Overall, our results determine that while there are likely advantages to implementing ODTs within acute and primary care settings, there are major barriers to its implementation. Specifically, the feasibility of implementation and acceptance amongst patients and providers was questioned. Additionally, there are systems-based barriers that impact its implementation. Representative quotes are highlighted within the main text, and quotes supporting each subsection can be found in Additional file 1.

Section 1: Perspectives on patient care Subtheme 1: Acceptability, access, and patient safety around ODTs in acute care settings

When examining the utilization of these services in acute care settings, participants thought that this would help reduce the harm from substance use and prevent patient-initiated discharges. It was felt that by providing a supportive environment where patients had the option of using substances safely while in the hospital, patients were more likely to stay engaged with the acute care health care team for their medical needs, and less likely to self-discharge from the hospital secondary to their substance use. These issues include concerns when patients have cravings for substances or go through active withdrawals.

However, interviewees brought up the difficulties in phone and technology access for this population as a barrier to accessing these services, particularly the hotline and phone app services, especially if they were using their own phones. “I would see it as a benefit to their safety and wellbeing. They’re going to use [substances] whether we want them to or not so how can we better facilitate their medical care if they are going to use… Anything that could promote them staying on the unit more I’m all behind…And if this service could do that well then by all means I think we should give it a go.” P13 (Urban peer support worker).

The barrier always will be phones for patients. I think a lot of people have pay-as-you-go phones and so don’t always have necessarily – they don’t have data or the ability to always have apps but then also they just don’t have phones too. P12 (Urban Registered Nurse).

Subtheme 2: Rapport building with PWUD

While some technology pieces, including reverse motion detectors and buttons, directly alert on-site health care staff, other forms of technology, such as mobile overdose response services such as the National Overdose Response Service (NORS) and Brave, work by engaging with third party virtual supervisors who would monitor the client in their current location, including acute care sites. Some services, such as Lifeguard, are automated with no interaction with PWUD. Due to these unique functional attributes, there were concerns that some ODTs would lead to less face-to-face time with onsite addictions and harm reduction support, limiting a potential therapeutic relationship that would form if there was a consistent engagement between these services and the admitted client.

Feelings were mixed regarding the ability of some ODTs to build rapport and a therapeutic relationship with PWUD, which was seen as a key aspect of managing PWUD. Some interviewees did see this as an opportunity for PWUD, who may not want to engage with onsite addiction staff, to engage with other external resources, such as the peer workers on the NORS hotline. However, many individuals felt as though in-hospital physical SCS would be a better option for PWUD if they were available. Physical SCSs provide additional opportunities for healthcare providers in acute care settings to engage meaningfully with individuals and develop ongoing rapport. This connection could be disrupted by third-party operators such as NORS or Brave. “I mean whenever you don’t have that face-to-face contact you’re losing an opportunity to engage the person and build those relationships. P12 (Urban Registered Nurse).

Subtheme 3: Stigma reduction

Similarly, interviewees believed that ODTs would allow for stigma reduction for PWUD, demonstrating to them that they are “worthy and important”. Anytime that we can support people to use substances safely, we do a little bit of work to destigmatize that, and empower people to know that they're worth—they’re worthy and important, and that we want them to stay alive. So, I think that having a virtual service can work towards that goal of destigmatizing substance use, which is what I'd love to see… I think there is a message behind it that states, “we want to keep you safe, we want to keep you healthy, we want to look after you, this is important.” P15 (Urban Harm Reduction Nurse).

The mobility of ODTs allows flexible implementation in acute care settings and services localized to patient’s rooms. With overdose motion detectors and buttons, they would need to be installed within set locations in which individuals who are assumed to use substances could be placed. One interviewee identified this method of harm reduction as inadvertently stigmatizing by segregating them. This would apply not only to ODTs but also to physical SCSs. I just think it does inadvertently say, “yeah, we care about you, but if you decide you want to use drugs, please go do it over here with these people, and we’re going to just take care of this section.” And I think when we do that, it is stigmatizing. P15 (Urban Harm Reduction Nurse).

Taken together, these quotes illustrate that while participants believe ODTs might represent a safe and acceptable harm reduction strategy in healthcare settings, they may be limited in their ability to build rapport and reduce stigma.

