RESUMEN
BACKGROUND: Deaths due to drug overdose are an international issue, causing an estimated 128,000 global deaths in 2019. Scotland has the highest rate of drug-related deaths in Europe, with those in the most deprived areas at greater risk than those in affluent areas. There is a paucity of research on digital solutions, particularly from the perspective of those who use drugs who additionally access harm reduction and homelessness support services. The Digital Lifelines Scotland programme (DLS) provides vulnerable people who use/d drugs with digital devices to connect with services. METHODS: This paper reports on the evaluation of the DLS from the perspective of service users who accessed services for those at risk of drug-related harms. A mixed methods approach was used including an online-survey (n = 19) and semi-structured interviews (n = 21). Survey data were analysed descriptively and interview data through inductive coding, informed by the Technology, People, Organisations and Macroenvironmental factors (TPOM) framework, to investigate the use, access, and availability of devices, and people's experiences and perceptions of them. RESULTS: Most participants lived in social/council housing (63.2%, n = 12), many lived alone (68.4%, n = 13). They were mainly over 40 years old and lived in a city. Participants described a desire for data privacy, knowledge, and education, and placed a nascent social and personal value on digital devices. Participants pointed to the person-centred individuality of the service provision as one of the reasons to routinely engage with services. Service users experienced an increased sense of value and there was a palpable sense of community, connection and belonging developed through the programme, including interaction with services and devices. CONCLUSIONS: This paper presents a unique perspective which documents the experiences of service users on the DLS. Participants illustrated a desire for life improvement and a collective and individual feeling of responsibility towards themselves and digital devices. Digital inclusion has the potential to provide avenues by which service users can safely and constructively access services and society to improve outcomes. This paper provides a foundation to further cultivate the insight of service users on digital solutions in this emerging area.
Asunto(s)
Tecnología Digital , Reducción del Daño , Humanos , Escocia , Femenino , Masculino , Adulto , Persona de Mediana Edad , Sobredosis de Droga/prevención & control , Consumidores de Drogas/psicología , Adulto Joven , Personas con Mala Vivienda , Trastornos Relacionados con Sustancias , Encuestas y CuestionariosRESUMEN
BACKGROUND: Buvidal is the only depot buprenorphine currently available in Europe. Buvidal offers a new treatment paradigm, which may require some adjustment in the national regulatory frameworks for opioid agonist treatments (OATs), as well as the national care systems. RESEARCH DESIGN AND METHODS: Data on the national dissemination of Buvidal, types of populations treated, and the national regulatory framework and care organization system through which Buvidal has been implemented were compared between the UK, Finland, Spain, and France, using a qualitative survey. RESULTS: In 2022, the proportion of people on OAT who received Buvidal was 2.1% in the UK, 60-65% in Finland, 1% in Spain, and 0.3% in France. In both Finland and the UK, the cost of the medication is covered by the national health system, whereas, in Spain and France, Buvidal is accessible only in specialized centers, which must carry its cost. Other national features may explain the gaps in Buvidal use, including the baseline level of OAT coverage, which was high in both France and Spain. CONCLUSIONS: Important national discrepancies are found regarding Buvidal dissemination among people on OAT.
