Discharge From the Trauma Hospital as A Transition Into Insecurity, - Experiences Among Physical Trauma Survivors

Background: Physical trauma is associated with mortality, long-term pain and morbidity. Effective pain management is fundamental in trauma care and opioids are indispensable for treating acute pain; however, the use and misuse of prescribed opioids is an escalating problem. Despite this, few studies have been directed towards trauma patients in an early phase of rehabilitation with focusing on experiences and perspectives of health and recovery including pain and persistent use of prescribed opioids with abuse potential. To explore pre- and post-discharge trauma care experiences, including exposure to opioids, physical trauma survivors were recruited from a major trauma center in Norway that provides the highest level of surgical trauma care. Method: Qualitative exploratory study. Individual semi-structured interviews were conducted among 13 trauma patients with orthopedic injuries, known to be associated with severe pain, six weeks post-discharge. The interviews were recorded, transcribed verbatim, and thematically analyzed with an interdisciplinary approach. Results: The overarching theme was that discharge from the trauma hospital and the period that immediately followed were associated with feelings of insecurity. The three main themes that were identied as contributing to this was a) unmet information needs about the injury, b) exposure to opioids, and c) lack of follow-up after discharge from the hospital. Participants experienced to be discharged with prescribed opioids, but without information about their addictive properties or tapering plans. This, and lack of attention to mental health and psychological impact of trauma, gave rise to unmet treatment needs of pain management and mental health problems during hospitalization and following discharge. Conclusion: The ndings from this study suggest that in addition to delivery of high-quality biomedical trauma care, health professionals should direct more attention to psychosocial health and safe pain management, including post-discharge opioid tapering and individually tailored follow-up plans for physical trauma survivors.


Introduction
Worldwide, physical trauma represents 10% of global mortality (1). It is a major contributor to years lived in disability and it is recognized as a public health concern because of its signi cant impact on and cost to the individual and society (2,3).
Traditionally, the evaluation of trauma care has primarily focused on mortality measurements (4).
However, as medical advancements have increased trauma survival rates, trauma care evaluations have gradually come to emphasize the signi cance of functional health, return to pre-injury lifestyle, and quality of life (5,6). The importance of self-reported health among patients has also been increasingly recognized (7). Additionally, exploring patient experiences might help health professionals to evaluate interventions and/or therapeutic concepts (8).
surgical care is provided. Seamless transitions between health care facilities have been a priority for the Norwegian Ministry of Health. Most trauma patients are admitted to local hospitals. Then, the severity of the injury determines whether they are transferred to regional trauma centers for treatment before they return to the associated local hospital. Also, some trauma patients are offered interdisciplinary therapy at rehabilitation clinics before they are discharged to homeThe municipality-level general practitioners (GPs) are then responsible for further rehabilitation and follow-up (30).

