Speaker 1: I've had a few patients who have had some very, very serious complications related to drug use. There's at least one patient who's literally been shocked back to life because of how sick they were from their infection in their heart and needed open heart surgery. And unfortunately, even though they were getting all of these aggressive, expensive, life-saving interventions, they were not having their addiction treated and ended up relapsing and getting a second infection, requiring, again, expensive cardiac surgery, other cardiac interventions. Some of the staff in the hospital were very upset with the patient for relapsing and weren't sure if the patient deserved basically getting medical care because they had kind of quote unquote done this to themselves. Our ethical obligation as providers is really to treat everyone and treat everyone equally. And I think, unfortunately, with the disease of addiction, there still is that perception that it's a moral failing. And so I think that that's something that a lot of medical settings really need to look at and address is how to make sure that patients are really getting the medical care that they need, including access to addiction treatment.

Speaker 2: Let's say that a pipe is leaking in your apartment, causing water damage to the floor and to all your furniture and belongings. Rather than fixing the leaky pipe, your landlord pays to replace the flooring and all your damaged furniture and belongings. Soon, the floors and your furniture need to be replaced again. You think to yourself, this doesn't make any sense. Why won't my landlord save us both the extra trouble and fix the leaky pipe? This is analogous to the way many patients with substance use disorder are treated in hospital settings. Often, patients with substance use disorders are high utilizers of the health care system and have higher rates of acute care readmissions than those without substance use disorders. The acute reason for the hospitalization is addressed, but the underlying cause, the individual substance use disorder, is often ignored or overlooked. Take, for example, a person who injects drugs. This person shows up at an emergency department seeking treatment for an infection related to injection drug use. The individual is given antibiotics to treat the infection, but the root cause of the infection, the substance use disorder that leads the patient to inject drugs, is ignored. As one might expect, the same individual shows up at the emergency department more frequently with infections from injection drug use that continue to become more severe. All patients deserve high-quality, evidence-based treatment in all health care settings, including during inpatient hospitalization. Treatment should be delivered in accordance with the four pillars of medical ethics. Even in a sophisticated medical setting, like a hospital, the majority of patients with a substance use disorder do not receive any treatment for their substance use. Patients with a substance use disorder do not receive the same quality of care in the hospital setting as other patients. This is unethical. It results in suboptimal treatment outcomes for the patient. Some issues regarding inpatient treatment of substance use disorder are due to a lack of knowledge about how to care for patients who use substances. The mistreatment comes from stigma and discrimination against people who use drugs. Many clinicians still believe that addiction is a choice rather than a proven medical condition. This may result in the patient being blamed for being sick and treated like a burden instead of receiving ethical and compassionate care. People know when they're being judged and treated disrespectfully. They are likely to avoid circumstances where this situation occurs. If patients are treated without respect and dignity, they may become afraid to ask for help and may avoid making contact with the health care system. They suffer in silence. Another ethical issue related to caring for inpatients with a substance use disorder is ensuring that symptoms related to alcohol and or drug use are adequately addressed. For example, health care teams often do not adequately treat patients' withdrawal symptoms. This can be due to a lack of education on how to address withdrawal symptoms appropriately, particularly if providers are managing other health needs, such as pain. Not managing a patient's withdrawal symptoms forces the patient to endure a great deal of pain and discomfort. In cases like this, the patient is unlikely to build trust with his medical team. A systematic review of over 1,600 studies concluded that for people who use drugs, the prevalence of leaving the hospital against medical advice ranged from 25 to 30 percent. Patients who do this are likely to get sick again and again. To ensure the ethical treatment of patients, it is important that hospital administrators and all members of clinical teams understand the laws regarding administration of medications for addiction treatment in the inpatient setting. Regulations regarding the use of buprenorphine and methadone for treatment of opioid use disorder in the inpatient setting are distinctly different from those for patients being treated in outpatient settings. The Controlled Substances Act, as amended by DATA 2000, and the Drug Enforcement Administration regulations give a provider authority to maintain or detoxify a person with an opioid use disorder using buprenorphine or methadone in an inpatient setting, even if the provider does not have a DATA 2000 waiver. Many hospital staff do not know the law. A hospital does not need to have a special license or approval to treat withdrawal with buprenorphine or methadone. It is essential that healthcare providers assess patients for substance use, treat withdrawal symptoms, and offer patients a link to long-term, evidence-based addiction treatment programs that include medications. For this reason, it is important that all hospital staff are trained on the etiology of substance use disorders and evidence-based treatments. For more information visit www.FEMA.gov