#### **ORIGINAL RESEARCH** ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_0_Picture_2.jpeg) # Staff perspectives on the impacts of the COVID-19 pandemic on the provision of emergency department care for patients who use opioids Nicole D. Gehring 1 · Sarah A. Weicker 2,3 · Elaine Hyshka 1 · Parabhdeep Lail 4 · May Mrochuk 2 · Katherine Rittenbach 5 · Kelsey A. Speed¹ · Ginetta Salvalaggio⁶ · Gillian Harvey⁷ · Shanell Twan⁸ · Kathryn Dong² Received: 25 June 2025 / Accepted: 9 October 2025 © The Author(s) 2025 #### **Abstract** Purpose The COVID-19 pandemic and Canada's drug poisoning crisis placed exceptional demands on emergency departments (ED). We aimed to explore the impact of these intersecting crises from the perspectives of ED staff to understand how EDs can improve care and protect the health and well-being of patients who use opioids, ED staff, and healthcare providers. Methods We conducted a focused ethnographic study involving 29 semi-structured interviews with ED staff who cared for patients who use opioids during the pandemic. Interviews explored ED staff perspectives on how the pandemic impacted care for patients who use opioids and how EDs can better serve this population. We conducted latent content analysis and main theme generation was informed by the socioecological model. Results Four main themes emerged. First, there was a change in patient behaviors, which impacted provider-patient relationships. Second, hospital pandemic policies and resource limitations created new barriers to care. Third, community service alterations, including the shift to virtual care and uncertain availability of services, further complicated patient care. Finally, participants highlighted opportunities to strengthen systems of care, including enhanced hospital addiction resources, improved addiction care training, expanded harm reduction services, and more robust community services. **Conclusions** The COVID-19 pandemic highlighted significant changes in ED care delivery for patients who use opioids. Efforts to enhance EDs should include anticipating the needs of people who use substances and the healthcare providers who care for them to mitigate unintended harm and ensure a more resilient healthcare system. **Keywords** Acute care · People who use substances · Opioid crisis · Emergency department · Qualitative research · Drug poisoning crisis · COVID-19 · Health services Nicole D. Gehring and Sarah A. Weicker contributed equally to this work. - kathryni@ualberta.ca - School of Public Health, University of Alberta, Edmonton, AB, Canada - Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada - Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada - Department of Medicine, University of Calgary, Calgary, AB, Canada Published online: 11 November 2025 - Department of Psychiatry, University of Calgary, Calgary, AB, Canada - Department of Family Medicine, University of Alberta, Edmonton, AB, Canada - Department of Art and Design, University of Alberta, Edmonton, AB, Canada - Boyle Street Community Services, Edmonton, AB, Canada ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_0_Picture_21.jpeg) ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_0_Picture_22.jpeg) #### **Résumé** **Objectif** La pandémie de COVID-19 et la crise d'empoisonnement par les drogues au Canada ont imposé des demandes exceptionnelles aux services d'urgence (SU). Nous avons cherché à explorer l'impact de ces crises intersectionnelles du point de vue du personnel des urgences pour comprendre comment les urgences peuvent améliorer les soins et protéger la santé et le bien-être des patients qui utilisent des opioïdes, du personnel des urgences et des fournisseurs de soins de santé. **Méthodes** Nous avons mené une étude ethnographique ciblée impliquant 29 entretiens semi-structurés avec le personnel du SU qui s'occupait des patients qui consommaient des opioïdes pendant la pandémie. Les entrevues ont exploré le point de vue du personnel des services d'urgence sur la façon dont la pandémie a eu une incidence sur les soins aux patients qui utilisent des opioïdes et comment les services d'urgence peuvent mieux servir cette population. Nous avons efectué une analyse du contenu latent et la génération du thème principal a été informée par le modèle socioécologique. **Résultats** Quatre thèmes principaux ont émergé. Premièrement, il y a eu un changement dans les comportements des patients, ce qui a impacté les relations entre le fournisseur et le patient. Deuxièmement, les politiques de lutte contre la pandémie dans les hôpitaux et la limitation des ressources ont créé de nouveaux obstacles aux soins. Troisièmement, les modifcations apportées aux services communautaires, y compris le passage à des soins virtuels et la disponibilité incertaine des services, compliquent davantage les soins aux patients. Enfn, les