Participants and recruitment
The participants in this study were all patients who were 18 years of age or older and able to consent, and who had experienced complex and/or severe surgical trauma. These traumas included one or more of the following three types of injuries: 1) more than one fracture of the extremities, spine, or pelvis, of which at least one of the fractures required surgical treatment, 2) isolated pelvic fracture with neurological injury (acetabulum or pelvic ring), and/or 3) isolated thoracic injury with more than two rib fractures.
Fourteen persons who met the inclusion criteria were enrolled in the study, but one was lost to follow-up. In addition, one re-hospitalized patient with pain experiences was included to pilot test the interview guide, and this data was included in the analysis. An overview of 12 of the 13 participants' injuries and surgical treatments was obtained with their consent from their medical journals at the trauma hospital, but data was missing for one participant.
Among the study sample were 11 men and two women. Mean age was 50 years, (median=50, range=19-78). The following sources of injury were represented: Motor vehicle accident (5), fall (1), hit by falling object (2), skiing (3), and sledge ride accident (1). All but two had injuries that required surgery. The length of hospital stay varied; four participants were hospitalized for less than 5 days, four for 5-16 days, and four for more than 16 days. The participants were admitted for a mean of 14 days (range 2-43 days).
Nine participants had partners and three were single. Three of the participants had young children living at home. At the time of the accidental injury, 10 were employed full time or engaged in full-time study, and two were retired. One to two months post-discharge, one participant worked 50%, and the rest were on sick leave. The time admitted to the Post-Anesthesia Care Unit ranged from one-seven days (mean=two and a half). None of the participants required invasive ventilation support during their time at the PACU or were admitted to the Intensive Care Unit. Two participants were discharged directly home, and eleven were transferred to the local hospital or a rehabilitation center before they returned home.
The semi-structured interviews took place at the participants' residence on an average of six weeks (range two-seven) after hospital discharge. Three of the interviews were conducted at local health institutions because of complicated injuries that required long-term residential care.
Interview guide and data collection An interview guide was developed in collaboration with two former trauma patients who had experienced major pain problems, opioid use, and affected quality of life. The interview guide was also pilot tested and adjusted accordingly. The interview guide consisted of ve main themes and contained open-ended and probing questions about trauma care, experiences of pain, opioids, post-discharge follow-up, and quality of life after trauma. Each interview lasted 45-90 minutes, and each interview was audio recorded and transcribed verbatim. The rst author conducted the interviews. To ensure an open space within which participant perspectives could be prioritized and inter-subjective understandings achieved, the interview guide had a exible design (31). In the interest of enhancing validity, ndings from the rst interviews were engaged as vignettes in subsequent interviews with new participants (32).

Analysis
The illness trajectory framework (Corbin and Strauss), which Halcomb and Davidson (33) have applied to traumatic injury, provides the theoretical framework for the study. Central to this framework is an emphasis on the bio-psychological impact of injury and an understanding that pre-injury factors affect recovery (34). Within this framework, the trauma care continuum is understood as a trajectory that consists of multiple phases, beginning from the time before the injury and continuing through the acute and stable to recovery phases. According to Halcomb and Davidson, "health is likely to be sustained or enhanced for many survivors along the stable phase of the trajectory for many years" (p.237) . Still, at some point, recovery may deteriorate and patients may enter the unstable phase, which includes complications in all aspects of health (33). In this study, participant experiences in the acute and stabilization phases were explored. The theoretical framework was engaged when planning the study and developing the interview guide, as well as during the analysis phase that focused on biological, psychological, and social aspects of the trauma care experiences.
The transcripts were processed and coded in NVIVO 11 (QRS International, 1999). A six-step inductive thematic approach guided the analysis (36): 1) To obtain an overview of the data, the rst author read and re-read the transcripts, while identifying potential codes and themes. 2) Codes were developed and modi ed. When new codes from subsequent interviews were added, the initial coding was re-analyzed and re-coded. 3) Codes were grouped into broader preliminary themes of signi cance before they were reviewed and modi ed in regular meetings among the co-authors. The rst author conducted the initial coding and held regular discussions with the last author to reach consensus during the process. 4) The review resulted in a nal re nement, which led to the fth stage of the analysis. 5) Three overarching themes with associated sub-themes were de ned: a) information needs, b) exposure to opioids, and c) lack of follow-up after discharge. The emerging theme, "feeling unsafe/insecure", evolved throughout the analysis process. To ensure that different clinical perspectives were taken into account in the nal steps of the analysis, all authors who have experience in anesthesiology, orthopedics, psychiatry, addiction, and primary health care participated in the discussions. Also, ndings were discussed with a former trauma patient with opioid use experience. 6) The ndings presented in this article represent the sixth step and end-point of the thematic analysis: to produce the report and give a full description of the themes, supported with empirical material in the form of quotations and in-depth descriptions.

