We supplemented quantitative data with qualitative data from interviews with 20 multi-disciplinary inpatient providers at the study hospital. Participants included attending physicians (n = 4), resident physicians (n = 4), nurses (n = 7), APPs (n = 2), social workers (n = 2), and a peer recovery specialist (n = 1) (Table 3). Interview participants primarily identified as White (65%), non-Hispanic or Latine (100%) and female (60%) with 1–5 years of experience (60%).
In our analysis, we found that providers across all professional groups agreed that the ACS positively impacted three features of patient care: 1) the management of pain and withdrawal in patients with SUD, 2) discharge planning and care coordination, and 3) provider moral distress and burnout associated with addiction care. However, nurse participants identified unique challenges with the ACS related to communication, role clarity, and team integration that their colleagues did not.
3.3.1 All: Improved management of pain and withdrawal
Across participant groups, the ACS was described as an important resource for improving the management of withdrawal and pain in patients hospitalized with SUD. Specifically, prescribers noted that the ACS helped them feel more comfortable ordering opioids for patients with high tolerance and provided protocols for managing withdrawal. One APP described:
We wind up writing probably more appropriate medication management for this population than previously I was comfortable writing for. Participant 3
Similarly, a resident physician reported that the ACS assisted in interpretating complex opioid use patterns, guiding safer and more effective treatment:
I’m almost shooting from the hip…trying to figure out what the hell does that mean in terms of how many morphine equivalents you’re getting. And I think the addiction team is much better at doing that. So I feel safer when the replacement plan has come directly from them. Participant 6
Some nurses also observed positive changes in clinical practice, particularly around the timeliness and appropriateness of treatment for withdrawal. One nurse explained:
[The] addiction medicine consult service really does help. They’ve made a huge impact for many reasons, not only are they just all great people that truly care about their patient population, but I feel like they have a more in-depth understanding than our traditional medicine teams of how to treat withdrawal and how to initiate a proper treatment right away. Participant 19
Attending physicians echoed this sentiment, noting that the consult team brought both expertise and legitimacy to novel practices which previously had been met with institutional resistance. This attending described a difference before and after the implementation of the ACS, referring to the use of short acting full-agonist opioids to stabilize acute withdrawal from illicit fentanyl:
Because the addiction consult team wasn’t there, and we didn’t have notes from pharmacists saying this was okay to do, we often got pushback from nursing because it was just sort of – to a lot of people, it seemed like this wild approach. So I think having the addiction consult team present and sort of making these recommendations and cosigning this approach has really helped different people throughout the hospital buy into this. Participant 26
These reflections illustrate how the ACS functions as both a clinical and cultural intervention, equipping providers with the guidance and institutional support to provide evidence-based withdrawal and pain management.
3.3.2 All: Improved discharge planning and care transitions
Interview participants also identified the critical role of the ACS in discharge planning and care transitions for patients with SUD. Many providers described improvement particularly in MOUD initiation and linkage to outpatient treatment and support services. For example, an APP emphasized the ACS role in bridging inpatient and outpatient care:
I really appreciate the ability to link to services as outpatients that we might not have thought of…and just being assured that they have a contact and a way to continue getting Suboxone or hooked into a methadone clinic. Participant 3
Similarly, an attending physician highlighted how the ACS provides a more reliable framework for safe and coordinated discharge:
I think we’re doing [discharge planning] right a much higher proportion of the time than we used to…there’s a lot more of, like, here’s who you’re going to go to get your Bupe, or the shelter you’re going to go to, or the SNF that’s methadone capable. There’s a lot more connectedness and continuity. If I had to pick one thing that the addiction medicine consult has helped with the most, I think that would be the dispositional planning. Participant 2
A nurse noted that the inclusion of a dedicated social worker with SUD-specific expertise helped address the complex needs of patients with SUD, which were often unmet by the general floor staff:
It’s helpful that there is a social worker case manager who specifically works with that population, because I think there’s a different array of needs that need to be met. And I think it would be too much for the [floor] case managers and social workers who have so many other challenges that they are trying to help other patients get through… Having dedicated team members who are thinking more holistically… makes me feel less like I’m just saying: “okay, bye, good luck.” Participant 10
One resident noted the value of the consult team’s role in care transitions, describing how the interdisciplinary team worked together to make the use of hospitalization as a ‘reachable moment’ to engage patients in outpatient support23:
The addiction consult service was utilized to essentially get this patient back on suboxone and then set him up with a more consistent outpatient provider, and then the social worker came and helped to find him a more stable housing option that was safe for him to get his suboxone and keep it safe from others. And so it was a way to see kind of how both the physicians and the ancillary service workers on the service, like the social workers and certified recovery specialist, were able to work together to positively impact this patient and take – almost kind of take advantage of the opportunity of him being in the hospital, to get him onto more stable suboxone dose and safely discharge him. Participant 11
Collectively, these perspectives suggest that the ACS not only improved clinical aspects of discharge, medication reconciliation and outpatient referrals, but also provided a more coordinated, person-centered approach to care. The inclusion of a dedicated SUD-trained social worker was a key structural component enabling these improvements.
3.3.3 All: Reduced moral distress and burnout
Across provider groups, the ACS was reported to alleviate some of the emotional burden of caring for patients with SUD. Participants emphasized that having a specialized team helped distribute the responsibility for complex care while reducing feelings of isolation and helplessness.