participants ont souligné les possibilités de renforcer les systèmes de soins, y compris l'amélioration des ressources hospitalières en matière de toxicomanie, l'amélioration de la formation dans le domaine des soins aux toxicomanes, l'élargissement des services de réduction des méfaits et l'amélioration des services communautaires. **Conclusion** La pandémie de COVID-19 a mis en évidence des changements signifcatifs dans la prestation des soins de SU pour les patients qui utilisent des opioïdes. Les eforts visant à améliorer les SU devraient inclure l'anticipation des besoins des personnes qui consomment des substances et des fournisseurs de soins de santé qui en prennent soin afn d'atténuer les dommages involontaires et d'assurer un système de soins de santé plus résilient. **Mots‑clés** soins aigus · personnes qui consomment des drogues · crise des opioïdes · service d'urgence · recherche qualitative · crise d'intoxication aux drogues · COVID-19 · services de santé #### **Clinician's capsule** #### *What is known about the topic?* The intersecting COVID-19 pandemic and Canada's drug poisoning crisis placed exceptional demands on EDs. # *What did this study ask?* What were the impacts of COVID-19 and the drug poisoning crisis for ED staf caring for patients who use opioids? # *What did this study fnd?* ED staf had to navigate evolving patient–provider dynamics while adapting to hospital policy, resource availability, and community care access challenges. #### *Why does this study matter to clinicians?* EDs should attend to addiction resources, staf training and well-being, and policy impacts on patients who use opioids. # **Introduction** Opioid toxicity killed more than 49,000 Canadians between January 2016 and June 2024 [[1\]](#page-8-0). Emergency departments (EDs) are a major touchpoint between people who use opioids and the health system [[2](#page-8-1), [3](#page-8-2)]. EDs can play a critical role in preventing drug poisoning deaths by identifying patients at risk of drug poisoning, initiating evidenced-based treatments, connecting patients to community addiction care, and providing other critical interventions (e.g., safer use education and naloxone kits) [[4,](#page-8-3) [5](#page-8-4)]. The unprecedented pressure of the COVID-19 pandemic had signifcant negative impacts on EDs [\[6](#page-8-5)]. Concurrently, the pandemic intersected with Canada's opioid poisoning crisis with a corresponding increase in drug poisoning events and deaths [\[8](#page-8-6), [9\]](#page-8-7). In 2019, there were a total of 18,302 opioid-related poisoning ED visits in Canada. This number rose to 22,732 in 2020, the year COVID-19 was declared a pandemic, and then dramatically rose again to 32,662 in 2021 [[1](#page-8-0)]. Importantly, EDs are still facing increased patient volumes [[1\]](#page-8-0) and presentation complexity [\[7](#page-8-8)] related to substance use post-pandemic. Given the increased demands placed on EDs, understanding challenges seen within EDs during the COVID-19 pandemic and drug poisoning crises can help EDs better care for this patient population. ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_1_Picture_19.jpeg) We explored the perspectives of ED staf who cared for patients who use opioids during the COVID-19 pandemic to determine: (1) how care for patients who use opioids was impacted during the pandemic; (2) the barriers and facilitators to providing efective opioid-related care during the pandemic; and (3) how ED care can be adapted for patients who use opioids. # **Methods** # **Study setting** The study was conducted at two large, urban acute care hospitals located in Edmonton and Calgary. These two hospitals have the highest volumes of ED visits and hospitalizations related to substance use in the province [[8](#page-8-6)]. Each hospital ofers access to an Addiction Medicine Consult Team (referred to herein as 'consult team'). These interdisciplinary teams provide in-hospital and in-ED consultation services to patients who use substances (see [[9–](#page-8-7)[11](#page-9-0)] for full details on services provided). # **Study design** We adopted a focused ethnographic design. This applied qualitative method is used to study highly specialized areas of society, such as healthcare settings [[12](#page-9-1)]. Focused ethnography commonly employs semi-structured interviews and often limits or omits participant observation [[12\]](#page-9-1). Due to COVID-19 pandemic restrictions, it was not possible to include participant observation. As such, focused ethnography enabled us to rapidly generate new knowledge that could be used to improve health service delivery. We report this study using the consolidated criteria for reporting qualitative research (COREQ; Additional fle 1) [[13\]](#page-9-2). The study received ethics approval from the University of Alberta's Health