Results
All participants were involved in traumatic accidents and suffered severe injuries that required activation and reception of a trauma team, highly specialized treatment at a trauma hospital, and access to trauma care. While hospitalized, all participants experienced severe pain and were treated with opioids. All were also discharged from the hospital with a prescription for opioids. All of the participants described major changes to their lives related to the unexpected physical trauma and its effects on their current life situation.
The overarching theme was that the participants described the trauma course, from the time of injury to rehabilitation, as a complex experience in which they were exposed to different factors that contributed to feelings of what we, in this article, describe as "insecurity and unsafety". This re ects our effort to translate from Norwegian to English a single term, "utrygghet". In Norwegian, "utrygghet" encompasses both the physical risks associated with trauma, trauma recovery, and opioids, and the immaterial and subjective insecurities associated with an unpredictable and uncertain recovery process in which the participants' perceived needs for information and follow-up care were not adequately met. This translation thus also re ects the three main themes that were identi ed as contributing to feelings of what the participants described as "utrygghet": a) unmet information needs, b) exposure to opioids, and c) lack of follow-up after discharge from the hospital.

Information needs
With respect to the acute phase to one to two months post-discharge, all of the participants recalled having experienced a lack of information from health professionals about the following three areas: a) the injury and expected level of physical function, b) psychological reactions to trauma and pre-existing premorbid mental disorders, and c) opioid side effects and tapering.
The manner in which the health professionals communicated was also a central area of concern. For example, many participants did not understand the information that was shared with them when physicians used medical terminology and unfamiliar words. Henning described this as follows: I had the impression that some of these attending physicians who are experts in their elds, they come in and explain your status and use foreign words that you have never heard before, which just leaves you with questions. .. Several times, I had to ask, "can you please explain it in a more lay person language". For Henning, an understanding of his injuries was essential. In particular, he wanted an explanation of his lung injury, because he had lung drainage and severe pain. Instead, he was met by physicians who used complicated language, which left him more confused and insecure. Also, Henning did not fully remember what information he had received at the trauma hospital, because opioids had profoundly compromised his memory.
Andrine described a different kind of communication barrier to having her information needs met. She felt that the physician who had informed her about her injuries crossed a line by trying to persuade her to quit her favorite hobby, which was also the source of her traumatic incident. She explained: .. . he almost started to nag that I should quit or nd a new sport. .. then I got a bit angry. .. and he (the doctor) tried to give information about the injured body part and stuff but it just did not work. .. I did not listen at all at that point. It is not his business what I do in my spare time.
The information about the physical trauma became unavailable to her after she blocked out what was said in response to what she perceived as her doctor's inappropriate and insensitive approach. For her, her hobby was a signi cant source of recovery motivation, which made it even more di cult when he challenged and dismissed, rather than tried to understand, how important this hobby was for her.
André offers another example of health professionals trying to provide information without knowing enough about the patient and, in this case, without knowing enough about the patient's medical history. Most of the participants did not experience that current and pre-morbid mental health problems received signi cant attention at the trauma hospital, but this had a particular meaning for André, who had struggled with severe depression. During trauma care, he was never asked questions about previous or current mental health status. Furthermore, he was uninformed that the injury could affect his mental health. André explained what he experienced at the time of discharge: .. . the doctor told me. .. I don't know if he meant it as a joke. .. "you are getting a lot of strong painkillers to take home and you can easily take an overdose and die". .. he told me. .. "but you don't have any plans of doing that", he said. .. "no I don't have any plans to do that", I said. .. "But clearly, if you were someone who planned to do that, you have the opportunity with a large pack of pills in the house. .. " André experienced that the physician was uninformed about his comorbid depression, which seemingly resulted in a misguided approach to communicating essential information. As a result, André did not receive the information that he needed or feel comfortable opening up about his mental health history and concerns.
Overall, participants experienced that health care professionals provided little information about how mental health could be affected by traumatic injury. While admitted to the trauma hospital, three participants were offered a psychiatric consultation, but André was not one of them.
The vast majority of the participants expressed that they rst and foremost needed a detailed explanation of their injuries, treatment plans, and surgical interventions from their attending health professionals.
They also desired information about the expected physical outcome of their injuries and the treatment and follow-up that they would receive following discharge from the trauma hospital. All participants experienced that several physicians were involved in their treatment process. While some desired better continuity, others found this unproblematic, like Børge, who explained: Everyone had different opinions on how things should be done. .. people handle tasks in different ways, so it did not bother me and if I asked I got an answer [. .. ] So, if you do not ask, then I do not think that you will get any further [answers] either.
Børge did not expect to be provided with information without asking; he took an active role, and he also described an experience of participation in the decision-making processes. Ulf, who suffered from severe lower extremity injuries and complicated fractures, did not experience involvement in the treatment process. During the acute phase, he was not provided with any information: Nobody told me anything in the beginning, they did not inform me [. .. ] It happened twice that doctors tore off [the bandage] and said "tomorrow I will perform surgery", but without it happening. .. and you get uncertain, when there is a professional ght going on in which the doctors seemingly disagree with each other.
Ulf experienced that his injury was more important to the doctors than he was, as he felt that the physicians were almost exclusively focused on the complicated fractures and challenging surgery. This made it di cult for him to participate in the treatment process.
A few participants experienced receiving incorrect information about their injuries. André provides an example: I felt that there was poor information along the way. .. rst, I heard that I had one fracture in my ankle, then I heard that there were two. .. and then one again. .. and the day that I got discharged from the hospital. .. then I was informed that I had had a fracture in my neck. .. and that was the rst time that I had heard of that.
André felt that his physical health was in jeopardy and he worried that the severity of the neck fracture had worsened during the period that he was unaware of it. Repeated incidents of incorrect information also compelled André to question the competence of the health care system in general.