An APP described how ACS support reduced emotional strain and modeled compassionate care, while affirming the difficult emotions that often arise when caring for this population:
Sometimes in burnout we lose compassion. And I think the addiction medicine team models compassionate care for patients, meeting them where they are. And I think that’s been really helpful for myself and for my colleagues to see. And it also validates, yeah, [this patient is] really tough to take care of. Participant 3
A resident similarly reflected on the relief of having clear, expert guidance and shared clinical responsibility, which they perceived also improves patient care:
It helps having a team that specializes in this, and sees this every day, to tell you, okay, this is what we’re gonna do next. And so I think it gives me a lot more support as a resident, and I think it also helps the patient. It helps take some of the burden off of our shoulders, because they’re going in and seeing the patient every day. Participant 5
Participants also described how the ACS mitigated feelings of futility and moral distress when confronting structural barriers that often fall outside the scope of inpatient care. One nurse explained:
I think some of the moral distress that I feel when caring for patients with SUD, is just this feeling that these problems are so huge and they’re somewhat larger than me, and larger than the patient. They’re just very enormous societal issues and I think we can’t fix these problems in the hospital. But at least it’s not just me bearing witness to this patient suffering alone. And I know also that when I reach out to providers for support, we’re on the same page, and that they’re also clued in to the broader picture…There’s more of an orientation towards compassion and trying to support patients’ wellbeing and less of a judgmental and withholding approach. Participant 10
An attending physician simply shared:
There’s just something very therapeutic about feeling like this is not your burden to hold alone.
Together, these reflections illustrate how the presence of the ACS not only improves clinical care but also helps clinicians connect with their values of quality, patient-centered care, reducing emotional exhaustion and making the work more sustainable.
3.3.5 Nursing-identified ongoing challenges
Although many nurses expressed appreciation for the ACS and its positive impact on patient care, several described ongoing challenges related to communication, team integration, and barriers to education on SUD. A recurring concern was that nurses were frequently uninformed regarding the ACS’ involvement in patient care. One nurse emphasized the importance of including nursing perspectives, explaining:
More transparency, communication, and including the nurse who was on the ground delivering the care and to hear what the patient is experiencing… We (nurses) are not in the loop about care… We don’t really talk to [the ACS]. They come in, they speak to the patient at times, and then kind of they just leave… We should be doing better with that, like a closed loop communication. Participant 9
Another nurse echoed this sense of exclusion, noting that while physicians on the care team may be aware of the ACS actions, nursing often is not:
I don’t think the communication is there all the time. Like, maybe the docs know and stuff like that, but I don’t know if the communication is there with the nurses. Participant 23
This lack of communication often left nurses uncertain about the ACS’ role, scope of work, or even their presence on the unit. This nurse contextualized this as a systemic issue:
In the hospital, as a nurse, we don’t always know what’s going on. We don’t know who’s going into the room… I don’t know who it is… I don’t know what’s happening… I did not have really direct contact or understanding as to what was going on. Participant 1
In some cases, nurses described cultural attitudes among staff that further complicated the integration of addiction medicine into routine care. One nurse noted the resistance among
some long-tenured colleagues, stating:
I do see a lot of nurses who have worked there for a long time who are pretty rude about the addiction medicine consult team, and about patients who have substance use disorders, and just will outwardly talk about these patients as crackheads, or druggies, or addicts. And I think it is more normal for nurses to tell horror stories to each other to blow off steam, but there’s a way to do it where you’re not calling somebody a crackhead. And then, also, sometimes nurses or pharmacists, or whatever, will roll their eyes at some of the things that are being suggested by the addiction medicine consult team, implying that it’s an overstep, and why would they do that for these patients? Participant 10
The stigmatizing attitudes described may reflect a culture among some clinical staff in which addiction care is de-valued, contributing to less satisfaction or positive engagement with the addiction consult team.
The same nurse elaborated that this disconnect may also be reflected in the structure of inpatient care, where teams often work in silos:
I think if we're able to have that ongoing communication, that would be really beneficial, in my opinion…because [the ACS] comes in kind of as a separate unit. I have my NP; we're doing our medical thing and here's [the ACS] over there. So just everybody being on the same page. Participant 1
Despite sometimes limited interaction with the team, many of the nurses we interviewed had a sense that the ACS has improved care for patients with SUD but were often not aware of the details of the changes. One nurse shared:
I wish I knew more about what addiction medicine does, but whatever they’re doing, I believe that it’s working. Participant 23
Nurses expressed desire to be better informed about best practices for managing SUD in the hospital setting, but many described barriers to accessing information or building their knowledge base, particularly amid the demands of bedside work. One nurse explained this in the context of xylazine, a veterinary tranquilizer that is an adulterant in the local street opioid drug supply:
I'm new to the tranq drugs…I'm not familiar with what you would use or not use to make a person comfortable… I probably need a little more education on what's happening with the tranq, but I don't have time to sit down and sometimes look it up because I'm running around all the time. So I'm just following orders and doing the best I can… Participant 1
Another nurse noted that current training opportunities are often optional, limiting their reach:
There’s a lot of opt-in educational opportunities for people who are interested in caring for patients with substance use disorders, but if you’re not opting in …. then you aren’t really getting that education. So I wonder about having more mandatory education, or building it into some of the existing educational requirements for nurses… And I think providing more information around what different medications do, what the goals are when we’re treating withdrawal, some of the other social challenges this population is experiencing. Participant 10
Others suggested systems-level changes, like incorporating education about SUD care into staff orientation, so that the burden doesn’t fall on individual nurses to seek out resources. One nurse reflected:
I maybe can also take accountability, and say I could take it on myself to learn…Like, what options do we have for unhoused patients? Where can we access that? … But also, just in general, these are things that we should all be able to know…Incorporating that into nursing orientation, how to access resources, so we can better serve our patients holistically too. Participant 9
Another emphasized the need for a standard of education for nurses around SUD:
There needs to be a level of education around what we’re doing and why. Participant 19
These accounts illustrate that limited communication, a lack of integration between nursing and the ACS, and gaps in education shaped how nurses experienced the ACS and their ability to engage in SUD-related care.