Method

Sample: This research team conducted a 4-year project which will involve the recruitment of up to 420 adults aged 16-85 years (from hospital, outpatients, community out-reach programs) with past experience or current use of methamphetamine. The study set out to recruit a minimum of 104 participants (with a maximum of 120) with past or current lived experience of methamphetamine use in based on the sample size calculation set out by Bartlett et al. (2001). Year 1 of the study oversaw an expansion in recruitment which expanded to participants outside of London, Ontario (maximum of 180 in total). For patients in years 3 and 4, patients must have been in the hospital when the new strategies were implemented. We also recruited health care/service providers who have direct contact with people who use methamphetamine to participate in focus groups and contextually supplement the study’s findings.

Procedure: During the first year of the study, up to 154 individuals with a present or past experience of methamphetamine usage were recruited for an individual interview to complete quantitative and open-ended qualitative items. Quantitative measures focused on demographics, substance use, community integration, health, service usage and quality of life. Furthermore, health care/service providers were invited to participate in qualitative interview discussions to explore their perspectives on actionable harm reduction strategies, as well as facilitators and barriers to implementation of the identified strategies. We will create and test an algorithm that could be used to identify people who use methamphetamine and look at secular trends, costs of care, and complications in administrative databases and ICES.

In the second year of the study, analyses were performed on the first year’s interview discussions. As well, the study performed an analysis of the health administrative data using the diagnostic algorithm developed in the first year to establish and compare baseline use of services and mortality rates of people using methamphetamine and people using substances but not methamphetamine.

The third and fourth years of the study saw the new strategies implemented. As well, individual interviews with 212 people with lived experience of using methamphetamine were conducted each year (107 and 105 respectively). Like the first year, these will involve questionnaires and open-ended qualitative questions but pertaining to experience with the new intervention. Qualitative discussions with health care/service providers were also provided each year.

Data Analysis

A standardized evaluation framework was instituted to facilitate systematic effectiveness, economic, ethical, and policy analyses (Forchuk et al., 2016). Descriptive analysis and frequencies were completed on all demographic and outcome variables. Independent group comparative analyses were completed on quantitative measures of participants pre- and post- intervention related to the main study outcomes (i.e., quality of life and community integration). Descriptive analysis (means, standard deviations, frequencies) and statistical inferences such as between-group ANOVAs were sought where meaningful to help generate descriptive level insights related to main outcomes before and after intervention. An ethnographic thematic analysis was performed on qualitative data collected from interviews and interview discussions.

Findings

Year 1

In Year 1, the study recruited 154 people with lived experience but this was based on an expansion which included people from outside London, Ontario. The qualitative data revealed that negative patient-staff interactions included stigma and a lack of understanding of addiction and methamphetamine use, leading to distrust, avoidance of hospital care and reduced help-seeking and health care engagement. The consequences can be infections, unsafe needle use, discharge against medical advice and withdrawal. Almost all participants were in favour of in-hospital harm reduction strategies including safe consumption services, provision of sterile equipment and sharps containers, and withdrawal support.

Attitudinal barriers such as stigma and lack of acceptance were reported but education, openness and community support were regarded as potential facilitators. Cost, space, time and availability of substances on site were regarded as Pragmatic barriers but potential facilitators such as organizational support, flexible harm reduction services and a specialized team were identified. Policy and liability were perceived as both a barrier and a potential facilitator. Safety and impact of substances on treatment were considered as both a barrier and a potential facilitator but sharps boxes and continuity of care were regarded as potential facilitators.

People with lived experience of methamphetamine use reported three choices upon admission: leave or avoid the hospital, stay but experience unsupported withdrawal, or stay but hide their substance usage from health care professionals. Health care/service professionals described two options: uphold zero tolerance that can lead to stigma and a lack of knowledge regarding addiction, or accept harm reduction but be unable to implement such strategies.

Year 2

In Year 2, new educational sessions for health care professionals were developed and provided by a nurse educator and a lived experience educator seconded from our community partner, Regional HIV/AIDS Connection. The practice of removing sharps boxes from the rooms of patients who use methamphetamine was rescinded by senior management and supported by the Registered Nurses Association of Ontario (RNAO). The algorithm was also successfully developed with high reliability and validity for detecting methamphetamine usage among patients accessing the hospital.

Years 3 and 4

Years 3 and 4 recruited 107 and 105 participants respectively to assess these changes. Reports of better therapeutic relationships and interactions were reported as well as improved knowledge and awareness of needs. Perceptions of stigma were still reported however. The majority of participants were in favor of not removing sharps boxes. Safety, infection control, greater engagement with health care and autonomy were reported as benefits. A total of 623 health care providers attended the education sessions with 211 completing a post-session questionnaire online. The questionnaires revealed highly encouraging results and the lived experience educator was highly valued according to the feedback.

Education Project

• Lived Experience Educator and a Nurse Educator recruited.

• Education sessions focused on substance use, harm reduction, withdrawal, symptomatic presentation, trauma-informed care and motivational interviewing.

• Delivered new educational sessions to over 400 hospital staff members.

• Average pre-session knowledge score of SUD: 3.6 out of 5.

• Average post-session knowledge score: 4.4 out of 5 (statistically significant increase).

• Average post-session scores:

• Preparedness for SUD 4.5 out of 5

• Recognizing intoxication 4.5 out of 5

• Recognizing withdrawal 4.5 out of 5

• Understanding of harm reduction 4.6 out of 5.

• Lived experience highly valued by attendees.

Publications

Forchuk C, Serrato J, Scott L, Rudnick A, Dickey C, Silverman M. "No Good Choice": What are the Issues of Having no Harm Reduction Strategies in Hospitals? Subst Abuse. 2023 Jul 16;17:11782218231186065. doi: 10.1177/11782218231186065. PMID: 37476501; PMCID: PMC10354823.

Forchuk C, Serrato J, Scott L. People with lived and living experience of methamphetamine use and admission to hospital: what harm reduction do they suggest needs to be addressed? Health Promot Chronic Dis Prev Can. 2023 Jun;43(6):338-347. doi: 10.24095/hpcdp.43.7.04. PMID: 37466399; PMCID: PMC10414816.

Forchuk C, Serrato J, Scott L. Identifying barriers and facilitators for implementing harm reduction strategies for methamphetamine use into hospital settings. Front Health Serv. 2023 Feb 7;3:1113891. doi: 10.3389/frhs.2023.1113891. PMID: 36926504; PMCID: PMC10012827.

Forchuk C, Serrato J, Scott L. Perceptions of stigma among people with lived experience of methamphetamine use within the hospital setting: qualitative point-in-time interviews and thematic analyses of experiences. Front Public Health. 2024 Feb 13;12:1279477. doi: 10.3389/fpubh.2024.1279477. PMID: 38414902; PMCID: PMC10896942.

Forchuk C, Silverman M, Rudnick A, Serrato J, Schmitt B, Scott L. The need for sharps boxes to be offered in the hospital setting for people who use substances: Removing sharps boxes puts all of us at risk. Front Health Serv. 2023 Apr 6;3:1113163. doi: 10.3389/frhs.2023.1113163. PMID: 37089452; PMCID: PMC10117891.

Kim HH, Silverman M, Anderson KK, Lodhi RJ, Sarma S, Dickey C, Forchuk C. Characterization of a Cohort of Persons Who Use Methamphetamine in London, Ontario, and In-Hospital Substance Use. Can J Addict. 2023 Dec;14(4):36-43. doi:10.1097/CXA.0000000000000191.

Investigators

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