Experience with opioids
Most of the participants were opioid-naïve before the injury, and their experiences of opioid effects were diverse and new. Opioids were experienced positively during hospitalization because of the considerable pain relief that they provided. Some participants described the opioid side effects as an experience of being heavily sedated by alcohol or illicit substances. Additionally, some described the opioids as generating feelings of well-being, calm, somnolence, and relaxation. Several participants expressed that the sense of well-being was so desirable that it was easy to understand why opioids are so addictive. When Henning was asked how he felt when he was given opioids, he responded: Lethargic, relaxed, and intoxicated. .. I clearly felt like that when I was taking painkillers. .. Right away, I felt that these [opioids] were addictive. .. I felt that it was totally okay to be bedridden for a few weeks as long as I could feel intoxicated like that.
Henning sustained multiple rib fractures. Besides, he had an upper extremity fracture that caused extreme pain and immobilized him. To him, the feeling of being high on opioids made the severe trauma and its effects bearable. Early in the acute phase, he understood that he would be immobilized for weeks. Hence, he allowed himself to lie in bed and enjoy the feeling of being high. He compared the feeling to being in a bubble in which he felt absent and "comfortably numb". On the other hand, Henning had mixed emotions about taking opioids. He knew that the analgesic effect was necessary and he enjoyed the pleasurable effect, but still, he wanted to stop using opioids because he understood that the enjoyable feeling could produce a desire to continue taking them.
The participants' negative experiences with opioids during the hospitalization period were related to negative side effects. Almost all of the participants experienced side effects, including, most commonly, constipation, nausea, reduced respiratory rate, and dizziness. Fred described having experienced severe side effects, including visual and auditory hallucinations, paranoid symptoms, and psychedelic nightmares, which he interpreted as symptoms of having acquired a severe mental illness: It was absolutely awful. I have never been so scared in my entire life. .. I did not dare to sleep because I felt that they were doing something to me. .. because they were attaching things to me and giving me electric shocks. .. It was terrible because I did not know. .. no one told me what they were doing to me. .. I was so incredibly scared.
Fred suffered paranoid symptoms and therefore neither trusted the hospital staff nor informed them about his experiences, resulting in what he described as a traumatic experience that continued after discharge. He had not been informed about this rare opioid side effect, and none of the health professionals at the trauma hospital had asked him how he was feeling. He associated opioid use with paranoid symptoms, hallucinations, and anxiety. Although he suffered severe pain, he refused to take oxycodone and tramadol because he was terri ed of returning to mental trauma. Subsequently, Fred struggled to understand why he had suffered hallucinations, paranoid symptoms, and severe nightmares.
A few participants also related feelings of shame to opioid use. This shame was triggered by memory loss and episodes during which the participants had experienced a lack of control. Fred, for example, vaguely recalled an episode in which he had misbehaved towards the nurses in the PACU. He remembered standing in bed, screaming, and then being yelled at and told that his behavior was unacceptable. He described feeling embarrassed and like he owed the nurses an excuse for his behavior.
However, no one talked to him about the episode afterward.