Asunto(s)
Analgésicos Opioides , Buprenorfina , Preparaciones de Acción Retardada , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides , Buprenorfina/administración & dosificación , Buprenorfina/uso terapéutico , Buprenorfina/economía , Humanos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Tratamiento de Sustitución de Opiáceos/métodos , Tratamiento de Sustitución de Opiáceos/economía , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Europa (Continente) , Encuestas y CuestionariosRESUMEN
OBJECTIVE: To investigate the association between opioid replacement therapy (ORT) and benzodiazepine (BZD) coprescription and all-cause mortality compared with the prescription of ORT alone. DESIGN: Population-based cohort study. SETTING: Scotland, UK. PARTICIPANTS: Participants were people prescribed ORT between January 2010 and end of December 2020 aged 18 years or above. MAIN OUTCOME MEASURES: All-cause mortality, drug-related deaths and non-drug related deaths. SECONDARY OUTCOME: ORT continuous treatment duration. ANALYSIS: Cox regression with time-varying covariates. RESULTS: During follow-up, 5776 of 46 899 participants died: 1398 while on coprescription and 4378 while on ORT only. The mortality per 100 person years was 3.11 during coprescription and 2.34 on ORT only. The adjusted HR for all-cause mortality was 1.17 (1.10 to 1.24). The adjusted HR for drug-related death was 1.14 (95% CI, 1.04 to 1.24) and the hazard for death not classified as drug-related was 1.19 (95% CI, 1.09 to 1.30). CONCLUSION: Coprescription of BZDs in ORT was associated with an increased risk of all-cause mortality, although with a small effect size than the international literature. Coprescribing was also associated with longer retention in treatment. Risk from BZD coprescription needs to be balanced against the risk from illicit BZDs and unplanned treatment discontinuation. A randomised controlled trial is urgently needed to provide a clear clinical direction. TRIAL REGISTRATION NUMBER: NCT04622995.
Asunto(s)
Benzodiazepinas , Tratamiento de Sustitución de Opiáceos , Humanos , Analgésicos Opioides/efectos adversos , Benzodiazepinas/efectos adversos , Estudios de Cohortes , Estudios Retrospectivos , Escocia/epidemiología , AdultoRESUMEN
BACKGROUND: Scotland has the highest rate of drug related deaths (DRD) in Europe. These are deaths in people who use drugs such as heroin, cocaine, benzodiazepines and gabapentinoids. It is a feature of deaths in Scotland that people use combinations of drugs which increases the chance of a DRD. Many deaths involve 'street' benzodiazepines, especially a drug called etizolam. Many of the 'street' benzodiazepines are not licensed in the UK so come from illegal sources. People who use opiates can be prescribed a safer replacement medication (e.g., methadone). While guidance on management of benzodiazepines use highlights that there is little evidence to support replacement prescribing, practice and evidence are emerging. AIM: To develop an intervention to address 'street' benzodiazepines use in people who also use opiates. METHODS: The MRC Framework for Complex Interventions was used to inform research design. Co-production of the intervention was achieved through three online workshops with clinicians, academics working in the area of substance use, and people with lived experience (PWLE). Each workshop was followed by a PWLE group meeting. Outputs from workshops were discussed and refined by the PWLE group and then further explored at the next workshop. RESULTS: After these six sessions, a finalised logic model for the intervention was successfully achieved that was acceptable to clinicians and PWLE. Key components of the intervention were: prescribing of diazepam; anxiety management, sleep, and pain; and harm reduction resources (locked box and a range of tips), personal safety conversations, as well as a virtual learning environment. CONCLUSION: A co-produced intervention was developed for next stage clinical feasibility testing.
Asunto(s)
Alcaloides Opiáceos , Trastornos Relacionados con Sustancias , Humanos , Trastornos Relacionados con Sustancias/tratamiento farmacológico , Hipnóticos y Sedantes/uso terapéutico , Benzodiazepinas/uso terapéutico , Escocia/epidemiologíaRESUMEN
There have been increases in prescriptions of high strength opioids for chronic non-cancer pain (CNCP), but CNCP patients perceive themselves as being at low risk of opioid overdose and generally have limited overdose awareness. This study examined how an overdose prevention intervention (opioid safety education, naloxone training, and take-home naloxone (THN)) delivered by community pharmacists for patients prescribed high-strength opioids for CNCP would work in practice in Scotland. Twelve patients received the intervention. CNCP patients and Community Pharmacists were interviewed about their experiences of the intervention and perceptions of its acceptability and feasibility. CNCP patients did not initially perceive themselves as being at risk of overdose but, through the intervention, developed insight into opioid-related risk and the value of naloxone. Pharmacists also identified patients' low risk perceptions and low overdose awareness. While pharmacists had positive attitudes towards the intervention, they outlined challenges in delivering it under time and resource pressures and during the COVID-19 pandemic. Overdose prevention interventions are required in the CNCP population as this group has elevated risk factors for overdose but are commonly overlooked. Customised overdose prevention interventions for CNCP patients attend to gaps in overdose awareness and risk perceptions in this population.
