“It Never Feels like Enough”: Hospital Clinician Distress In Caring for Patients with Opioid Use Disorder

Background and Purpose: Substance use disorders (SUDs) touch nearly all providers but are especially increasing in hospital settings. Clinicians report uncertainty and affective distress when caring for patients who may not plan to stop substance use. These challenges occur within broader structural constraints in hospital care delivery. This study examined clinician distress, decision-making, and perspectives on harm reduction when caring for hospitalized patients with SUDs.

Methods: Hospital clinicians (n=65) at a large, urban hospital were interviewed between March and August 2025. The interview included a cascading clinical vignette about a fictional hospitalized patient with endocarditis related to fentanyl and methamphetamine use. This patient does not plan to stop substance use following discharge and expresses fears about inadequate pain and withdrawal management during hospitalization; the patient ultimately returns to the hospital one year later and initiates buprenorphine. Clinicians were asked about their likely clinical actions (e.g., discuss the patient’s pain/withdrawal fears, safer injection practices) and rated affective distress at three time points (scale of 1–10). Qualitative responses were analyzed using thematic analysis. Quantitative data were analyzed using linear mixed-effects models.

Results: Clinician distress decreased as the vignette progressed (decreasing from 4.5 to 2.7 on average from the first to third timepoint; p<0.0001). Qualitative findings highlighted key themes: 1) a strong commitment to patient-centered care amidst affective distress when caring for a critically ill patient planning to continue substance use after discharge; 2) discomfort/uncertainty around discussing SUD, especially around safer-use; and 3) challenges managing pain and withdrawal, including concerns about both under- and over-treatment and reliance on other team members for dosing decisions. Affective distress was encapsulated by one clinician’s comment that “It never feels like enough,” highlighting a sense of persistent inadequacy despite a strong commitment to patient care.

Conclusions and Implications: Clinicians are committed to providing patient-centered care for individuals with SUD but experience affective distress when doing so. These findings highlight the need for clearer clinical guidance, harm reduction training, and improved interdisciplinary communication. Harm reduction conversations during hospitalization represent an important component of high-quality care for patients with SUD, especially those who plan to continue to use following discharge.