Abstract
Background: Increased drug use has disproportionately impacted rural areas across the U.S. People who use drugs are at risk of overdose and other medical complications, including infectious diseases. Understanding barriers to healthcare access for this often stigmatized population is key to reducing morbidity and mortality, particularly in rural settings where resources may be limited.Methods: We conducted 20 semi-structured interviews with people who use drugs, including 17 who inject drugs, in rural southern Illinois between June 2018 and February 2019. Interviews were analyzed using a modified grounded theory approach where themes are coded and organized as they emerge from the data.Results: Participants reported breaches of trust by healthcare providers, often involving law enforcement and Emergency Medical Services, that dissuaded them from accessing medical care. Participants described experiences of mistreatment in emergency departments, with one account of forced catheterization. They further recounted disclosures of protected health information by healthcare providers, including communicating drug test results to law enforcement and sharing details of counseling sessions with community members without consent. Participants also described a hesitancy common among people who use drugs to call emergency medical services for an overdose due to fear of arrest.Conclusion: Breaches of trust by healthcare providers in rural communities discouraged people who use drugs from accessing medical care until absolutely necessary, if at all. These experiences may worsen healthcare outcomes and further stigmatize this marginalized community. Structural changes including reforming and clarifying law enforcement's role in Emergency Departments as well as instituting diversion policies during arrests may help rebuild trust in these communities. Other possible areas for intervention include stigma training and harm reduction education for emergency medicine providers, as well as developing and implementing referral systems between Emergency Departments and local harm reduction providers and medically assisted drug treatment programs.
Highlights
People who use drugs, especially via injection, are at increased risk for medical complications, including HIV, hepatitis C virus (HCV), sexually transmitted infections (STIs), endocarditis, skin and soft tissue infections, psychiatric illnesses, and overdose (O’Connor et al, 2014; Kievlan et al, 2015; CDC, 2018, 2019)
There are no definitive descriptions of drug use prevalence in the area studied, but our sample appears to reasonably align with substance use patterns suggested by local harm reduction providers, drug treatment programs, police drug seizures, and newspaper reports
The primary finding is that participants reported multiple, interrelated barriers to seeking medical care
Summary
Especially via injection, are at increased risk for medical complications, including HIV, hepatitis C virus (HCV), sexually transmitted infections (STIs), endocarditis, skin and soft tissue infections, psychiatric illnesses, and overdose (O’Connor et al, 2014; Kievlan et al, 2015; CDC, 2018, 2019). It is highly likely that people who use drugs are at increased medical risks from COVID-19 (Vasylyeva et al, 2020; Volkow, 2020) Despite these risks, people who use drugs access primary care less often and utilize emergency medical services (EMS) more frequently than the general population. The primary sources of discrimination reported by participants in this study included pharmacies, doctors, and hospitals This correlates with findings that medical providers may harbor negative attitudes toward people who use drugs and often lack sufficient training or knowledge to address their medical concerns (Merrill et al, 2002; Brener et al, 2010; van Boekel et al, 2013; Pullen and Oser, 2014; Chiarello, 2016). Understanding barriers to healthcare access for this often stigmatized population is key to reducing morbidity and mortality, in rural settings where resources may be limited
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