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Abstract

Background:

Infective endocarditis (IE) has increased markedly among people who inject drugs (PWID). Harm reduction is a tool to help PWID improve health outcomes and mitigate IE.

Objectives:

To understand the knowledge, perceptions, past engagement, and planned use of harm reduction services from syringe services programs (SSPs) for PWID hospitalized with IE.

Design:

Qualitative study of PWID hospitalized with IE.

Methods:

The research team conducted semi-structured interviews with 16 participants at a large academic hospital from June 2021 to May 2022. Two study personnel coded the interviews and analyzed the data using a combination of structural codes, applied thematic analysis, and thematic comparison.

Results:

The majority of participants reported past experiences obtaining safe injection supplies from SSPs, and participants generally viewed SSPs as places for facilitating safer injecting practices, receiving sterile supplies, learning about harm reduction, and/or obtaining overdose reversal kits. However, some participants reported being unable to access SSPs because of their rurality, lack of SSP availability, or transportation barriers. In addition, some participants reported a lack of interest in receiving SSP information during hospitalization, believing that it would enable an undesired return to drug use, while others felt that SSP services would not be relevant for them post-hospitalization.

Conclusion:

Patient past and planned use of harm reduction services offered by SSPs was impacted by geographic barriers to accessibility and patient concerns that SSPs would facilitate an undesired return to drug use. Health systems have an opportunity to improve patient usage of harm reduction services post-hospitalization by improving patient education and integrating harm reduction services as tools of care.

Keywords

harm reduction infective endocarditis injection drug use syringe services programs

Introduction

Infective endocarditis (IE) is a life-threatening complication of injection drug use (IDU) in which the lining of the heart is infected by bacteria or fungi. The United States has seen a recent increase in IDU-associated IE (IDU-IE) cases resulting in long and costly hospitalizations.¹ Post-hospitalization, patients surviving IDU-IE remain at risk for other complications related to substance use, including drug poisoning and overdose. From 2002 to 2022, the rate of overdose deaths in the United States has nearly quadrupled, with over 100,000 Americans dying from a drug overdose in 2023 alone.^2,3 As overdoses and IDU-IE cases rise, attention has focused on preventing harm due to IDU via the use of syringe service programs (SSPs).⁴ SSPs can facilitate access to naloxone and sterile injection supplies, and provide a link to services for IDU-IE patients most at risk of overdose deaths post-hospitalization, including medication for opioid use disorder (MOUD), as many may be lost to outpatient care.^4,5

Although SSPs have increased in the US, barriers to accessing services remain. In North Carolina (NC), for example, only 58 of 100 counties, and 1 federally recognized tribe, have a registered SSP.⁶ SSPs are unequally distributed and underrepresented in rural counties,⁷ leading to concern over their accessibility for those needing them most. People leaving the hospital after IDU-IE are among those most at risk for fatal overdose and future infections, representing one group that could benefit most from the use of SSPs. Despite the benefits of harm reduction resources for people at most risk of harm from IDU, there is a lack of literature reflecting the voices of patients hospitalized with IDU-IE and exploring linkages to SSPs. In this study, we examined barriers and motivators to SSP utilization among people hospitalized with IDU-IE. We aimed to gain insight to strengthen collaboration between public health entities and healthcare providers in helping IDU-IE patients utilize harm reduction services.

Methods

Setting and participant recruitment

We conducted one-time semi-structured interviews (SSI) during hospitalization for IDU-IE among patients at a large medical center in central NC. Eligibility criteria were: diagnosis of IE, English-speaking, aged ⩾18, and self-report of IDU in the last 3 months. Participants were only excluded if they were unable to complete the interview prior to inpatient discharge. Patients were recruited via a review of inpatients evaluated by the inpatient infectious diseases services. Potential participants were approached, given information outlining the study and eligibility criteria, asked to provide verbal consent, and compensated for their participation. The study was reviewed by the institutional review board of the University of North Carolina.