Section 2: Impacts on healthcare workers Subtheme 1: Impact of ODTs on healthcare worker burden

Regarding how these services would impact healthcare workers, participants believed that these services would likely decrease the financial and human resource strain on participating facilities by freeing up nursing time that otherwise would have been focused on checking in on patients. Indeed, patients at risk of an overdose in their rooms often took nurses away from their other nursing duties and limited their ability to manage multiple patients simultaneously as they were focused on ensuring the wellness of a high-risk patient. “I think it would help, especially if it came down to like our staffing, right? The emergency room staff are so burned out, so stressed out enough as it is, if there’s a way to implement this sort of service so that would free up staff to not have to worry about, I could see some benefit in that.” P13 (Urban peer support worker).

Subtheme 2: Stigma and buy-in from health care providers

The largest identified barrier to implementing this type of service in acute care settings, and in turn, ensuring it was advertised to patients was buy-in from healthcare providers and leadership. Participants recognized that stigma against PWUD continues to be pervasive within the healthcare system and many healthcare providers continue to feel as though harm reduction initiatives are enabling drug use.

“I think the biggest barrier would be staff attitude and changing the kind of conversation about people feeling territorial, and oh why would they need that when they're in hospital? Or why are we even supporting substance use and those kind of attitudes.” P5 (Rural Registered Nurse).

“ A lot of staff are weary to promote something like that because they feel like that’s enabling” P6 (Urban Registered Nurse)

Section 3: System-level challengesSubtheme 1: Coordination of emergency response

In regard to the feasibility of these services, participants called for additional opportunities to support people who use substances in care such access to opioid agonist treatments, and other harm reduction strategies including access to naloxone kits, and sterile supplies. There were concerns raised about responses in case of emergency or drug poisoning events while using ODTs, and how the response would be coordinated, including who would be conducting the response, whether it be nursing staff, or specialty code teams within the hospital. Again I think it’s, the biggest reason I can think of is the logistics of the emergency response when it’s needed, how does that work? P3 (Urban Nurse Educator).

Subtheme 2: Policy and legal issues

Many participants “Would say policy is the biggest (barrier).” P2 (Urban primary care physician).

Health authorities were identified as being apprehensive about implementing these services in case adverse events are not appropriately attended to or responded to. Indeed, there continue to be voiced concerns about “promoting drug use and enabling” P12 (Registered Nurse) and “who is liable for a patient who is using” P11(P11 Resident Physician) but in general, participants were still supportive of the main aim of promoting safety in substance use. Similarly, organizations responsible for ensuring the health and safety of staff members may also not be supportive of these services.

“I think you definitely would have to have a whole overhaul on your policy within a hospital and it would have to have the buy in from like the upper echelons, but also the nursing too. I think even with our supervised injection site opening here at the hospital there was a lot of concern about what their liability was and things like that.” P12 (Urban Registered Nurse).

Subtheme 3: A holistic approach to harm reduction in acute care settings

Lastly, a consistent theme throughout the interviews was that participants identified that ODTs should be implemented as one aspect of a comprehensive harm reduction support system within healthcare settings. Participants recognized a holistic approach is required, including in-person peer support services, sterile supplies, naloxone kits, and options for physical SCS. A combination of services to suite a variety of needs patients may have was felt to be the best option for engaging people who use substances in healthcare settings. “It needs to be seen as one aspect of the whole plan and not the plan. P14 (Urban health research project lead). Many participants also suggested these services be recommended to patients on discharge planning, potentially in conjunction with the distribution of naloxone (P12 Registered Nurse) or as part of information for individuals to read over an explanation of various services and their usage (P11 Resident Physician).

“I think that we, as an organization, can certainly maybe on discharge, recommend these services to folks.” P15 (Regional Nursing Lead).

Overall, participants expressed mixed opinions about implementing ODTs in acute care settings from a systems-based level. They highlight that there are limitations and barriers to implementing ODT-based services, as well as the importance of a comprehensive model of integrating harm reduction into these settings. Such an integrated and comprehensive approach is core to supporting the healthcare of PWUD accessing healthcare facilities and decreasing stigmatizing attitudes held by healthcare professionals and decision-makers. Furthermore, participants expressed positive attitudes towards ODTs and their inclusion in comprehensive discharge planning.