptualized as ‘micro environments’ with various components (i.e. social, physical and resource). One-on-one interviews were conducted with 57 individuals working in EDs and shelters in Atlantic Canada.

          Findings

          The social, physical and resource environments within some EDs and shelters are key forces in shaping the challenges facing those providing services. For example, the social environments within these settings are focused on acute health care in the case of EDs, and housing in the case of shelters. These mandates do not encompass the complex needs of many PWUD. Resource issues within the wider community (e.g. limited drug treatment spaces) further contribute to the challenges.

          Conclusions

          Structural issues, internal and external to EDs and shelters need to be addressed to reduce the challenges facing many who work in these settings when providing services to PWUD.

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          Most cited references43

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          Are drug treatment services only for 'thieving junkie scumbags'? Drug users and the management of stigmatised identities.

          Polly Radcliffe, Alex Stevens (2008)
          This article uses qualitative interviews with 53 problematic drug users who had dropped out of treatment in England, UK to explore how they describe the stigmatisation of drug users and drug services. It discusses the construction of the category of the junkie through its association with un-controlled heroin use and criminality. It shows how some drug users carefully manage information about their discreditable identities by excluding themselves from this category, while acknowledging its validity for other drug users. The junkie identity was generally seen as shameful and therefore to be avoided, although it holds attractions for some drug users. For many of the interviewees, entry to treatment risked exposing their own activities as shaming, as they saw treatment as being a place that was populated by junkies and where it becomes more difficult to manage discreditable information. The treatment regime, e.g. the routine of supervised consumption of methadone, was itself seen by some as stigmatising and was also seen as hindering progress to the desired 'normal' life of conventional employment. Participation in the community of users of both drugs and drug services was perceived as potentially damaging to the prospects of recovery. This emphasises the importance of social capital, including links to people and opportunities outside the drug market. It also highlights the danger that using the criminal justice system to concentrate prolific offenders in treatment may have the perverse effects of excluding other people who have drug problems and of prolonging the performance of the junkie identity within treatment services. It is concluded that treatment agencies should address these issues, including through the provision of more drug services in mainstream settings, in order to ensure that drug services are not seen to be suitable only for one particularly stigmatised category of drug user.
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            Hospital utilization and costs in a cohort of injection drug users.

            J. Müller, Lisa Schechter, A Palepu … (2001)
            Many injection drug users (IDUs) seek care at emergency departments and some require hospital admission because of late presentation in the course of their illness. We determined the predictors of frequent emergency department visits and hospital admissions among community-based IDUs and estimated the incremental hospital utilization costs incurred by IDUs with early HIV infection relative to costs incurred by HIV-negative IDUs. The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study involving IDUs that began in 1996. Our analyses were restricted to the 598 participants who gave informed consent for our study. We used the participants' responses to the baseline VIDUS questionnaire and, from medical records at St. Paul's Hospital, Vancouver, we collected detailed information about the frequency of emergency department visits, hospital admissions and the primary diagnosis for all visits or hospital stays between May 1, 1996, and Aug. 31, 1999. The incremental difference in hospital utilization costs by HIV status was estimated, based on 105 admissions in a subgroup of 64 participants. A total of 440 (73.6%) of the 598 IDUs made 2763 visits to the emergency department at St. Paul's Hospital during the study period. Of these 440, 265 (160.2%) made frequent visits (3 or more). The following factors were associated with frequent use: HIV-positive status (seroprevalent: adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2-2.6; seroconverted during study period: adjusted OR 3.0, 95% CI 1.6-5.7); more than 4 injections daily (adjusted OR 1.5, 95% CI 1.1-2.1); cocaine use more frequent than use of other drugs (adjusted OR 2.0, 95% CI 1.2-3.6); and unstable housing (adjusted OR 1.5, 95% CI 1.1-2.2). During the study period 210 of the participants were admitted to hospital 495 times; 118 (56.2%) of them were admitted frequently (2 or more admissions). The 2 most common reasons for admission were pneumonia (132 admissions among 79 patients) and soft-tissue infections (cellulitis and skin abscess) (90 admissions among 59 patients). The following factors were independently associated with frequent hospital admissions: HIV-positive status (seroprevalent: adjusted OR 5.4, 95% CI 3.4-8.6; seroconverted during study period: adjusted OR 2.9, 95% CI 1.4-6.0); and female sex (adjusted OR 1.8, 95% CI 1.1-3.1). The incremental hospital utilization costs incurred by HIV-positive IDUs relative to the costs incurred by HIV-negative IDUs were $1752 per year. Hospital utilization was significantly higher among community-based IDUs with early HIV disease than among those who were HIV negative. Much of the hospital use was related to complications of injection drug use and may be reduced with the establishment of programs that integrate harm reduction strategies with primary care and addiction treatment.
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              Transition and the HIV risk environment.

              Milena Simic, Tim Rhodes (2005)
              Article 0 comments Cited 46 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Drugs (Abingdon Engl)
                Journal ID (iso-abbrev): Drugs (Abingdon Engl)
                Journal ID (publisher-id): DEP
                Title: Drugs (Abingdon, England)
                Publisher: Informa UK Ltd.
                ISSN (Print): 0968-7637
                ISSN (Electronic): 1465-3370
                Publication date (Print): June 2014
                Publication date (Electronic): 13 January 2014
                Volume: 21
                Issue: 3
                Pages: 244-253
                Affiliations
                1School of Health and Human Performance, Dalhousie University , Halifax, NS, Canada
                2Atlantic Health Promotion Research Centre, Dalhousie University , Halifax, NS, Canada
                3Department of Sociology and Social Anthropology, Dalhousie University , Halifax, NS, Canada
                4AIDS Saint John , Saint John, NB, Canada
                5Faculty of Nursing, University of New Brunswick , Fredericton, NB, Canada
                6School of Social Work, Dalhousie University , Halifax, NS, Canada
                Author notes
                * Correspondence: Lois A. Jackson, School of Health and Human Performance, Dalhousie University , 6230 South Street, Halifax, NS B3H 4R2, Canada. Tel: 011 1 902 494 1341. Fax: 011 1 902 494 5120. E-mail: Lois.Jackson@ 123456dal.ca
                Article
                DOI: 10.3109/09687637.2013.870534
                PMC ID: 4046876
                PubMed ID: 24954982
                SO-VID: 264f1115-5a05-41d5-9888-1c63173de266
                Copyright © © 2014 Informa UK Ltd. All rights reserved: reproduction in whole or part not permitted
                License:

                This is an open-access article distributed under the terms of the CC-BY-NC-ND 3.0 License which permits users to download and share the article for non-commercial purposes, so long as the article is reproduced in the whole without changes, and provided the original source is credited.

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