Data collection and analysis:

An SSI guide was developed to explore patient perspectives surrounding topics related to IDU-IE, including knowledge of IE, drug use practices, experience with substance use disorder treatment, perspectives on harm reduction services, and antibiotic treatment (Supplemental Material). The SSI guide was drafted by authors with expertise in infectious diseases and qualitative research and reviewed and iteratively edited by others, including those in substance use epidemiology and harm reduction. SSIs were conducted by two female graduate research assistants, trained in qualitative research methodology. SSIs typically lasted 60 min or more, were audio-recorded, and were conducted privately in the participant’s hospital room. Participants self-reported demographic information. Additional information about their hospitalization (e.g., discharge disposition) was extracted from medical records. Recordings were transcribed verbatim by the study team using NVivo transcription and reviewed manually by two reviewers for accuracy prior to uploading into NVivo 20, Lumivero (Denver, CO) (QSR International). Names and identifying characteristics were redacted. Transcripts were coded in NVivo using an inductive approach based on a thematic codebook developed by the primary investigator, study coordinator, and research assistants. Coding was performed by two independent coders. Inter-rater reliability checks were performed, and discrepancies were resolved. All text coded for harm reduction-related issues was reviewed to identify themes. Recruitment was halted when thematic saturation was achieved, defined by the absence of new themes emerging in later interviews. The study was conducted and reported in accordance with the COREQ statement (COREQ checklist provided as Supplemental Material).⁸

Socio-ecological model

To formulate our discussion for impactful public health interventions, we mapped our results into the Socio-ecological Model (SEM) (Figure 1). The SEM is a theoretical framework for examining the complex interplay between individual, interpersonal, community, and societal factors that impact health behaviors and health outcomes.^9,10 By mapping our themes onto the SEM, we were able to conceptualize barriers and motivators at each level to spur targeted public health interventions.

Figure 1.

Barriers and motivators to engagement with syringe service program, mapped on the social-ecological model.

Results

Sixteen participants were enrolled. The majority were women and white. Ages ranged from 30 to 39 years (Table 1). Six of the participants reported their home county as a non-metropolitan county in NC, most were uninsured or insured by Medicaid, and 19% left the hospital before medically advisable (known as against medical advice) at a time after the interview.

Table 1.

Demographic and clinical characteristics of participants.

Characteristics	N (%)
Self-identified gender
Female	11 (69%)
Male	4 (25%)
Bigender	1 (6%)
Age
20–29 years old	6 (37%)
30–39 years old	7 (44%)
40–49 years old	3 (19%)
Race/Ethnicity
White	9 (56%)
Black/African American	2 (13%)
Native American	3 (19%)
Other/Unknown	2 (12%)
Annual Income
Less than $10,000	11 (68%)^a
$10,000–$50,000	2 (13%)
Greater than $50,000	1 (6%)
Unknown	2 (13%)
Metropolitan Statistical Area^b
Metropolitan	9 (60%)
Micropolitan	4 (27%)
Neither	2 (13%)
Previous Infective Endocarditis Hospitalization
Yes	6 (38%)
No	10 (62%)
Type of Management
Surgical Management	10 (62%)
Medical Management Only	6 (38%)
Length of Stay
Less than 14 days	0 (0%)
14–30 days	1 (6%)
30–60 days	13 (81%)
Greater than 60 days	2 (13%)
Insurance Payor
Medicaid	7 (44%)
Commercial	1 (6%)
Uninsured	7 (44%)
Other	1 (6%)
Disposition
Routine	12 (75%)
Facility Transfer	1 (6%)
Before Medically Advisable (Against Medical Advice)	3 (19%)
Died	0 (0%)

All 11 individuals reported an annual income of $0.00.

One individual was excluded due to an out-of-state residency.

We identified awareness of resources and experiences with SSPs, barriers to engagement with SSPs, and motivators to attend SSPs as themes, each with several subthemes. Below, we present each theme with descriptions of the accompanying subthemes and illustrative quotes. In the discussion, we then map the identified motivators and facilitators to the SEM.

