Understanding and learning from rural drug service adaptations to opioid substitution therapy during the COVID-19 pandemic: the What C-OST? study.

Introduction: In April 2020, in response to government COVID-19 advice, changes were made to the way English drug services operated. Methadone and buprenorphine were typically dispensed in 1- to 2-week supplies, and key working was conducted by phone/online. Previous studies have examined the impact of these changes on people from urban settings. This study adds the experiences and perspectives of people receiving care from drug services in rural areas and makes suggestions for future emergency planning. Methods: Telephone semi-structured interviews were conducted with 15 people receiving care in Somerset, Wiltshire, and Suffolk, rural counties in England. Reflexive thematic analysis was used. Results: Three overarching themes were found. "Challenges of rural lockdown" (theme 1) describes how rural community challenges, especially reduced or no rural public transport, were experienced. This hampered some OST collections, with consequential drug use. It also impeded connections to loved ones, worsening isolation. For participants who were struggling pre-pandemic, the intersection between this and their experience of revised drug service operations is embodied in "Amplification of Social Disconnection: Cut off and unheard" (theme 2). They felt a lack of support, particularly from remote provision key working. Participants who had supportive relationships and time in the pandemic occupied in ways they found meaningful, and others who struggled with anxiety or depression, found pandemic changes "Fits better with my life" (theme 3). They experienced more freedom for other things, gained support by other means, such as family, or felt more comfortable with remote engagement. A cross-cutting sub-theme "Understandable Interruptions" showed acceptance of pandemic disruptions. Conclusion: National guidance and organizational policy impacted participants in different ways. Those who had supportive relationships and occupied time were better able to make positive use of newfound freedoms and engage with community-level support. In contrast, those who had less stability, including mental health struggles and social isolation, felt cut off and unheard, particularly from key workers. Reduced rural transport was a significant community-level issue, which impeded OST collection and social support. We suggest emergency response plans be created for individuals taking account of their pre-existing personal situations.

Detachable low dead space syringes for the prevention of hepatitis C among people who inject drugs in Bristol, UK: an economic evaluation.

BACKGROUND AND AIMS: Traditional detachable syringes used by people who inject drugs (PWID) retain larger volumes of blood when the plunger is depressed than syringes with fixed needles-referred to as high (HDSS) and low dead space syringes (LDSS), respectively. Evidence suggests that using HDSS may result in greater hepatitis C virus (HCV) transmission risk than LDSS. We evaluated the cost-effectiveness of an intervention to introduce detachable LDSS in a needle and syringe programme (NSP). DESIGN: HCV transmission and disease progression model with cost-effectiveness analysis using a health-care perspective. Detachable LDSS are associated with increased costs (£0.008) per syringe, yearly staff training costs (£536) and an estimated decreased risk (by 47.5%) of HCV transmission compared with HDSS. The intervention was modelled for 10 years, with costs and health benefits (quality-adjusted life-years: QALYs) tracked over 50 years. SETTING: Bristol, UK. PARTICIPANTS AND CASES: PWID attending NSP. INTERVENTION AND COMPARATOR: Gradual replacement of HDSS at NSP, with 8, 58 and 95% of HDSS being replaced by detachable LDSS in 2016, 2017 and 2018, respectively. Comparator was continuing use of HDSS. MEASUREMENTS: Net monetary benefit. Benefits were measured in QALYs. FINDINGS: Introducing detachable LDSS was associated with a small increase in intervention costs (£21 717) compared with not introducing detachable LDSS, but considerable savings in HCV-related treatment and care costs (£4 138 118). Overall cost savings were £4 116 401 over 50 years and QALY gains were 1000, with an estimated 30% reduction in new infections over the 10-year intervention period. In all sensitivity analyses, detachable LDSS resulted in cost savings and additional QALYs. Threshold analyses suggested that detachable LDSS would need to reduce HCV transmission risk of HDSS by 0.26% to be cost-saving and 0.04% to be cost-effective. CONCLUSIONS: Replacing high dead space syringes with detachable low dead space syringes in needle and syringe programmes in the United Kingdom is likely to be a cost-saving approach for reducing hepatitis C virus transmission.

The Antibiotic Guardian campaign: a qualitative evaluation of an online pledge-based system focused on making better use of antibiotics.

BACKGROUND: The Antibiotic Guardian Campaign was developed to increase commitment to reducing Antimicrobial Resistance (AMR), change behaviour and increase knowledge through an online pledge system for healthcare professionals and members of the public to become Antibiotic Guardians (AG). This qualitative evaluation aimed to understand AG experiences of the campaign and perceived impact on behaviour. METHODS: Ninety-four AGs (48 via a survey and 46 who had agreed to future contact) were invited to participate in a telephone semi-structured interview. The sample was based on self-identification as a healthcare professional or a member of the public, pledge group (e.g. adults, primary care prescribers etc.), pledge and gender. Interviews explored how participants became aware of the campaign, reasons for joining, pledge choices, responses to joining and views about the campaign's implementation. Interviews were analysed using the Framework Method. RESULTS: Twenty-two AGs (10 healthcare professionals and 12 members of the public) were interviewed. AGs became aware of the campaign through professional networks and social media, and were motivated to join by personal and professional concern for AMR. Choice of pledge group and pledge were attributed to relevance and potential impact on AMR and the behaviour of others through pledge enactment and promotion of the campaign. Most AGs could not recall their pledge unprompted. Most felt they fulfilled their pledge, although this reflected either behaviour change or the pledge reinforcing pre-existing behaviour. The campaign triggered AGs to reflect on AMR related behaviour and reinforced pre-existing beliefs. Several AGs promoted the campaign to others. Responding collectively as part of the campaign was thought to have a greater impact than individual action. However, limited campaign visibility was observed and the campaign was perceived to have restricted ability to reach those unaware of AMR. CONCLUSIONS: AGs were motivated to reduce AMR and most felt they fulfilled their pledges although for many this appeared to be through reinforcement of existing behaviours. We recommend that the campaign engages those without pre-existing knowledge of AMR by increasing its visibility, capitalising on the diffusion of its message and including more awareness-raising content for those with limited AMR knowledge.