Unmet needs for information about opioid use
Almost all of the participants experienced that the health professionals who administered their opioid treatment did not provide information about side effects, addiction, or tapering. A few participants said that they did not expect information about opioids because they were already aware of the potentially harmful effects. Also, some said that information was easily accessible on the package lea et. Others were surprised that health professionals administered strong, addictive medications without providing further information. Helge explained: I can´t remember that they gave me information like "these are strongly addictive and you need to quit as soon as possible". .. I have never been told that. .. I have been told that "if you have pain you should take pills because you´re not supposed to be in pain." Helge associated opioids with illicit substances and was aware of the risk of dependence. He preferred to withhold parts of his daily dose and feel pain rather than take what he regarded as unnecessary dosages.
David provides another example of how physicians failed to give vital information about opioids. He explained how his experience at discharge affected him and his wife in the days that followed: I was given 100 tablets (paracetamol + codeine), 4 (grams) per day. .. that was the message I got. .. nothing about the dangers or anything. I was a bit frightened by that. .. my wife was sitting here reading about everything and she was the one who mentioned it. .. in the drug lea et it said that the recommended dose was maximum 3 grams per day. .. and I got 4 (laughs). .. and she saw that my eyes were starting to turn yellow. .. then [. .. ] I did not want to do this anymore.
David and his wife experienced that they had to obtain information about opioids themselves. To them, David's physical health appeared to have been jeopardized by the health professionals who had not provided them with appropriate information.

Tapering of opioids
At the time of discharge from either the trauma or local hospital, nine participants lacked a plan for tapering off opioids. The four participants who had a tapering plan had received it from physicians at the local hospital or rehabilitation clinic, implying that physicians at the trauma hospital did not discharge any of the participants with a plan for or information about tapering off opioids. At the time of the interview, seven participants were taking opioids, but in lower doses than those that were prescribed upon discharge from the trauma hospital.
Following discharge, the participants who lacked a tapering plan sought information from other sources, and several reported that the Internet was their primary source of information. They felt responsible for starting the process of tapering, but described this as a challenging process during which they experimented according to what they thought was best for them, but while feeling insecure. Fred provides an example: It is something that I´m experimenting with. .. nobody has said anything to me. .. the only thing the doctor said was "don´t take more pills than it says on the medicine package" [. .. ] I´m just experimenting because I know I need to stop taking them. .. but I don't think I will get addicted, I don't think so. . .
Despite lacking a tapering plan, most participants had started to taper on their own. Different strategies were used; some stopped abruptly or tapered over the course of a few days while others tapered over an extended period. Some participants wanted to stop using opioids because they felt disappointed that they were still taking them. Some were also motivated to start taping due to assumptions that opioids are physically harmful. These assumptions were informed by the Internet and television. Some participants tapered even though they were still in pain, as they felt better tolerating the pain than being on opioids. A range of non-pharmacological pain management strategies were also engaged, including most prominently relaxation and diversionary activities.
Several of the participants developed symptoms of tolerance. Even after short-term use, they experienced that they needed more opioids to achieve the same level of pain relief. They perceived this as concerning and as supporting their understandings of opioids as powerfully addictive agents. A few participants experienced severe withdrawal symptoms. Henning, for example, suffered from a chronic condition and had previously been prescribed large quantities and high doses of benzodiazepines. He described his prior, pre-injury experiences with tapering as awful. Henning decided to withdraw completely four weeks after the traumatic injury, he explained: When I was in that phase and decided that now I just have to quit everything [. .. ] then I started to taper and it was ve days of pure hell. I understand why people become addicted and, like, start with heroin or other things, because I was lying in bed cold sweating in pain. .. I rarely cry, but, at that time, I was crying three nights in a row.
Henning was the only participant who planned to taper in cooperation with his GP. He knew that the period of withdrawal would be physically and mentally demanding, and that managing it together with his GP would help him to feel safeguarded and supported.

