 a woman who had two valves that were infected from injection drug use. She really needed to have surgery in order to survive. She was on medications to keep her blood pressure up and medications to keep her heart beating. All while this was happening, her withdrawal from opioids was not being well managed. She was having, getting a dose here and a dose there. And we had the cardiac surgeon come by to see her to assess whether she would be able to have surgery. And the cardiac surgeon asked her, can you promise that you'll never use drugs again? If you can promise that you'll never use drugs again, I'll operate. And she looked at the cardiac surgeon and she said, I can't make that promise. That's not how addiction works. And it turns out that that surgeon didn't operate on this patient. Later she got sicker and a different surgeon operated on that, operated on her. But it highlights how even the most basic addiction care, management of withdrawal, engaging patients while they're in the hospital, isn't routinely being done. And the variability in the kind of care that patients get and the treatment that patients get, that other patients with other kinds of conditions wouldn't receive. This just shows how much better we can do in all of the interactions that we have with patients. One of the common reasons people who inject drugs come to the hospital is for help with infections. When a needle breaks the skin's barrier, there is a risk of an infection. Viruses like HIV, hepatitis C, and hepatitis B live on previously used needles and can spread if the needle is shared. Bacteria that live on the body or in the environment can also cause infections. Streptococcus pneumoniae, methicillin resistant Staphylococcus aureus, MRSA. Staphylococcus aureus. The risk decreases if sterile techniques are used when the skin is cleaned with alcohol, when needles are not reused or licked, and when drugs or solvents are free from contamination. Preventing infections is a challenge, especially when there is no clean, private place to prepare and use drugs. Meet Robert, a custodian, who has been injecting heroin and fentanyl for three years. He injects heroin in a closet at work in order to keep his use hidden from his employer and his girlfriend. His opioid use has increased, yet he has kept his job. He develops redness and pain at an injection site on his arm. Robert has managed smaller infections on his own, but he doesn't think he can continue to manage this infection. Soon, Robert starts to experience chills, sweats, and fevers. Robert is reluctant to seek help for the infection. Robert's reluctance to seek care is because of negative experiences in the past. He felt dehumanized by the way hospital staff treated him when he sought help for health issues related to his opioid use disorder. One of the situations Robert experienced in the past was not being offered adequate pain control. His clinical team did not believe his repeated reports of pain and accused him of drug seeking rather than taking his concern seriously. Robert ended up leaving the hospital against medical advice due to his extreme physical and emotional discomfort. In spite of his apprehension from his prior experiences, Robert finally decides to seek medical care for his infection. Robert is worried about his infection and his symptoms. Robert wants help treating his infection because it is currently causing him intense pain. He's not looking for treatment for his opioid use disorder, which is the underlying cause of his injection drug use and infection. Robert's symptoms must be taken seriously. The infection at the injection site could indicate a skin infection called cellulitis that needs treatment with antibiotics, or it could be an abscess, a collection of pus that needs to be drained. Fever and chills could indicate a bloodstream infection or a more serious infection of the heart valve called endocarditis. More serious infections, like those that reach the bloodstream, require longer courses of antibiotics, and in some cases may require heart surgery. While Robert's infection is being investigated and treated, he must be treated with dignity and respect. Every conversation and interaction that Robert has with the emergency department front desk staff to the nurse providing IV antibiotics and the physician who does his exam represents an opportunity to rebuild his trust in the healthcare system. It is important that he is treated with respect and compassion in each interaction. Healthcare providers have an opportunity to treat the patient's infection and build trust in the health system. In Robert's case, this is an opportunity to address his acute medical needs and his underlying substance use disorder. Humane and respectful care is not just a matter of good manners. In addition to managing his pain, Robert must be monitored for withdrawal symptoms from opioids. This will allow Robert to participate in his care and better characterize his pain and his withdrawal symptoms. When he starts to go through withdrawal, Robert must be managed with adequate doses of methadone or buprenorphine. When Robert's infection improves and his withdrawal is controlled, a longitudinal plan to reduce the risks associated with his drug use can be discussed. And he should be offered the chance to start on a therapeutic dose of methadone or buprenorphine. If he is interested, Robert will need to be linked to an outpatient provider who can continue Robert on medication for addiction. This will reduce his risk of overdose and other health problems related to his drug use. If Robert is not ready, he should be counseled about safe injection practices and referred to harm reduction services so that he can obtain naloxone, sterile needles, sterile water, alcohol swabs, and other materials to reduce his risk of infection and overdose. Robert should be reassured that his nurses and doctors are glad he came in for care and that his team will be available if he ever needs help again. Substance use disorders are chronic, relapsing diseases, and people who inject drugs are at high risk of infections. If a patient with substance use disorder arrives at a hospital with an infection as the immediate concern, it is crucial that the patient's pain and withdrawal symptoms are managed concurrently. Establishing trust during a hospitalization for an infection can provide an opportunity to begin substance use disorder treatment in addition to education on how to reduce the risks associated with drug use.