Research Ethics Board (Pro00104233). # **Research team and refexivity** Our research team consisted of eleven members. Primary afliations of our team members were fve clinicians (who have experience caring for people who use substances), fve academics (who work in public health, including substance use), and one community liaison (who has lived experience of substance use). Ten members identify as cisgender women and one as non-binary. Ten team members have advanced experience in qualitative methods, substance use, and/or medicine. Our interdisciplinary team previously collaborated together and regularly engaged in self- and teamrefexivity throughout the study via feld notes, electronic correspondence, and meetings to reduce potential bias. In addition, our team regularly engaged with patients throughout the study through ongoing consultation with an established Community Advisory Group comprised of people with lived experience of substance use and hospitalization. # **Recruitment and data collection** Staf who work and/or provide consultative services in the ED and had experience caring for patients who use opioids were invited to participate via purposive sampling given the specialized topic. The consult team and ED operational leads at both hospitals helped identify potential participants through personal invitations, posters, and presentations. Interested participants contacted the research team directly via email or phone. The interview guide (Additional fle 2) explored staf perspectives on the impact of COVID-19 on caring for patients who use opioids within the ED, as well as how ED staf can best care for this patient population. The interview guide was piloted and revised base on the frst three interviews. A member of the research team (NDG) conducted 29 one-time semi-structured interviews via Zoom between June 15 and November 31, 2021 [EH and EC (noted in the acknowledgements) sat in on some of the interviews]. No participants refused to participate or dropped out. Participants were ofered a \$50 e-gift card. The interviews were audio-recorded, transcribed verbatim, and de-identifed. No transcripts were returned to participants for corrections and participants did not provide feedback on the fndings; however, our Community Advisory Group provided feedback on the fndings. The average length of the interviews was approximately 1 h and all participants provided verbal informed consent. #### **Data analysis** We used NVivo 12 software to manage the data [[14](#page-9-3)] and we performed latent content analysis. NDG coded persistent concepts, considering their context, for each transcript via line-by-line coding to develop a preliminary codebook. KAS then co-coded 20% of the transcripts; coding was iteratively refned between NDG and KAS to reach consensus. Once no new ideas or codes were emerging from the data set, NDG grouped the codes into overarching themes. Overarching themes began to emerge refecting components of the socioecological model, which considers health as an interplay between individual, interpersonal, organizational, community, and policy levels of infuence [[15\]](#page-9-4). SAW and NDG revisited the emerging themes in relation to the socioecological model post hoc to help inform fnal theme generation. Several strategies were used to ensure rigor [[16\]](#page-9-5): (1) use of feld notes and an audit trail; (2) generation of a codebook and co-coding, as well ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_2_Picture_15.jpeg) as several members of the team reviewing the codebook, transcripts, and categorization; and (3) recruiting comparable numbers of participants from each site. # **Results** The majority of participants self-identifed as white (76%) and as women (83%). Participant numbers were similar between Edmonton (55%) and Calgary (45%). Most were nurses (62%) and the majority were ED staf not afliated with the consult team (66%) (Table [1](#page-3-0)). Four main themes emerged. We then mapped the major concepts from the four themes onto the socioecological model to demonstrate the interplay between individual, interpersonal, organizational, community, and policy levels that afected care delivery (Fig. [1\)](#page-4-0). **Table 1** Participant characteristics (*n* = 29) | Acute care location, n (%) | | |-----------------------------------------------------|-----------| | Edmonton | 16 (55.2) | | Calgary | 13 (44.8) | | Role, n (%) | | | Nurse | 18 (62.1) | | Physician | 8 (27.6) | | Othera | 3 (10.3) | | Part of AMCT, n (%) | | | No | 19 (65.5) | | Yes | 10 (34.5) | | Gender, n (%) | | | Woman | 24 (82.8) | | Man | 4 (13.8) | | Non-binary | 1 (3.4) | | Ethnicity/race, n (%) | | | White | 22 (75.9) | | Asian | 1 (3.4) | | Southeast Asian | 1 (3.4) | | Chinese | 1 (3.4) | | Sri Lankan | 1 (3.4) | | Indian | 1 (3.4) | | Indigenous | 1 (3.4) | | Mixed | 1 (3.4) | | Years working in ED, average ± SD | 4.8 ± 5.4 | | Years of experience in total, average ± SD | 8.5 ± 7.0 | | Specialization in substance use treatment in the ED | | | No | 20 (69.0) | | Yes | 9 (31.0) | All characteristics were self-reported a Other included addiction counsellors or peer support workers ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_3_Picture_8.jpeg) ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_3_Picture_9.jpeg) # **Changes in patient behaviors and patient–provider relationships** Participants observed changes in perceived patient unwillingness to access ED care as a result of fear and mistrust. Patients were noted to "*be afraid of coming to the hospital because they were worried about getting COVID" (Participant 15, non-consult team staf)*, which in some cases led to delays in accessing care and contributed to increased complexity of presentations. Participants also observed increased patient *"mistrust in the system,"* in part due to ED staf being overburdened by COVID-19 and substance use presentations: *"Currently, it feels very much like patients might not trust us as much because we're so burnt out. And the department is so full. Our wait times at night are ten hours now normally. Especially for someone who is withdrawing, that's a long time." (Participant 11, nonconsult team staf)* Participants also reported an apparent increase in aggressive and challenging patient behavior. Some respondents reported more erratic behavior following opioid poisoning reversal, attributing this to the *"multiple, multiple, multiple doses"* of naloxone required and the presence of unknown contaminants in the drug supply. Participants noted that due to the high acuity of ED presentations during the pandemic, they had less time available to verbally de-escalate patients, leading to a greater dependence on protective services. Often as a result of *"frustration and exhaustion"*, some respondents noted an erosion of the relationship between ED staf and patients. #### **The changing hospital landscape** Many participants highlighted that new hospital policies, designed to mitigate the spread of COVID-19, created barriers in the provision of ED care. For instance, donning and dofng personal protective equipment (PPE) resulted in less efcient care and less time to address the unique needs of patients who use substances*.* Participants also noted a decreased ability to build rapport with patients, in part due to PPE, and that pandemic policies made the hospital a less conducive environment for supporting patient well-being (e.g., exclusion of hospital visitors). As one emergency physician discussed: *"[I]n COVID, I think the biggest diference for managing that population was you used to be able to have a family member or friend come to the bedside for these overdose patients in crisis and we couldn't have anybody there. And I think it was so, so isolating, not* ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_4_Figure_1.jpeg) **Fig. 1** Four main themes in relation to the socioecological model *just for the patient who was quite sick [...] but for any family member or support person who's usually there advocating for the patient." (Participant 16, non-consult team staf)* Participants also described that there were no *"in-and-out privileges"* for patients, which was frustrating for individuals who wanted to leave the ED temporarily to use substances. Participants noted that hospital-based addiction resources were adversely impacted during the pandemic. For example, participants from the Edmonton site discussed changes in supervised consumption service policies. Participants reported that prior to the pandemic, members of the community could also access the service to obtain supplies (e.g., naloxone kits and sterile drug consumption materials); however, this practice was not permitted during the pandemic. Moreover, several participants described how patients were required to have a staf-escort to attend the supervised consumption service, whereas prior to the pandemic they were free to visit the site independently. As one nurse described: *"[T]he nurse has to bring them or a member of the Supervised Consumption Site staf can bring them. But that's a barrier right. These patients are not used to waiting. They're used to having a certain amount of freedom and for someone to ask nursing staf, hospital staf, if they could call someone so they could use their substance. The stigma that they get […] is defnitely a barrier." (Participant 14, consult team member)* The pandemic contributed to increased levels of burnout experienced by hospital staf. Our participants noted that many staf appeared to be in "*survival mode*", which limited their ability to provide compassionate care. One physician noted "*growing frustration*" and "*fatigue*" among ED providers in treating patients with substance use. In addition, participants noted that burnout resulted in some staf reducing their hours or seeking other employment opportunities. For example, one nurse remarked on the dramatic loss of senior addiction staf and peer support workers during the pandemic "*because they're so exhausted, and burnt out, and tired" (Participant 6, non-consult team member).