Improving hospital substance use care from the ground up and from the outside in.

settingThe Queen Elizabeth II (QEII) Health Sciences Centre in Halifax, Nova Scotia, is an academic, tertiary care hospital that lacked policies related to unregulated substance use, harm reduction, and addiction care. Substance use care was of poor quality and inconsistent, and the community-based standard-of-care was unavailable to hospitalized patients.

interventionA group of frontline hospital- and community-based healthcare providers, trainees, harm reduction workers, and people with lived experience organized to navigate this "policy vacuum". We invited community-based groups and resources into the hospital, developed informal policies and procedures to standardize care, and trained ourselves and others in substance use care best practices. OUTCOMES: We introduced several harm reduction initiatives from the community-including take-home naloxone kits, needle and syringe distribution, and oral and injectable opioid agonist treatment-without institutional policy support. We drafted our own informal harm reduction policies for the internal medicine inpatient unit, holding a focus group with people with lived experience for feedback and revision. This work contributed to funding for an addiction medicine consultation service and an institutional commitment to implement harm reduction-oriented substance use policies for healthcare settings across the province. IMPLICATIONS: Despite a lack of institutional policies or buy-in from senior leadership, harm reduction measures can be implemented in hospitals from the bottom-up and the outside-in-by healthcare providers organizing, leveraging existing community resources, and listening to people who use drugs. Clinicians at other hospitals could model our collaborative approach to improve care and push their health systems towards institutional change.