Gillian Rn Otway

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.

In-hospital substance use is common among patients with addiction because of undertreated withdrawal, undertreated pain, negative feelings, and stigma. Health care system responses to in-hospital substance use often perpetuate stigma and criminalization of people with addiction, long etched into our culture by the racist War on Drugs. In this commentary, we describe how our hospital convened an interprofessional workgroup to revise our in-hospital substance use policy. Our updated policy recommends health care workers respond to substance use concerns by offering patients adequate pain control, evidence-based addiction treatment, and supportive services instead of punitive responses. We provide best-practice recommendations for in-hospital substance use policies.