Awareness of resources and experiences with SSPs

Most participants had engaged with SSPs previously, and almost all were aware of SSPs, via materials such as pamphlets or YouTube videos. Others knew of SSPs from friends, members of their community, or others who had utilized SSPs, including the distribution of naloxone. Participants were also aware that SSPs provided harm reduction education to their clients via varied modes of educational outreach. Some participants mentioned receiving pamphlets on safe injection practices, slow injection practices, and drug supply testing. Other participants mentioned receiving skill-based training and education from their SSP, such as naloxone training and information about cleaning and disposing of needles. Participants also mentioned how SSPs serve as important connections for PWID to basic social services such as food assistance, medical supplies, and hygiene products.

You go to needle exchange, you get new needles and you only use them once and they come with everything, possibly you can use . . .. (Female, 34)

. . . if you sign up with them inside like the office, they just they give you Narcan. . .They give, they give you food. Sometimes eyecare products or wherever wash your hair, or something. If you have a cut, they might help you get, you know, something for it. (Female, 34)

Yeah, they would give you like pamphlets on not sharing needles and on using clean needles and on being safe and trying to prevent infection and stuff like that, they would always have pamphlets in there. (Female, 37)

Barriers to SSP engagement

Although many participants believed that SSPs provided helpful services and were positive forces in helping their community access sterile equipment, some participants said they would not utilize SSPs in the future. Below, we describe subthemes of factors that participants cited as reasons they would not use SSPs after discharge from the hospital, which are also summarized in Figure 1.

Intention to stop using substances post-hospitalization

Most participants conveyed an intention to quit using substances post-hospitalization and reported they did not need information about SSPs, as it would no longer apply to them. Since most participants believed that they were going to quit using substances post-hospitalization, they discussed that they did not desire to receive information about SSP services from hospital staff members or peer specialists.

Interviewer: Um, so what would you think if one of the staff members offered to give you information about a syringe access program that was close to you?

Yeah, that’s fine, but I don’t need it now. (Male, 38)

Yeah, but . . . I can’t go home and [use drugs]. I- I’m not going to, I can’t. So I mean, yeah, if I was planning, you know what I mean? I’m going home and doing whatever, but I, I’m not I-I’ve gotta get my daughter and I gotta get better. (Female, 32)

Fear that SSP engagement would facilitate substance use

For some of the participants, getting the information about SSPs from hospital staff felt like an admission that they were going to return to drug use despite their desire to be abstinent.

[Receiving information about SSPs] just kinda scares me cuz it’s almost like opening up that option for me. (Female, 32)

One participant felt like visiting SSPs would “make it easier” for her to return to undesired substance use post-hospitalization.

if you’re going to use anyway, we’re going to help you be safe. Yeah, yeah. But at the same time, it does make it easier. You know what I mean? (Female, 37)

Logistical barriers to SSP usage

Nearly half of the participants mentioned that they felt that SSPs were largely unavailable to them. Although these participants were aware of the SSP services in other towns and counties, they described these services as being unavailable to them because of where they lived or their lack of access to reliable transportation. This inability to access SSP services was particularly acute for participants living in rural areas of NC.

. . . I live in a rural area, small town. I know in cities they get in and out all the time, but now where I live, you know the health department, I called up there like a couple of weeks ago. About the needle exchange and they said they don’t do it no more. He- you know, and the health department was the only place I [knew of]. So it’s hard to get resources down . . . you know in a rural area. (Male, 49)

Participants also cited other external factors, such as COVID-19 and financial burdens, that impacted their ability to access SSP services, such as cost to staff members.

Yeah, she ain’t able to give [clean needles] out no, no more because she’s paying for it out of pocket and it got too expensive. You know, she still gives out Narcan, though, and lectures when you can, you know. (Male, 21)

Motivators to attend SSPs

Avoid infection and overdose

Participants mentioned that they were motivated to utilize SSPs, upon discharge, to procure naloxone.