* Respondents also described that stafng shortages resulted in the closure of ED and acute care beds and limited supervised consumption service capacity. Despite high levels of burnout, several participants described hospital staf going *"above and beyond"* and working *"tirelessly"* to fnd *"creative ways"* to bridge gaps in patient care. Participants noted that some staf took an active role in ofering addiction services in the ED rather than outpatient services. For instance, some providers reported that they made greater eforts to initiate patients on opioid agonist treatment in the ED. One emergency physician shared the following: *"I would sort of push a little bit harder in terms of assessing [the patient's] sort of readiness [for treatment], or encouraging them one way or the other to get opioid [agonist] therapy or some sort of mental health, or some sort of addictions follow up. I would try to square that away in the emerg rather than ofoad that to a clinic that may or may not be functioning at the time." (Participant 3, non-consult team staf)* Several participants also acknowledged that the ED may have served as a patient's only connection to the healthcare system during the pandemic; in some cases, staf advocated for patients at particularly high risk to stay in the ED longer or be admitted to facilitate needed care. # **Alterations in community services** Participants described a high level of uncertainty regarding the availability of community services. One addiction counselor described how the unclear continuity of community care created new barriers for patients: *"[We are not] sure that services are even available because of COVID because so many things have gone virtual [...] what do we do [...] if the pharmacy isn't open? What if the clinic isn't open? Are we able to go down there because so many places are closed? And so, there's that, I think, extra level of anxiety on the parts of the patient." (Participant 1, consult team staf)* In particular, respondents highlighted concerns about changes in operating hours, closures resulting from outbreaks or stafng shortages, and reduced capacity to accommodate patients due to social distancing measures. In response to the pandemic, participants noted that community addiction services adapted care delivery to include virtual options. Participants described how many services began allowing patients to connect with healthcare providers over the phone or computer. Participants described how virtual care provided more fexible opioid agonist treatment dosing for patients, with less stringent urine toxicology testing requirements to reduce patient exposure to COVID-19 and support self-isolation. However, numerous respondents noted challenges in accessing virtual services for structurally vulnerable individuals with limited technology literacy or access: *"[Virtual care is] a barrier, because not everyone has access to telehealth. I think that there's an expectation that everyone has a phone or a smart phone, or access to reliable internet, or a phone number. Telehealth is great if I'm sitting at home in my house with a good wireless connection, but [not] if you're in a shelter or […] on the street." (Participant 25, non-consult team staf)* Participants also shared that some patients struggled without the structure and *"human connection"* provided by in-person care. In some cases, this *"limited [individuals] wanting to seek help because they didn't have those supports right in front of them"* (*Participant* 8*, non-consult team staf*). The pandemic complicated disposition planning for ED patients. Participants noted that in-person detox facilities and addiction services would screen incoming patients for COVID-19 symptoms. Withdrawal symptoms such as runny nose, fatigue, or gastrointestinal upset often overlapped with COVID-19 symptoms. One nurse shared: *"If you're wanting to send someone from the Emergency Room, they would often ask you about those core symptoms. And if they did have any them, even if it was withdrawal related, it made it very challenging for that person to be transferred to that centre." (Participant 14, consult team staf)* Some participants noted that these screening measures resulted in delays in care and reduced ED patient fow. Isolation facilities were developed by community organizations with support from the provincial government for patients experiencing lack of housing who were required to isolate or quarantine under COVID-19 