Lack of follow-up
For most participants, hospital discharge marked the end of a period of constant care and the beginning of a new period in which they and, in some cases, their next of kin had to assume care responsibilities themselves. Most participants received minimal amount of information about the follow-up possibilities from the trauma hospital, which led participants feel insecure about the injury recovery process several weeks after discharge. More than half of the study participants had not been in contact with their GP after discharge. For those who had, the GP was described as having been well informed about the injury, but themes such as mental health, pain experiences, opioid use, and the importance of tapering were not typically focal points. Moreover, most participants did not have access to specialists at the trauma care hospital during the one-to-two month post-discharge period, so their needs for information could not be directed there.
For some, the post-discharge period was more challenging than expected, as pain and limited physical functionality made activities of daily life problematic. Still, the main difference was the absence of health care and the lack of access to health professionals. Helge had suffered complicated injuries and required constant care during the rst weeks of his admission at the trauma hospital, which he described as having made him feel important and safeguarded. For him, returning home was challenging, and he expected but did not receive comprehensive follow-up: But if a doctor who had access to my medical record had called and asked me some questions. .. if he had just read through the whole medical record and then naturally made some thoughts about what to ask me [. .. ] I think it is a little strange that no follow-up was planned. .. But I do not know, when I have been home for three days, why no doctor has called.
Prior to his injury, Helge had not been to his GP for twenty years. Following his injury, he did not understand why he would arrange to see his GP. Because no one had informed him of what follow-up he could expect after discharge from the local hospital, there was a considerable discrepancy between that which he expected and that which he received.
Henning lacked con dence about his ability to manage his injury during the recovery period, which he related to a lack of information about what exercises he could do and a fear of aggravating the injury by pushing himself too far. As he explained: [Trauma patients] could get some simple guidelines that are kind of reassuring. .. a list of what´s perfectly normal with broken ribs. .. that you feel uncomfortable with sudden movements. .. as simple as that. .. like a guideline for dummies, so that you don't have to Google stuff to be reassured in a way.
As described, Henning experienced an uncomfortable role shift. At the hospital, information was easily accessible, he could ask questions, and he felt safe and cared for. At home, he had to seek out information actively, and he did not know who to approach when he was insecure and needed informed reassurances regarding his recovery status, functionality, and treatment plan.
Feeling insecure about post-discharge recovery Several weeks after discharge from the trauma hospital, many participants felt insecure about the injury recovery process. At the trauma hospital, most participants had received information about the expected long-term outcome of the orthopedic injury, but little or no information about what to expect during the different phases of the recovery process. Stein provides an example. He felt well informed by health professionals, but he did not want detailed information about his injury or elaborate explanations of the surgical intervention. Still, when he was asked if anyone at the hospital had talked to him about his expected physical functioning after discharge, he said: Nothing, that especially was something I missed [. .. ] How long it will take before I can get rid of the crutches and go back to normal, no one has said anything to me, so I have no idea. .. I imagine that I heard six to eight weeks on crutches so I imagine that I can start walking a bit then. .. I know nothing.
To him, not knowing what to expect during the recovery process made it di cult to know what he could reasonably anticipate with respect to daily and weekly physical improvements, resulting in a more passive lifestyle. Godtfred, on the other hand, was highly motivated to exercise every day, as he believed in the positive effect of an active lifestyle through the recovery process. Still, he felt uncertain about whether his physical status and experience of pain was within the normal range, because he did not know what to expect. He explained: My leg is worse than I expected, but again now I am on the seventh week so I do not know. .. is this. .. am I within the normal range? I really don't have a clue. .. I think that I have adjusted quite well, but it all comes down to not knowing how far you should have come, where in the process you are.