RESUMEN
AIM: This developmental study tested the feasibility of training pharmacy staff on the psychologically informed environments (PIE) approach to improve the delivery of care. BACKGROUND: Community pharmacies provide key services to people who use drugs (PWUD) through needle exchange services, medication-assisted treatment and naloxone distribution. PWUD often have trauma backgrounds, and an approach that has been demonstrated to work well in the homeless sector is PIEs. METHODS: Bespoke training was provided by clinical psychologists and assessed by questionnaire. Staff interviews explored changes made following PIE training to adapt the delivery of care. Changes in attitude of staff following training were assessed by questionnaire. Peer researchers interviewed patient/client on observed changes and experiences in participating pharmacies. Staff interviews were conducted six months after training to determine what changes, if any, staff had implemented. Normalisation process theory (NPT) provided a framework for assessing change. FINDINGS: Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rated training structure and delivery as 'very good' or 'excellent'. There was no statistically significant change in attitudes. COVID-19 lockdowns restricted follow-up data collection. Staff interviews revealed training had encouraged staff to reflect on their practice and communication and consider potentially discriminatory practice. PIE informed communication skills were applied to manage COVID-19 changes. Staff across pharmacies noted mental health challenges for patients. Five patients were interviewed but COVID-19 delays in data collection meant changes in delivery of care were difficult to recall. However, they did reflect on interactions with pharmacy staff generally. Across staff and patient interviews, there was possible conflation of practice changes due to COVID-19 and the training. However, the study found that training pharmacy teams in PIE was feasible, well received, and further development is recommended. There was evidence of the four NPT domains to support change (coherence, cognitive participation, collective action and reflexive monitoring).
Asunto(s)
COVID-19 , Servicios Comunitarios de Farmacia , Farmacias , Humanos , Estudios de Factibilidad , Control de Enfermedades Transmisibles , Encuestas y Cuestionarios , Escocia , Farmacéuticos/psicologíaRESUMEN
BACKGROUND: Opioids were implicated in approximately 88,000 fatal overdoses (OD) globally. However, in principle all opioid OD are reversible with the timely administration of naloxone hydrochloride. Despite the widespread availability of naloxone among people who use opioids (PWUO), many who suffer fatal OD use alone, without others present to administer the reversal agent. Recognising this key aspect of the challenge calls for innovations, a number of technological approaches have emerged which aim to connect OD victims with naloxone. However, the acceptability of OD response technologies to PWUO is of key concern. METHODS: Drawing on the Technology People Organisations Macroenvironment (TPOM) framework, this study sought to integrate acceptability-related findings in this space with primary research data from PWUO, affected family members and service providers to understand the factors involved in harm reduction technology acceptability. A qualitative study using a focus group methodology was conducted. The participant groups were people with lived experience of problem opioid use, affected family members and service providers. Data analysis followed a multi-stage approach to thematic analysis and utilised both inductive and deductive methods. RESULTS: Thirty individuals participated in one of six focus groups between November 2021 and September 2022. The analysis generated six major themes, three of which are reported in this article-selected for their close relevance to PWUO and their importance to developers of digital technologies for this group. 'Trust-in technologies, systems and people' was a major theme and was closely linked to data security, privacy and confidentiality. 'Balancing harm reduction, safety and ambivalence' reflects the delicate balance technological solutions must achieve to be acceptable to PWUO. Lastly, 'readiness-a double bind' encapsulates the perception shared across participant groups, that those at the highest risk, may be the least able to engage with interventions. CONCLUSION: Effective digital strategies to prevent fatal OD must be sensitive to the complex relationships between technological, social/human, organisational and wider macroenvironmental factors which can enable or impede intervention delivery. Trust, readiness and performance are central to technology acceptability for PWUO. An augmented TPOM was developed (the TPOM-ODART).