public health orders. Participants described how patients with symptoms of COVID-19, a positive test result, or who were a known close contact of a COVID-19 case were transferred to these centers from the ED upon discharge. Several respondents highlighted that these facilities were particularly benefcial for unhoused patients who use substances as they provided integrated patient care, including temporary housing, health services, and addiction care. One physician shared: ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_5_Picture_18.jpeg) *"I think [the isolation facilities were] a bit of silver lining because these people who maybe had been marginally housed before actually got to be in a place where there was 24-hour nurse supervision and like clean sheets and a bathroom. But […] now [they're] legally required to be in a hotel for 14 days so […] it was a bit of a double-edged sword." (Participant 18, nonconsult team staf)* Participants described that some patients struggled to adhere to isolation requirements and left isolation facilities to use substances or see friends and family. In some cases, this resulted in patients being apprehended under public health legislation and brought back to the ED for involuntary hospital admission, inadvertently placing additional pressures on EDs. # **Areas for improvement** Participants advocated for improvements in substance use care through the establishment of ED care pathways for common substance use concerns as well as increased access to addiction medicine expertise. One physician shared: *"I think honestly, we need [addiction consult teams] in all hospitals so that we have a constant addictions medicine presence, which leads to improved education around substance use disorders." (Participant 7, consult team staf)* In addition, participants reported that ED care spaces stafed with personnel with dedicated substance use training could better address the unique needs of patients who use substances by ofering a multidisciplinary approach, tailored care provision, and follow-up coordination. Many respondents expressed concerns regarding inadequate substance use training. For example, one ED nurse shared the following: *"There needs to be a bit more training and education just around substance use in general. But specifcally, opioids because we're just seeing so many people right now who are asking to start [opioid agonist treatment] […] and there's still a lot of people who don't understand the process of it, how the medication really works […] what the follow-up is." (Participant 26, consult team staf)* Participants described the need for further education on a variety of topics, including opioid agonist treatment initiation, withdrawal management, trauma informed care, motivational interviewing, and community addiction resources. Participants also described the need for improved harm reduction services. Numerous respondents felt that EDs should take a more active role in providing patients with safer drug consumption supplies, such as *"packages with [a] tourniquet, and sterile water, and a syringe, and alcohol wipes, and a cooker" (Participant 2, non-consult team staff).* Hospital-based supervised consumption services were highlighted as an efective way to reduce harms and stigma associated with substance use; participants stressed the importance of expanding supervised consumption services to additional hospital sites to maximize their impact. Other harm reduction suggestions included introducing drug checking services as well as ofering prescribed safer supply medications. Finally, participants reported that the current system of addiction care often resulted in patients seeking ED care only after experiencing adverse substance use health outcomes, and noted that improved access to community addiction supports may reduce ED presentations. Specifcally, respondents called for greater investment in low-barrier multidisciplinary services to manage withdrawal, harm reduction services, opioid agonist treatment, longitudinal care, and access to bed-based treatment. As one physician shared: *"We just are generally under resourced to treat these patients. We just don't have great options to help these folks in general […] We don't have enough detox centres to treat them. We're losing our [community-based] safe injecting site. That's devastating to try to protect these people from the harms that come with using, not just the substances themselves." (Participant 15, nonconsult team staf)* Furthermore, respondents underscored the importance of streamlining access to community follow-up services for ED patients and maintaining a blend of in-person and virtual care options. # **Discussion** ## **Interpretation of fndings** The COVID-19 pandemic created new barriers in the provision of ED care for patients who use opioids. ED staf had to navigate evolving