Discussion
In this study, we included accidental trauma patients with injuries known to be associated with severe pain. We explored experiences with pre-and post-discharge trauma care. Results show that the participants experienced discharge from the trauma hospital as a transition into feeling unsafe and insecure. Concerning pain management with opioids, the participants reported that they were discharged without tapering plans and with unmet information and treatment needs. This affected their physical, mental, and social wellbeing.

Opioids and side effects
Almost all of the participants were opioid-naïve before the traumatic injury. They were given opioids while hospitalized and they described diverse physical and mental side effects, particularly in the acute phase. At least one had experienced frightening hallucinations that were understood as opioid-induced. None of the participants reported having received information about side effects, and several were unaware that the symptoms that they experienced were known or typical side effects of opioids; thus, they did not inform the hospital staff. Nearly 80% of patients who use opioids experience at least one side effect (37,38), particularly in the acute phase (39). Approximately 25% of opioid-naïve individuals experience cognitive impairment (40). This and the emotional distress that is related to the injury may affect cognitive function (11). Therefore, patients may not be able to su ciently process and remember information given about opioid use and trauma, particularly in the acute phase.

Lack of a tapering plan
All of the study participants were discharged with opioid prescriptions as part of their pain management treatment plans. The vast majority did not recall having received information about the addictive nature of opioids, the risk of withdrawal symptoms, or the need for a tapering plan. According to the literature, more than half of trauma patients receive an opioid prescription upon hospital discharge (19,41). This may already introduce a risk of dependence, because opioid tolerance can develop within only a few weeks of continued use (42). Nevertheless, the study participants experienced that their trauma care was predominantly discontinued upon discharge. Those without tapering plans sought information on the Internet and experimented with dosage reduction due to a fear of developing dependence. Some of the participants also felt that their opioids might serve functions other than pain relief, such as a 'time-out' from a di cult life situation and temporary relief from symptoms of depression. Studies have shown that patients with chronic non-cancer pain and depression are more likely than those without depression to use opioids to alleviate symptoms that are not pain-related (43). Additionally, Helmerhorst and colleagues found that patients who continued using opioids one to two months after musculoskeletal trauma had higher pain scores, more psychological distress, and more disability than those who discontinued opioid treatment (44). Moreover, lack of pain management information and unclear discharge materials have previously been identi ed as a barrier to using analgesic regimens as prescribed (45). Furthermore, chronic pain is correlated with depression (46).

Mental health problems related to the injury
The participants commonly reported psychological reactions and emotional distress as a consequence of their traumas, including feeling depressed. This nding is consistent with previous studies showing that survivors of trauma have an increased risk of developing mental health problems (11,21,47,48). Studies have shown that trauma patients have increased risk for developing PTSD and associated comorbid conditions, such as anxiety and depression (10)(11)(12)(13). It has also been shown that 25% of trauma patients were diagnosed with a mood or anxiety disorder during the rst three years post-injury (49). At the same time, there is existing evidence that a mental health diagnosis may heighten the risk of opioid misuse (43). Life-threatening experiences have been identi ed as a predictor of psychological reactions and PTSD (50), thus underscoring the need for health professionals to inform patients of this possibility and map psychological responses at an early phase. While admitted to the hospital, only a minority of the participants received information about common psychological reactions to trauma and offered a psychiatric consultation. At discharge, physicians did not map pre-existing mental disorder or present mental health status, nor did they provide information about how to proceed and seek help if psychological challenges should follow. This nding is of signi cant concern, as studies have shown that, even years after the injury, trauma survivors have a heightened risk of hospital admission because of mental health concerns, as well as elevated suicide rates (51). Furthermore, the literature clearly emphasizes the importance of offering mental health resources to survivors after physical trauma (11, transitions from trauma hospitals to primary care are an essential goal in trauma care. To achieve this, the revision of the "National trauma plan -trauma systems in Norway" includes recommendations for trauma patients to receive an individual plan of follow-up and further rehabilitation when discharged to primary care in the municipality (61). Although our sample is small, our ndings indicate that these recommendations are far from ful lled in today's practice.

