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Executive Summary: State-of-the-Art Review: Frame Shift—Focusing on Harm Reduction and Shared Decision Making for People Who Use Drugs Hospitalized With Infections

Year: 2023

Type: article

Abstract: As the overdose crisis continues to worsen, infectious complications from substance use also continue to rise [1]. It is important to understand that people with substance use disorder (SUD) may delay seeking care due to several barriers, thus impacting clinical presentation. Barriers to accessing harm-reduction services and SUD treatment range from restrictive policies to logistic challenges, such as lack of transportation, to fear of law enforcement. Patients may also delay or avoid medical care because of stigma and distrust of clinicians. Notably, there are also racial and other inequities in the diagnosis and prevention of infections, as well as in the management of infections and SUDs. As infectious disease clinicians, it is upon us to recognize—and act—to address these inequities and to provide trauma-informed care in order to optimize patient health (Figure 1) [2]. Key tenets of improving infectious diseases care of people who use drugs include reframing our clinical decisions around principles of shared decision making, health equity, harm reduction, and that all doors should be open to engagement in infection and/or substance use disorder treatment. Traditionally, patients with injection drug use–associated infections such as infective endocarditis or osteomyelitis may be subjected to prolonged hospitalizations for intravenous antimicrobial treatment. Treating SUDs in hospitalized patients is now considered standard of care [3]. While hospitalizations can—and should—give patients the opportunity to engage in treatment for SUD, some patients may prefer not to pursue SUD treatment options, or may lack treatment options. Given the growing body of evidence to (1) include patient voices in antimicrobial treatment decisions, (2) support various antimicrobial treatment options for hospitalized people with SUD [4–7], and (3) provide multidisciplinary management, this review highlights clinical presentations, diagnostic approaches, and management of people who use drugs. Additionally, the review provides an intentional focus on shared decision making, harm reduction, and approaches to mitigate health inequities in patients with SUD. We present several clinical cases to illustrate a spectrum of scenarios and provide viewpoints, particularly where robust data are lacking. In this review, we propose drawing on principles of shared decision making and harm reduction to optimize patient autonomy, health, and safety. Author Contributions. K. T.: Conceptualization, writing—original draft; writing—reviewing and editing; A. A.: Conceptualization, writing—original draft; writing—reviewing and editing; J. C. A. M. and A. G.: Writing—original draft; writing—reviewing and editing; J. B.: Writing—reviewing and editing; C. T.: Writing—reviewing and editing; K. F.: Conceptualization, writing—original draft; writing—reviewing and editing; A. W.: Conceptualization, writing—original draft; writing—reviewing and editing.

Source: Clinical Infectious Diseases

DOI: 10.1093/cid/ciad665