Asunto(s)
Sobredosis de Droga , Trastornos Relacionados con Opioides , Humanos , Analgésicos Opioides/uso terapéutico , Naloxona/uso terapéutico , Trastornos Relacionados con Opioides/tratamiento farmacológico , Sobredosis de Droga/prevención & control , Sobredosis de Droga/tratamiento farmacológico , Tecnología , Antagonistas de Narcóticos/uso terapéuticoRESUMEN
BACKGROUND: Drug overdose deaths, particularly from opioids, are a major global burden, with 128,000 deaths estimated in 2019. Opioid overdoses can be reversed through the timely administration of naloxone but only if responders are able to administer it. There is an emerging body of research and development in technologies that can detect the early signs of an overdose and facilitate timely responses. OBJECTIVE: Our aim was to identify and classify overdose-specific digital technologies being developed, implemented, and evaluated. METHODS: We conducted a "state-of-the-art review." A systematic search was conducted in MEDLINE, Embase, Web of Science, Scopus, ACM, IEEE Xplore, and SciELO. We also searched references from articles and scanned the gray literature. The search included terms related to telehealth and digital technologies, drugs, and overdose and papers published since 2010. We classified our findings by type of technology and its function, year of publication, country of study, study design, and theme. We performed a thematic analysis to classify the papers according to the main subject. RESULTS: Included in the selection were 17 original research papers, 2 proof-of-concept studies, 4 reviews, 3 US government grant registries, and 6 commercial devices that had not been named in peer-reviewed literature. All articles were published between 2017 and 2022, with a marked increase since 2019. All were based in or referred to the United States or Canada and concerned opioid overdose. In total, 39% (9/23) of the papers either evaluated or described devices designed to monitor vital signs and prompt an alert once a certain threshold indicating a potential overdose has been reached. A total of 43% (10/23) of the papers focused on technologies to alert potential responders to overdoses and facilitate response. In total, 48% (11/23) of the papers and 67% (4/6) of the commercial devices described combined alert and response devices. Sensors monitor a range of vital signs, such as oxygen saturation level, respiratory rate, or movement. Response devices are mostly smartphone apps enabling responders to arrive earlier to an overdose site. Closed-loop devices that can detect an overdose through a sensor and automatically administer naloxone without any external intervention are still in the experimental or proof-of-concept phase. The studies were grouped into 4 themes: acceptability (7/23, 30%), efficacy or effectiveness (5/23, 22%), device use and decision-making (3/23, 13%), and description of devices (6/23, 26%). CONCLUSIONS: There has been increasing interest in the research and application of these technologies in recent years. Literature suggests willingness to use these devices by people who use drugs and affected communities. More real-life studies are needed to test the effectiveness of these technologies to adapt them to the different settings and populations that might benefit from them.
Asunto(s)
Sobredosis de Droga , Telemedicina , Humanos , Estados Unidos , Naloxona/uso terapéutico , Analgésicos Opioides/uso terapéutico , TecnologíaRESUMEN
INTRODUCTION: Despite opioid prescribing for chronic non-cancer pain (CNCP) having limited therapeutic benefits, recent evidence indicates significant increases in the prescribing of high-strength opioids for individuals with CNCP. Patients prescribed opioids for CNCP have overdose risk factors but generally have low opioid overdose awareness and low perceptions of risk related to prescribed opioids. Currently, there are few bespoke overdose prevention resources for this group. METHODS: This qualitative study investigated views on a naloxone intervention for people prescribed high-strength opioids for CNCP delivered via community pharmacies. The intervention included overdose risk awareness and naloxone training and provision. Interviews were conducted with eight patients, four family members and two community pharmacists. Participants were convenience sampled and recruited through networks within the Scottish pain community. The Framework approach was used to analyse findings. RESULTS: All participants had positive attitudes towards the intervention, but patients and family members considered risk of overdose to be very low. Three themes were identified: potential advantages of the intervention; potential barriers to the intervention; and additional suggestions and feedback about the intervention. Advantages included the intervention providing essential overdose information for CNCP patients. Barriers included resource and time pressures within community pharmacies. DISCUSSION AND CONCLUSION: While patients had low overdose knowledge and did not see themselves as being at risk of opioid overdose, they were receptive to naloxone use and positive about the proposed intervention. A feasibility trial is merited to further investigate how the intervention would be experienced within community pharmacy settings.