Strengths And Limitations
This study generates new and detailed insight into patient experiences with pre-and post-discharge trauma care. A notable strength of this study is the heterogeneity of the participant sample, with respect to background, age, and injury type and severity. Limitations include the low number of participants and their recruitment from a single hospital. Because the inclusion criteria were narrow, the ndings may not re ect the experiences of trauma patients with non-orthopedic injuries. The ndings from this study cannot be generalized in a statistical sense. Instead, they should be recognized as an essential contribution to a more nuanced understanding of trauma patients' experiences with unintentional injury, trauma care, and opioids. The participants were interviewed a short time after discharge from the hospital, which reduces the risk of recall bias. However, it is possible that the accuracy and volume of particular memories were compromised by the effect of opioids and sedatives. Also, it is possible that the hallucinations, paranoia, and derealization that the participants had interpreted as opioid-induced were caused by other factors, such as delirium and side effects or discontinued use of other medications.

Clinical Implications
Our ndings point toward some critical implications for clinicians. First, there is a need to identify preinjury and injury-related mental health problems to enable referral to specialized or interdisciplinary care.
Second, health professionals need to provide information about the injury, common psychological reactions to accidental trauma, treatment options, pain management, and opioid use based on patient needs and comprehension. Verbal information may be reinforced with written guidelines and postdischarge access to a health professional at the trauma hospital. Third, individually tailored plans for follow-up care in the municipalities should be integrated into trauma care. By establishing trauma outpatient clinics for routine consultation and follow-up, the ability to detect post-discharge challenges could be enhanced (11).

Conclusion
Based on patient experiences one to two months after discharge, our ndings indicate that the primary focus of health professionals at the trauma hospital seems to be the delivery of high-quality biomedical treatment for inpatients, and that more attention should be directed to psychosocial health and safe pain management, including post-discharge opioid tapering plans.

Declarations
Ethics approval and consent The Regional Committee for Medical and Health Research Ethics approved this study (2018/2477). Approval was also obtained from the Data Protection O cer at OUH (P360 nr.19/0175). Independent nurses made the initial contact with the potential participants, after which the researcher provided information about the study and invited those who were eligible to participate. Recruitment was approached in this manner in the interest of ensuring that eligible patients would not be in uenced to participate. All participants provided voluntary and written informed consent. Patients with severe head injuries and impaired cognitive function, as well as those who were for any other reason considered unable to consent, were excluded. Participants were offered additional consultations with health professionals and referrals to treatment providers, if desired. In addition to the formal requirements, an emphasis was placed on ensuring anonymity throughout the publication process. Pseudonyms have been used for all participants.

Consent for publication
Not applicable Availability of data and materials Not applicable

Competing interests
The authors declare that they have no competing interests Funding This was an unfunded study Authors contributions LAR and OR had the original idea for the study. All authors contributed to the nal design. JF performed the interviews, and JF and IH coded the transcripts of the interviews. JF and IH conducted the analysis with support and discussion with LAR, OR and TC. JF and IH took the lead in writing the rst draft of the manuscript. All authors provided critical feedback and contributed in further drafts and approved the nal manuscript for submission.