Cyril Hatfield doesn’t know exactly when he was “red-flagged” as a drug user in the Halifax hospital system, but he says he’s endured the poor care that’s come with it for decades.

Hatfield, 45, who avoids the hospital unless he has “a bone sticking out of my arm,” said he was in emergency care more often when he was actively using drugs about 25 years ago.

That’s when the Dartmouth man thinks some kind of “red flag” was placed on his file, if not earlier.

From that point on, Hatfield said, he can recall every type of mistreatment.

On one occasion, when he declined freezing in his face, nurses started “tugging” on his stitches in what he suspects was retaliation.

In the wake of a serious car collision, he said, he was put in an exam room to “sleep it off” as staff presumed he was intoxicated.

In that second case about 20 years ago, Hatfield actually had bleeding in his brain and slipped into a coma. He said hospital staff only found out hours later in a CT scan after failing to wake him up.

In the end, Hatfield suffered no serious memory loss or brain damage — something so surprising, he said, that a surgeon visited him in disbelief after reading his medical chart.

“Once you’re red-flagged they don’t see you as someone who’s sick or hurt. They see you not only as a second-class or third-class citizen. They see you as if you’re undeserving, almost,” Hatfield said.

“You brought it on yourself, and I don’t trust you.”

Now a new study supported by the Nova Scotia Health Authority (NSHA) Research Fund is looking into how patients like Hatfield have been treated when in hospital and how the voices of people who use drugs could inform new harm-reduction policies and more effective care.

“The way we’ve been approaching this for decades, it doesn’t work,” said Dr. Tommy Brothers, who is leading the study.

“The abstinence-based model doesn’t work. People get pushed away, people die.”

Nova Scotia has seen 22 confirmed and 21 probable opioid toxicity deaths this year as of Aug. 31, according to the health department.

Brothers is conducting the research with the help of advocate Natasha Touesnard of HANDUP (the Halifax Area Network for Drug Using People, of which Hatfield is also a member).

Touesnard will connect Brothers with patients as part of the interview portion of the study.

The pair have known one another for several years and written op-eds together around harm reduction.

Brothers said Touesnard’s background at various community opioid treatment services and her current role as physician’s assistant at Dartmouth’s Open Door Clinic has been vital.

The idea for the research came about after Brothers perceived a large gap in the opioid treatment services available in the community compared to what happens in hospital.

There’s an entire network of community-based services such as Direction 180, Mobile Outreach Street Health, Mainline Needle Exchange and others where people can access clean needles, methadone (a synthetic opioid replacement) and Naloxone (an antidote used to treat overdoses).

They’re often led by peers with experiences of drug use themselves, Brothers said.

“But then suddenly when people are ill, potentially as a complication of injecting, and come into the hospital, we say, ‘Oh, you can’t have any of these health-care services anymore,’ which seems absurd, and it is,” Brothers said in an interview alongside Touesnard.

He added that all of these interventions have been proven cost effective because they prevent expensive health complications, thereby getting people well sooner so they can reconnect with family and get involved in the community.

Traditionally, Nova Scotia hospitals have few doctors with training in methadone, Brothers said.

Right now he’s the only one at the QEII Health Sciences Centre, even though he’s still a resident and needs supervision while practising.

Until May, there was a federal law requiring practitioners to get an exemption from Health Canada before they could prescribe, sell or administer methadone.

The first half of his research has Brothers going back five years through the charts of patients at the QEII who have been treated for endocarditis — an infection of the heart’s valves or inner lining that’s more common among IV drug users.

He’s already covered two years and found 10 patients. He expects to gather a total sample size of 30 to 40 people.

Brothers will compare their treatment to patients at New Brunswick’s Saint John Regional Hospital, which has over the last 10 years enacted policies like a needle exchange and offered methadone and its milder cousin Suboxone.

“There’s a very different kind of culture and attitude in that hospital around this,” Brothers said.

In the second phase, Brothers plans to interview hospital clinicians, NSHA policy-makers or hospital leadership as well as those with lived opioid experience, asking them about how they see things now and what could be better.

The work of Brothers and Touesnard is “exciting,” said Dr. Sam Hickcox, and will hopefully create a more helpful environment in N.S. hospitals.

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Hickcox is a family physician who estimates half of his practice involves addiction medicine, bringing him to methadone clinics as well as the Nova Scotia Hospital. He’s also the physician lead for addictions medicine at NSHA — a role Hickcox considers a sign of shifting attitudes, as it didn’t exist until this year.

Although many of Hickcox’s patients have described poor treatment in hospital, he said, it’s hard to know how to address the situation of individuals like Hatfield because there are multiple sides to every story.

If someone has a history of opioid addiction, even 20 years ago, Hickcox said physicians need to know. If they’re prescribed opioids, their risk of relapse is higher.

“You have to do a few things differently, so that can sometimes feel like the person is being treated unfairly,” Hickcox said.

However, Hickcox agreed that patients do obviously run into various forms of prejudice — including addiction stigma but also sexism, racism and transphobia — that leads to poor treatment.

Currently, Brothers said, users encounter a “haphazard” system when they come in. Some patients are tested for HIV or hepatitis C but others aren’t, while some are offered the chance to speak with an expert about methadone or Naloxone, but not always.

“We’re not really even offering people these things that are life saving,” Brothers said.

Halifax hospitals should have a mechanism for automatically screening people for HIV and hepatitis C, said Dr. Lisa Barrett, an infectious disease physician and clinician scientist at NSHA and Dalhousie University.

Rather than targeting people and asking them about “risky” behaviours, hospital staff could instead ask everyone, “Hey, would you like to be tested?”

“Reducing the upfront questions about ‘riskiness’ is one of the big ways we can help practitioners to be less stigmatizing,” Barrett said.

She said the two main issues around patients who inject are keeping them in hospital long enough to get treatment and preventing future infections. She estimates that about half of those patients leave the hospital prematurely when clinicians would prefer they stay longer for optimal care.

Touesnard, who has also used drugs and been in opioid treatment, said there’s “a lot” of work that needs to be done building trust between the health-care system and people who use drugs.

She added that people who aren’t given opioids, Suboxone or methadone to manage withdrawal symptoms are being given a “door to leave.”

“Why would you stay if you’re in excruciating pain and withdrawal, (even to) receive life-saving treatment?” she said.

Brothers said that while Nova Scotia may be behind other parts of the country, he’s encouraged by the funding of his study and the openness of many doctors, nurses and other health-care providers to new harm-reduction strategies.

The potential is there, but he says he still hears the argument that these things can’t be done in Halifax “because we’ve never done it here” and that Nova Scotia doesn’t have a lot of health-care funding.

That’s when Brothers points to Saint John, N.B., an even smaller Maritimes city with fewer resources.

“It just takes a different attitude in recognizing we’re in a public health crisis,” Brothers said.

The study will likely take place over the next year, Brothers said, and hopefully start conversations that could lead to real changes “little by little” over the next three years.

Hatfield also wants to see more doctors, nurses and health-care providers educated on opioid use and treatment — and to keep an open mind so they don’t judge the next patient.

“People are afraid if they educate and inform themselves, then they’ve exposed themselves in some weird way … If you open yourself up to knowing, then it can’t be black and white; there’s a grey area for compassion and understanding,” Hatfield said.

“I do understand that’s how things happen, but that’s not an excuse, and it’s not the end of the story. It has to change.”

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