patient–provider dynamics while adapting to shifts in hospital policies, resource availability, and access to community care. Our fndings underscore the need for EDs to proactively protect the health and well-being of patients who use opioids and the healthcare providers who care for them. ## **Comparison to previous studies** This study builds on existing literature describing how the dual public health crises further increased harm to patients who use opioids [[7,](#page-8-8) [8,](#page-8-6) [17\]](#page-9-6) while simultaneously ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_6_Picture_20.jpeg) ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_6_Picture_21.jpeg) restricting access to health and social services [[18](#page-9-7), [19](#page-9-8)]. As EDs remain a main point of care (during crises and normal circumstances), EDs must be counterbalanced with community services and resources in other parts of the healthcare continuum to ensure comprehensive care. While innovative adaptations during COVID-19, such as expanded virtual opioid care and isolation facilities, were implemented (albeit closed rapidly post-pandemic [\[20\]](#page-9-9)) to respond to community gaps [\[21\]](#page-9-10), they must be designed to allow equitable access. For instance, implementation of virtual care modalities should be accompanied by investments in training and infrastructure to ensure access for individuals with housing instability, fnancial barriers, and limited technology literacy [\[22\]](#page-9-11). Previous research has also shown that crises disproportionately impact populations experiencing health and social inequities [[21,](#page-9-10) [23](#page-9-12)]. Governments responded rapidly and robustly to the COVID-19 pandemic; however, public health action specifc to people who use substances (e.g., isolation facilities, allowing/enhancing encampments, and virtual opioid care) were not implemented until much later in the pandemic timeline [\[24](#page-9-13), [25](#page-9-14)]. Supply chain disruptions of the illegal drug market during the pandemic led to an increasingly toxic drug supply [[26](#page-9-15)], which was identifed in this study as leading to more complex and higher acuity presentations. Innovative interventions such as access to safer supply [[27](#page-9-16), [28\]](#page-9-17), expanded access to withdrawal management services, and expansion of supervised consumption services may reduce the immediate risk of death from supply chain disruptions. Moreover, stigma and discrimination in healthcare settings is widely reported by patients who use substances [\[29](#page-9-18), [30](#page-9-19)] and this study highlighted that the pandemic inadvertently increased patient mistrust in healthcare systems. # **Strengths and limitations** This study included a diverse mix of ED staf, ofering a broad perspective on how multiple disciplines responded to the dual public health crises. However, we completed this study in 2021 at two urban acute care centers in Alberta with established addiction consult teams which may limit generalizability to EDs without integrated substance use resources. Regardless, Alberta's opioid poisoning crisis remains a signifcant challenge for ED care (between 2022 and 2024 there were 17,075 opioid-related poisoning ED visits [[31\]](#page-9-20)). As such, we believe our fndings and recommendations remain applicable for ED clinicians who care for people who use substances. In addition, our interview guide focused on patients who use opioids which limits our understanding of the complexity of the drug poisoning crisis, which has increasingly afected people who use substances other than opioids (e.g., stimulants) [[1\]](#page-8-0). However, many participants discussed patients who use substances more broadly and the term 'substance use' was used throughout the manuscript to refect this. Finally, patient perspectives were not included within this analysis, but are being examined within a separate study. # **Clinical implications** This study underscores the importance of prioritizing ED staf well-being. Our fndings noted that staf burnout and moral distress—attributed to increased workload, uncertainty and lack of addiction resources, and stafing shortages—contributed to reduced ability to provide compassionate substance-related care. EDs should include strategies to protect staf health and well-being in an efort to protect patient–provider relationships and maintain high-quality care for people who use substances. For example, efective human resource planning, such as reallocating staf, limiting overtime, and appropriate remuneration could potentially mitigate moral distress and burnout, and improve compassionate care for people who use substances [\[32](#page-9-21)]. Although we do acknowledge that this may not always be feasible under the constraints of