Can a novel Pharmacist independent prescriber/third sector homeless charity outreach intervention help prevent overdose in people experiencing homelessness (PEH)?

Problem

Scotland has the highest rate of drug-related deaths (DRDs) in Europe despite innovative strategies to counter this. A clear link between DRDs and PEH is apparent. PEH typically present with complex multi-morbidities and social challenges that are traditionally difficult to manage. PEH also have complex problems including childhood sexual trauma/violence and chaotic polysubstance misuse. A new approach to tackling these multiple needs is required to improve outcomes for Scotland’s most destitute citizens.We describe:- comprehensive physical health, mental health, problem substance use, quality of life, health care contacts, prescribing, and physiological measures of PEH who have had at least one non-fatal overdose in the previous six months; and - methods of an ongoing pilot randomised controlled trial in Glasgow.

Approach

Prospective pilot randomised controlled trial of the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx (PHOENIx) intervention, involving NHS Pharmacist independent prescribers working with third sector workers assessing, treating and referring PEH on outreach while offering help with social problems. Funded by Scottish Drug Deaths taskforce to ascertain any differences between PEH in intervention and usual care at 6 and 9 months. Baseline data were collected during face-to-face interviews within low threshold accommodation and includes an assessment of health and addictions, housing, benefits, treatment burden. Additional data were gathered from hospital and community systems to ascertain attendance at Emergency Department(ED), GP and addictions services. Participants were then randomised to PHOENIx or usual care. The approach also includes embedded qualitative and economic analyses.

Findings

One hundred and twenty eight participants were recruited as planned, via assertive outreach. Ninety-one (71.1%) are male, mean age 42.8(SD8.4) years. Median duration of homelessness 23.5(12–19.8) years. Forty-six (35.9%) participants reside in unsupported hostel accommodation. Most participants have 8 or more long term health conditions, the most common being seizures (98;76.5%) and blood borne viruses (50;39.0%). Fifty-eight (45.3%) participants had been recently assaulted and 24(18.8%) feel unsafe. Fourteen participants (11.2%) had 6-10 overdoses prior to recruitment. Forty-six participants (36.0%) reported “street Valium” as the main cause of overdose; 102(82.0%) participants presented at ED and 89(69.5%) had at least 1 hospital admission. Sixty two (48.4%) participants were allocated to weekly PHOENIx outreach for 6 months and 66 (51.6%) remained in usual care.

Consequences

These baseline data together with follow-up results will inform progression to a definitive RCT. Six and 9 month follow up data will be available in the second and third quarter of 2022. The generalisable PHOENIx intervention may show a signal of improvement in drug related deaths and other outcomes, which is long overdue and much needed.