Asunto(s)
Dolor Crónico , Sobredosis de Droga , Sobredosis de Opiáceos , Trastornos Relacionados con Opioides , Farmacias , Humanos , Analgésicos Opioides/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Trastornos Relacionados con Opioides/prevención & control , Trastornos Relacionados con Opioides/tratamiento farmacológico , Sobredosis de Opiáceos/tratamiento farmacológico , Farmacéuticos , Dolor Crónico/tratamiento farmacológico , Pautas de la Práctica en Medicina , Naloxona/uso terapéutico , Sobredosis de Droga/tratamiento farmacológico , Sobredosis de Droga/prevención & controlRESUMEN
The impact of COVID-19 itself and societal responses to it have affected people who use drugs and the illicit drug economy. This paper is part of a project investigating the health impacts of COVID-19 related control measures on people who use drugs in Scotland. It examines their roles and decisions as economically situated actors. It does this within a moral economy perspective that places economic decisions and calculations within a context of the network of social obligations and moral decisions. The paper uses a mixed methods approach, reporting on a drug trend survey and in-depth interviews with people who use drugs. It finds they were affected by restrictions in the drug consumption context and changes in the supply context, both in terms of what was supplied and changes in the relationship between sellers and buyers. Face to face selling became more fraught. Participants in more economically precarious circumstances were faced with dilemmas about whether to move into drug selling. The double impact of loss of income and reduced access to support networks were particularly difficult for them. Despite the perception that the pandemic had increased the power of sellers in relation to their customers, many full-time sellers were reported to be keeping their prices stable in order to maintain their relationships with customers, instead extending credit or adulterating their products. The effect of spatial controls on movement during the pandemic also meant that the digital divide became more apparent. People with good access to digital markets and easy drug delivery through apps were in a better position to manage disruption to drug sales contexts. We make recommendations in relation to how policy can respond to the interests of people who use drugs in a pandemic.
RESUMEN
In Scotland drug policy and consequently the progress of evidence-based treatment options has been struggling for many years. Political inaction is brought about by a complex chain of legal and operational obstructions with local authorities deferring to national Government which in turn is paralysed by international convention. Scotland represents a case study demonstrating the adverse consequences of management by non medical requirements rather than implementation of a clinically proven progressive policy. The difficulty of translating theory and evidence into practice is acknowledged but suggestions are made for pragmatic and humanitarian initiatives.
Asunto(s)
Sobredosis de Droga , Política Pública , Benzodiazepinas , Sobredosis de Droga/prevención & control , Reducción del Daño , Política de Salud , Humanos , Política , EscociaRESUMEN
This commentary piece reviews the paper by Cowden et al. on Characteristics on Non-fatal overdoses.