Canada's current healthcare system, they are critical considerations for substance use care. In addition, COVID-19 public health and hospital measures restricted ED staf ability to develop rapport with patients who use substances and de-escalate challenging situations. For any newly developed policies and procedures, ED policymakers and clinicians should consider their impacts and tailor policies specifcally for patients who use substances [[33](#page-9-22)]. At the minimum, EDs should incorporate the perspectives of patients with lived experience of substance use during policy development to better understand their needs during crises and beyond. #### **Research implications** It is essential to proactively strengthen EDs for patients who use opioids through the expansion and evaluation of education and training, institutional protocols, and engagement across sectors to improve clinician readiness to provide substance use interventions [[34](#page-9-23)[–36](#page-9-24)]. Future research could examine whether dedicated ED staf and care spaces could be used to better support the unique needs of patients who use substances; for example, the implementation of ED substance use navigators (trained staf who provide motivational interviewing, strengths-based counseling, harm reduction, resource coordination, etc.) has been associated with higher patient engagement in addiction treatment post-discharge [[37\]](#page-9-25). ![](https://assets.reachrx.ai/images/10.1007%E2%98%8Ds43678-025-01042-w/_page_7_Picture_11.jpeg) # **Conclusion** The pandemic resulted in an escalation of substancerelated harms while placing a strain on ED resources and disrupting access to community services. EDs should anticipate the needs of patients who use substances and the healthcare staf who care for them—both in times of crisis and routine care. This includes enhancing addiction resources and staf training within EDs, prioritizing ED staf well-being, carefully considering and mitigating the impacts of new policies on patients who use substances, and maintaining fexible and innovative approaches to addiction service delivery. # **Glossary** COREQ COnsolidated criteria for REporting Qualitative research ED Emergency Department PPE Personal protective equipment **Supplementary Information** The online version contains supplementary material available at. **Acknowledgements** We respectfully acknowledge that this work took place on Treaty 6 Territory, a traditional gathering place for diverse Indigenous Peoples, including the First Nations, Métis, and Inuit. The authors are thankful to the participants who shared their time and expertise, Brynn Kosteniuk who helped in the early stages of the study, and Ethan Candler who participated in some of the interviews. **Author contributions** Gehring: data curation, formal analysis, project administration, and writing—original draft. Weicker: formal analysis and writing—original draft. Hyshka: conceptualization, data curation, funding acquisition, investigation, methodology, resources, supervision, and writing—review and editing. Lail: conceptualization, funding acquisition, investigation, methodology, resources, and writing review and editing. Mrochuk: conceptualization, funding acquisition, investigation, methodology, resources, and writing—review and editing. Rittenbach: conceptualization, funding acquisition, investigation, methodology, resources, and writing—review and editing. Speed: project administration, validation, and writing—review and editing. Salvalaggio: conceptualization, funding acquisition, investigation, methodology, resources, and writing—review and editing. Harvey: conceptualization, funding acquisition, methodology, resources, and writing—review and editing. Twan: conceptualization, funding acquisition, methodology, resources, and writing—review and editing. Dong: conceptualization, funding acquisition, investigation, methodology, resources, supervision, and writing—review and editing. **Funding** This study was funded by the Canadian Institutes of Health Research (CIHR—448953). The views expressed are those of the authors and do not necessarily represent the views of the funders. Dong received a medical leadership salary from Alberta Health Services as the medical lead for the Edmonton Addiction Medicine Consult Team during the time data collection was taking place. **Data availability** The data set analyzed for this study are not publicly available to protect participant anonymity. Additional information may be provided upon reasonable request to the corresponding author. # **Declarations** **Conflict of interest** The other authors declared no conficts of interest. **Open Access** This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modifed the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. 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