Yeah, cuz they give us Narcan at the um, needle exchange. [. . .] They would give you the nasal spray or to shoot you in your muscle. (Female, 40)

Another factor that facilitated the usage of SSPs was a desire for sterile equipment. Participants specifically mentioned using SSPs to limit the risk of acquiring infections.

I didn’t believe that they were getting this stuff from this lady. But that’s the way to keep the diseases down, is they give clean needles to uh I, it’s. (Female, 33)

Protect their community and loved ones

Some expressed interest in learning more about SSPs, not for themselves but for their community, friends, and loved ones. Participants discussed how SSP services are a “good thing for people,” and that they wanted to use SSPs to prevent the spread of infection and overdoses in their community. Even if they intended to be abstinent from drug use, they understood the value of SSPs in preventing infections for their friends.

Yeah. I would take it. Even if not for me, cuz I can’t go back to using. It’s a choice now? It’s cuz it’ll be either me living or dying, and I know I’m not ready to die.[. . .]You know what I’m saying? So, you know, used to, used to be, you know, what could happen. You know, now it’s come down to worse. You see the way I choose; I choose how I live or die. But I will still take the information for, I got friends, you know what I’m saying? I’d love to see them get sober, so that I will pass on to them, you know what I’m saying? To keep them from like catching AIDS or hepatitis or anything, like that, you know what I’m saying? (Male, 49)

Societal value of substance users’ lives

Participants voiced that SSPs provided overall life-saving services for people who use drugs, despite drug use being otherwise stigmatized. Participants voiced a previous personal experience with overdosing or helping someone who overdosed. In addition, participants knew someone who had died from substance use. Participants seemed to indicate that the life-saving services of SSPs imbued them with a particular sense of meaning or worth that ran contrary to societal messages labeling them as “bad people.”

You know, sh-she tries to help because Narcan is good to have, man. People you know, drug addicts ain’t bad people. Yeah, they don’t deserve to die like that you know, most of them are good enough people. We don’t deserve to die in a ditch or a car . . . (Male, 21)

Discussion

IE is one of the most severe complications of IDU. Persons surviving IDU-IE require intensive support as they remain at risk for further drug-related harms, such as repeat IE, viral hepatitis, HIV, and overdose. We characterized hospitalized IDU-IE patients’ motivators and barriers to utilizing an important community-based resource, SSPs. Our findings can help physicians, public health workers, and hospital staff create stronger messaging about SSPs to help link IDU-IE patients to SSPs at the time of hospitalization and transition to outpatient care.

Studies have previously examined the general barriers and facilitators to SSP access for PWID.¹¹ Such studies have identified geographic disparities in SSP access, program resource restrictions caused by the COVID-19 pandemic, and funding restrictions limiting SSP services as barriers to engagement in SSPs.^7,12–15 Factors facilitating SSP engagement include positive peer networks, resources to prevent infections and overdose, and feeling dignity from SSP staff.^11,16 Our study also found these variables largely to be factors influencing engagement in SSPs; however, a unique theme that emerged in our study was participants’ concern about SSPs facilitating unwanted return to use. By interviewing patients hospitalized with the most severe injection-related complications, in the hospital at the time of awaiting or receiving care for a life-threatening disease, we were able to capture unique perspectives on harm reduction from those who are at highest risk and may benefit most from SSP services. Further, the participants in our study provided the unique viewpoints of individuals early in their recovery who generally reported a desire to remain abstinent from drug use. Given the high rates of return to drug use that occur during individuals’ recovery journeys, combined with inconsistent access to primary care among PWID,¹⁷ linkages to SSPs can be particularly valuable resources for engagement. Understanding the perspective of PWID at this juncture is a unique viewpoint that aligns well with the moment in which inpatient healthcare providers typically interface with PWID.

