The COVID-19 pandemic has had a profound effect across society, but it has been especially devastating for people with substance use disorder.

A new study, published in the journal PLOS ONE, sheds light on the experience of patients with substance use disorder who were hospitalized during the initial surge of COVID-19 cases in Oregon last spring. Researchers with Oregon Health & Science University conclude that health systems nationwide could benefit from a better understanding of people who struggle with the basics.

"We need the system to be designed and implemented for patients who may lack phone access, who may not have access to WiFi or may be living on the streets," said lead author Caroline King, M.P.H., a health systems researcher and current M.D./Ph.D. student in the OHSU School of Medicine's bioengineering program.

King led the study with two other OHSU medical students, Taylor Vega and Dana Button.

Researchers conducted a series of interviews with 27 patients hospitalized at OHSU last April and May with acute medical or surgical conditions who also have substance use disorder.

The research was done through an OHSU program known as Project IMPACT, or Improving Addiction Care Team.

In normal circumstances, Project IMPACT brings together physicians, peer-recovery mentors, social workers and community addiction providers to address addiction when patients are hospitalized. However, during the first few months of the pandemic, IMPACT had more limited interactions with patients given new pandemic-related hospital policies implemented to prevent the spread of the SARS-CoV-2 virus.

Researchers identified four key takeaways from telephone interviews with patients.

• Basic survival: For many of the patients who were interviewed, housing instability intensified due to the pandemic. They also struggled accessing food, employment, social services and bathrooms. Virtual recovery meetings such as Alcoholic Anonymous didn't help for many patients, half of whom didn't own a phone.
• Hospital is a safety net: Although many participants were concerned about exposing themselves to the novel coronavirus by going to a hospital, many reported they had nowhere else to turn. Telehealth visits for outpatient services are not possible for those without phones or electronic devices. Some participants reported that a lack of readily available in-person medical care caused a cascade of medical issues that worsened to the point that they required hospitalization.
• Hospital is isolating: Participants reported that they felt isolated due to the constraints on visitation and wearing of personal protective equipment by health care providers, although simultaneously comforted by the precautions taken to prevent the spread of the virus.
• Uncertain transition home: Almost every patient interviewed expressed concern about leaving the hospital. For almost every patient, housing was a top worry. Participants worried they wouldn't be able to take care of their medical needs given shuttered community services and broad disruptions in the medical and social safety net.

Senior author Honora Englander, M.D., an associate professor of medicine (hospital medicine) in the OHSU School of Medicine who directs Project IMPACT, said the study makes clear that properly caring for these patients does not end when they're wheeled out of the hospital's front doors.

In some ways, the most difficult part of their journey only begins there.

What does it mean to be 'medically ready' for discharge if a patient is leaving to an unsafe situation with no phone or housing in a pandemic? We have a role to play as advocates in direct patient care, and as health care providers we can also apply pressure on powerful and sometimes-inflexible systems to make their care better."

Honora Englander, Associate Professor of Medicine, OHSU School of Medicine