Resisting Inadequate Care is Not Irrational, and Coercive Treatment is Not an Appropriate Response to the Drug Toxicity Crises

This article refers to:

Revive and Refuse: Capacity, Autonomy, and Refusal of Care After Opioid Overdose

We read Marshall et al.’s paper with great interest but were left with many questions and concerns (Marshall et al., in press). As a group of public health researchers and practitioners (nursing, social work, and bioethics) committed to advancing harm reduction and the rights of people who use drugs (PWUD) to the highest standard of health care, we are aware of the devastating impact the drug toxicity crisis has had across North America and the challenges faced by health care providers. In Canada, 40,642 drug toxicity deaths were recorded between January 2016 and June 2023 (Federal, provincial, and territorial Special Advisory Committee on the Epidemic of Opioid Overdoses 2023). In the United States, over 100,000 deaths were recorded in the last 12 months alone (Ahmad et al. 2024). This drug toxicity crisis is impacting the spectrum of PWUD across demographics and socioeconomic status, type of drug (opioid, stimulant, polysubstance), route of administration (e.g., injecting, smoking, and snorting) and length of use. Driven by a combination of unregulated fentanyl and its analogues (e.g., carfentanil and fluorofentanyl) in the drug supply and the presence of adulterants (e.g., benzodiazepines and xylazine), this crisis is making overdoses more frequent, complex, difficult to reverse and fatal. New approaches in clinical practice are needed as medication-assisted treatments (e.g., methadone and buprenorphine) become less effective in preventing withdrawal for those using unregulated fentanyl, and the need to offer safer alternatives to the toxic drug supply becomes more urgent. Finally, it requires implementing and scaling innovative harm reduction intervention responses in the community and across healthcare settings, including in hospitals (Fraimow-Wong et al. 2024). However, health systems responses tend to be dominated by epidemiological and legal considerations at the expense of ethical and just healthcare delivery. Against this backdrop, we read Marshall et al.’s analysis looking for ethical insights but found it reductive in its characterization of PWUD and unsupported by research evidence on their care needs in hospitals. We consider some of their arguments, offer an alternative framing rooted in growing calls for hospital-based harm reduction, and conclude by calling for more collaborative research and practice that is both empirically supported and ethically defensible.

First, while we share Marshall et al.’s (2024) concern about the health risks of overdose, we disagree with their construction of PWUD as “irrational” to justify coercive medical interventions. Contrary to being framed as lacking autonomy and decision-making capacity, PWUD make myriad decisions about their substance use and health in the context of the decades-long “war on drugs” which criminalizes them, the worsening drug toxicity crises which has devastated their communities, and societal stigma toward drug use (including in healthcare systems) (Buchman, Leece, and Orkin 2017). Despite pervasive stereotypes about who is more/less likely to use drugs and significant racial inequities in health access and criminal justice involvement (Earp, Lewis, and Hart 2021), PWUD are a very diverse group (even more so when accounting for lifetime use). While the authors mention mistrust, perceived stigma, and fear of law-enforcement, these considerations are downplayed in place of reductive neuroscientific explanations for why large numbers of PWUD decline care. This ignores research evidence documenting the varied reasons patients decline observation and leave against medical advice (Spooner et al. 2017). It is not clear why PWUD should be held to a different standard than the general population who decline medical advice and fail to comply with treatments. In place of a nuanced discussion that acknowledges the reasons any patient might decline care (e.g., work and family responsibilities), crude archetypes are presented about PWUD, which reduces them to their drug use and forestalls discussions about how to better support them.