Barriers to SSP utilization

One of the most notable barriers to linkage to harm reduction care for patients with IDU-IE exists on the individual level: participants’ desire for abstinence from substance use and their feeling that they would not benefit from, or even be hindered in their recovery by, referral to SSPs. Studies have shown that, when confronted with the harmful effects of substance use, such as prolonged hospitalization or life-threatening illness, PWID may be more motivated to quit.^18–21 Echoing this sentiment, many in our study voiced the physical, mental, and emotional tolls IDU-IE had taken on their lives and were convinced that hospitalization would catalyze them to remain abstinent.

Although there is growing acceptance of SSPs as harm reduction principles become increasingly mainstream, stigma and misconceptions remain. For example, people believe that SSPs could facilitate drug use and that their services do not help people interested in treatment or recovery. In contrast, studies have found that SSPs can prevent overdoses via naloxone and referrals to MOUD.^22–24 In one study, 31% of SSP participants reported substance use cessation compared with only 12% of people not using SSPs.^22,25 Nonetheless, many participants echoed narratives that receiving information about SSPs may interfere with their planned abstinence and facilitate future drug use. To combat this hesitancy against accessing harm reduction services, hospital staff can help educate patients about the breadth of harm reduction services offered at SSPs and how SSPs can help facilitate treatment and recovery (Table 2). In addition, hospital staff can mitigate external stigma and help patients feel empowered to utilize SSPs post-discharge by receiving tailored harm reduction education as part of their training (Table 2). Addressing these stigmatizing narratives and educating patients on the benefits of harm reduction services can help combat the internalized stigma for individuals, such as those being discharged with IDU-IE or comparable infections, who stand to benefit from SSP services.

Table 2.

Proposed intervention strategies for healthcare systems.

Intervention	Description	Healthcare system parties involved
Patient Education	Throughout hospitalization, educate IDU-IE patients on the breadth of harm reduction services offered by regional SSPs. This may include informational handouts about harm reduction services offered at SSP, referrals to peer specialists with more information about harm reduction, and contact information to local SSPs or harm reduction organizations	Residents Attending Physicians nurses and nursing assistants
Harm Reduction Education for Hospital Staff	Conduct continuous harm reduction education as part of the continuing education requirements/training for hospital staff. Educate staff on the principles of harm reduction. Teach staff how to utilize a compassionate care model to understand and address patients’ barriers to seeking harm reduction services. Promote evidence-based information about harm reduction services. Frame harm reduction services as a resource for people in active substance use and for people in recovery.	Residents Attending Physicians RN/CNAs Hospital Case Managers
Linkages to Care²⁶	Provide patients with linkages to harm reduction and MOUD services by creating a bridge model of transitional care and/or warm hand-offs to SSP services. Establish a care-coordination model to coordinate linkage to SSP services before discharge from the hospital.	Hospital Case Managers Attending and Resident Physicians SSP representatives
Connection Opportunities for SSPs Pre-discharge	Facilitate SSP connections with patients to discuss harm reduction resources before discharge. Strengthen social connection with harm reduction community and encourage warm hand-off post-hospitalization.	Hospital Case Managers SSP representatives

IDU, injection drug use; IE, infective endocarditis; SSP, syringe service program.

On a community level, participants mentioned logistical barriers, including rurality and transportation. For example, the distribution and geography of SSPs across the state played a role in participants’ perceived access to SSPs, with some invoking the notion that SSPs were inaccessible in rural counties. Further, although a county may have one active SSP, the location may not necessarily be accessible to all residents of that county. NC counties range widely in terms of population density, rurality, and public transportation resources; therefore, SSP access should be thought of beyond the county level, by which it is typically reported. Although these logistical barriers may present difficulty to some patients, hospital staff can still help patients by providing linkages to care and warm hand-offs to SSP services or other harm reduction providers (Table 2). On the societal level, COVID-19 and unstable funding were notable barriers.^6,27 To address the barriers identified by participants and to capitalize on the existing awareness of SSPs among participants, we propose the following broad areas of intervention to enhance engagement in SSPs following IDU-IE (Table 2).

