In-Hospital Substance Use: A Qualitative Study of Patient and Staff Experiences

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Abstract
Objectives: To understand patient and staff experiences with in-hospital substance use (IHSU) and develop recommendations to better support patients and staff navigating IHSU. Methods: Semi-structured qualitative interviews with patients engaging in and hospital staff responding to IHSU in the past year at a safety-net hospital in San Francisco, California, from July 2024 to August 2025. We used iterative thematic analysis to identify major themes. Results: Patients (n=19) were recruited from the community (84.2%) and hospital (15.8%). Most identified as men (73.7%), White (63.2%), and unhoused (57.9%); most used fentanyl during hospitalization (57.9%). Staff (n=21) included clinicians (28.6%), nurses (28.6%), nurse leaders (19.0%), administrators (14.3%), and other staff members (9.5%); primary work areas were administration (23.8%), the addiction consult team (19.0%), and medical-surgical departments (19.0%). We identified seven themes regarding patient and staff experiences: (1) IHSU helped patients endure hospitalization; (2) punitive responses exacerbated patient experiences of mistrust, stigma, and distress; (3) patient-centered responses improved patient and staff experiences; (4) staff were concerned for patient and staff safety; (5) nurses were concerned about personal liability; (6) nurses felt unheard in concerns; and (7) staff felt underprepared to respond to IHSU. Conclusions: IHSU helped patients avoid patient-directed discharge but distressed staff—especially nurses—due to a lack of training and support. To improve patient and staff experiences, hospitals can implement standardized addiction medicine training, proactive evidence-based inpatient addiction treatment, trauma-informed IHSU responses, and evidence-based patient-centered policies for responding to IHSU that support patients and staff.

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