Second, we disagree with the claim that “there is a paucity of research on why patients with OUD are non-compliant with medical recommendations” (Marshall et al. 2024, 21). As we have argued elsewhere, leaving against medical advice needs to be viewed in terms of patients’ experiences in and responses to hospitals as “risk environments” (Strike et al. 2020). In Marshall et al., post-overdose observation is constructed as a “benign intervention” that only an irrational person would decline. However, this response needs to be considered within the context of hospitals as risk environments which undermine the ability of PWUD to access care and perpetuate the conditions that cause patient/provider conflicts (Strike et al. 2020). When an overdose is reversed abruptly in someone who is opioid dependent (it is important to distinguish between intentional and accidental opioid use leading to an overdose), and severe withdrawal is precipitated, it may understandably be difficult for them to accept that clinicians genuinely care about their welfare if they have been treated poorly in the past. There is a compelling body of research about PWUD reporting hospital clinicians ignoring their symptoms, accusing them of being “drug seeking,” providing poor care and blaming them for their health problems (seeing drug use only as the presenting health issue instead of a strategy for managing pain, mental illness, trauma, and poverty), experiences of boredom and isolation, and being subjected to surveillance, harassment, police detainment and discharge (Chan Carusone et al. 2019). While we agree that having an overdose reversed with naloxone can make healthcare decision-making difficult, we see this as a consequence of the situation (which can be traumatic) and not an inherent deficit in the person or a distinct effect of opioid use disorder on the brain (and not all overdoses are due to an opioid use disorder). The consequences of naloxone withdrawal and the stress of being in the hospital can be mitigated through a combination of patient-centred and medication-assisted approaches (e.g., buprenorphine microinduction), which can make patients comfortable and permit opportunities for shared decision-making (Hughes, Nasser, and Mitra 2024). We appreciate that this is not always possible, but more can be done to support patients and reduce tension.

Third, hospitals should be sites of harm reduction innovation and better serve PWUD in their communities (Guta et al. 2021). Instead of clinicians holding PWUD to higher standards than other groups when it comes to receiving and processing complex health information and proving their inherent dignity, autonomy and human rights, they should be working to improve care in hospitals. We respect the important knowledge that emergency department teams have, and their practice experience should be used to counter the hospital risk environment context itself. For example, they may wish to partner with public health units, community-based harm reduction programs, and PWUD to develop patient-centered interventions and education that get the message out about the health risks following an overdose, what to expect in the hospital, and any options available on-site (e.g., access to buprenorphine). We should not be surprised when patients (whether because of substance use, language barriers, or culture and faith) fail to live up to our expectations of the model rational health seeking actor when presented with post-hoc expectations. Considering the number of overdoses happening every day in the U.S., discussions about complex medical issues (e.g., post-naloxone pulmonary edema) should not be left it until after someone has been resuscitated and is confused and scared. Another option is to engage non-clinicians (e.g., PWUD working as patient navigators) to provide information and support. They are more likely to present and communicate in ways that resonate with patients, provide meaningful support, and adopt a nonjudgmental approach (Perera et al. 2022). In Canada, research found physicians informally working with PWUD to support their substance use needs in the hospital (e.g., matching unregulated street drugs with pharmaceutical alternatives and integrating harm reduction education into their practice) and having protocols in place to link patients with community resources (Strike et al. 2020). Years later, this is formally sanctioned as “prescribed safer supply,” and many hospitals have specialized clinical and peer roles to support PWUD. Several Canadian hospitals have innovative overdose prevention sites, and there has been a shift in medicine toward trauma-informed care. This changes the relationship between PWUD, healthcare and hospitals. There is a difference between asking people to stay for observation (because of potential risks compared to the imminent risk of withdrawal and lost opportunity costs for time spent in the hospital) when you have nothing to offer them to address withdrawal, and a history of conflict, compared to having a range of options to offer them in the context of a nonjudgmental and safe environment. While in the U.S., prescribed safer supply interventions and hospital-based overdose prevention sites are far from the current reality, there is growing interest and support for these approaches and feasibility and implementation research are needed.

Finally, and most concerningly, we read Marshall et al.’ paper in the context of growing anxiety and fear about substance use which is leading to an increasing number of harm reduction opponents (politicians, recovery industry leaders, and some healthcare providers) calling for a return to coercive and involuntary drug treatment. Where we have failed to arrest our way out of the drug toxicity crises, we are unlikely to succeed with involuntary detox and court-mandated recovery on a population-level. Existing opioid agonist therapy programs have retention rates of less than 50% after one year. Besides being ethically troubling (most likely to affect those at the intersections of substance use, mental illness, racism, and poverty) mandated treatment is unlikely to be feasible or effective (Werb et al. 2016). Arguments that undermine the autonomy and capacity of PWUD will be used to justify this punitive turn away from recognizing drug use as a complex medical and public health issue that needs to be managed with evidence-based approaches and compassion. We call for greater ethical imagination—across interdisciplinary health teams, researchers, harm reduction providers and communities of PWUD—for better responses to the drug toxicity crises that are both empirically supported and ethically defensible. Greater funding should be allocated for the development of harm reduction interventions that center the lived experience and needs of PWUD, explore the range of current and potential behavioral and pharmacological options for responding and providing care in post-overdose situations, and the development of ethical decision-making tools for use in hospitals.

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