Motivators to SSP utilization

Participants generally valued SSP resources for overdose prevention and sterile supplies, which highlights their importance, given the post-hospitalization risks. After IDU-IE, patients remain at high risk for adverse outcomes. In NC, 8% of people hospitalized for IDU-IE die within a year, and overdose is the primary cause of death in the first 3 years after IDU-IE.²⁸ PWID are at risk for recurrent IDU-IE or other infections from nonsterile injection, ranging from abscesses to HIV. For patients who have lost or decreased their opioid tolerance during hospitalization, the risk of early post-discharge overdose is high. Therefore, participants’ motivation to receive naloxone from SSPs is particularly salient.

Participants desired SSP services post-hospitalization to help their loved ones and members of their community who use drugs participate in safer injecting practices. On an interpersonal level, some participants mentioned that they would participate in the practice of secondary syringe exchange, gathering supplies, naloxone, and educational information to pass on to their loved ones. Indirect or secondary syringe exchanges through peer networks increase the reach of SSP efforts.^4,29

Finally, participants found SSPs valuable in advocating for the worth of PWID in society. Many participants mentioned the stigma they face for being a PWID. This stigma made them feel like society did not value their lives or that people did not care whether they lived or died. PWID are viewed by society as dangerous and worthy of blame for their substance use disorder.³⁰ Stigma toward PWID can not only impact them negatively on a personal level, but can influence systemic legal, healthcare, and policy decisions about them.³⁰ Therefore, the availability of SSPs may help combat both societal and internalized stigma.

Limitations

This study is limited by a small sample size, although the sample was adequate to reach thematic saturation. Participants were predominantly white, which does not represent all PWID in NC. This study was recruited from one medical center, although participants were drawn from numerous counties across the state. Nonetheless, the results may not be generalizable. Sampling bias may have been introduced by including only participants consenting to an hour-long interview, not critically ill, and who had not left before medically advisable prior to enrollment. Comments made by participants on SSP accessibility were based on self-reported, perceived access and may not reflect whether there truly were SSPs accessible. Despite limitations, this study is notable for including the voices of individuals with lived experience of IDU-IE. Few prior studies have evaluated patient perspectives on IDU-IE on public health strategies.

Conclusion

In the setting of rising harms related to drug use, it is important that SSPs be seen as valuable tools that are compatible with treatment or recovery. For patients hospitalized with IDU-IE, who are likely at increased risk of overdose after hospitalization, SSPs can facilitate access to MOUD programs, naloxone, and other potentially life-saving services. Therefore, public health entities should collaborate with clinicians and other healthcare workers to develop messages to meet and address patient concerns about SSPs to increase utilization of SSPs following medical hospitalizations.

Supplemental Material

sj-docx-2-tai-10.1177_20499361251353322 – Supplemental material for Perspectives on syringe services programs among patients hospitalized with injection drug use-associated endocarditis: a qualitative study

Supplemental material, sj-docx-2-tai-10.1177_20499361251353322 for Perspectives on syringe services programs among patients hospitalized with injection drug use-associated endocarditis: a qualitative study by Bailey McInnes, Eunice A. Okumu, Maisun M. Ansary, Bayla Ostrach, Vivian H. Chu, Li-Tzy Wu, Carol Golin, David L. Rosen and Asher J. Schranz in Therapeutic Advances in Infectious Disease

Supplemental Material

sj-pdf-1-tai-10.1177_20499361251353322 – Supplemental material for Perspectives on syringe services programs among patients hospitalized with injection drug use-associated endocarditis: a qualitative study

Supplemental material, sj-pdf-1-tai-10.1177_20499361251353322 for Perspectives on syringe services programs among patients hospitalized with injection drug use-associated endocarditis: a qualitative study by Bailey McInnes, Eunice A. Okumu, Maisun M. Ansary, Bayla Ostrach, Vivian H. Chu, Li-Tzy Wu, Carol Golin, David L. Rosen and Asher J. Schranz in Therapeutic Advances in Infectious Disease

Footnotes

Acknowledgements

None.

Declarations

ORCID iD

Asher J. Schranz

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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