Fear of inpatient opioid withdrawal: Addressing a modifiable barrier to health-care access for people who use illicit opioids.

Background: Drug related deaths and hospitalisations for bacterial, including invasive, infections among people who inject drugs (PWID) have steadily risen over the past decade in the United Kingdom. Causes of premature mortality and morbidity among the most marginalized are multifactorial, with barriers to timely medical care exacerbating complications and overdose vulnerability. Understanding the dynamics of health care delay is crucial to inform effective community-acceptable interventions.

Methods: Structured survey (n=455) and in-depth interviews (n=37) with PWID recruited through drug treatment services and homeless hotels across London from 2017-2019 (Care and Prevent study), provided detailed data on injecting practices, health conditions and medical care experiences. Analyses were iterative and utilized mixed-methods triangulation.

Results: Survey participants reflected the aging UK population of PWID, with a mean age of 46 years. The majority were unstably housed, 78% reported a history of street homelessness. Lifetime prevalence of skin and soft tissue infections (SSTI) was high at 65% (n=296). Of those with an SSTI, 46% reported a related hospitalisation, 24% septicemia and 9% endocarditis. Severity of infection was associated with time taken to seek healthcare (>10 days). Qualitative accounts unpack the dynamics of care delay. Fear and experience of opioid withdrawal in hospital informed delayed presentation, self-discharge against medical advice, drug and money stockpiling before admission, and use of illicit drugs on wards.

Conclusion: Delayed opioid substitution therapy prescribing to PWID in hospital settings constitutes a major barrier to health care access among this population, contributing to late presentation, serious complications, self-discharge, re-admission and heightened need for surgical intervention. We introduce an intervention commencing in 2022, based on the principles of cultural safety, which aims to improve OST prescribing practice and policy in UK National Health Service Hospital Trusts.