RESUMEN
INTRODUCTION: People experiencing homelessness often experience intersecting mental and physical health problems, alongside problem substance use and a range of overlapping challenges, including access to appropriate treatment. New long-acting opioid replacement therapies (ORT) offer potential benefits for this group. This study explored the views of people who are homeless and dependent on prescribed or illicit opiates/opioids on the range of ORT delivery options, including long-acting buprenorphine (LAB) depot injection, methadone liquid, and sublingual/wafer buprenorphine. METHODS: The research team conducted three focus groups (n = 9 participants) and individual interviews (n = 20) with people living in Scotland and Wales. We sought to explore participants' experiences and views on a range of ORT options, and to explore experiences and perceptions of the acceptability and utility of LAB for this group. RESULTS: Twenty-nine people participated (8 women, 21 men) and described experiences of poor mental health and interaction with the criminal justice system, including prison. All had experience of ORT and some had a preference for the "comfort" of methadone while others liked the clear headedness of buprenorphine. Participants saw LAB as a valuable addition to the treatment options. Potential benefits included freedom from the challenges associated with daily dispensing and the freedom to be able to attend to their priorities and regain control over their day-to-day lives. LAB naïve participants required reassurance regarding the duration of effect and wanted information and evidence from both their health care providers and their peers. CONCLUSION: Participants generally recognized the potential of LAB. The research team identified crucial themes for those experiencing homelessness: emotions, trust, and time. A move to LAB represents a shift in the locus of control to the individual, which, for some is exciting, but for others is daunting. Providers should address this shift in control, and it must to be central to joint decision-making on whether someone is ready for LAB, the information they require to help them decide, and the support they will require during treatment.
Asunto(s)
Buprenorfina , Personas con Mala Vivienda , Trastornos Relacionados con Opioides , Analgésicos Opioides/uso terapéutico , Buprenorfina/uso terapéutico , Femenino , Humanos , Masculino , Metadona/uso terapéutico , Tratamiento de Sustitución de Opiáceos/psicología , Trastornos Relacionados con Opioides/tratamiento farmacológicoRESUMEN
INTRODUCTION: People who use drugs (PWUD) are considered vulnerable to COVID-19 exposure and the sequelae of infection due to their social circumstances, health conditions, drug purchasing, and substance use. They can depend on access to services that provide harm reduction, substance use treatment, recovery and support, and general healthcare. Social distancing measures and service restrictions posed significant challenges to the health and wellbeing of PWUD. METHODS: Ethical approvals were secured. PWUD were recruited from voluntary sector homeless and housing, harm reduction, and recovery organisations across central Scotland. Data was collected via semi-structured interviews and analysed using the Framework Method. RESULTS: Twenty nine PWUD participated and reported mixed experiences of the impacts of COVID-19 lockdown. Several benefitted from policy and practice developments designed to sustain or increase access to harm reduction services. Some PWUD reported improved access to substitute prescribing and/or appreciated being trusted to manage multiple take-home doses. Others noted the loss of regular in-person contact with treatment providers and dispensers. Access to recovery support was challenging for many, especially those unable to access or uncomfortable with online provision who experienced greater isolation. Lack of access to general healthcare services was common, and especially problematic for PWUD with chronic physical and mental health conditions. CONCLUSIONS: This qualitative research describes the impacts of COVID-19 social and service restrictions on PWUD in Scotland. These impacts were anticipated by policy makers and service providers. Effective and acceptable developments were shown to maintain and even increase service provision for PWUD. Developments were geographically dependent and significant challenges remained for many people. The learning generated can inform responses to increase service access and uptake in post-pandemic times.
Asunto(s)
COVID-19 , Trastornos Relacionados con Sustancias , Control de Enfermedades Transmisibles , Reducción del Daño , Accesibilidad a los Servicios de Salud , Humanos , Investigación Cualitativa , Trastornos Relacionados con Sustancias/terapiaRESUMEN
BACKGROUND: For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues. OBJECTIVES: The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial. DESIGN: A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures. SETTING: The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England. PARTICIPANTS: Participants were people experiencing homelessness and problem substance use (n = 68) (intervention). INTERVENTION: This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support. MAIN OUTCOME MEASURES: Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure. RESULTS: The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies. LIMITATIONS: Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited. CONCLUSIONS: A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention. FUTURE WORK: A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments. TRIAL REGISTRATION: This trial is registered as ISRCTN15900054. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.
People who are homeless have worse physical and mental health, and higher rates of drug/alcohol (substance) use, than the general population. For people experiencing these challenges, completely stopping the use of substances can be difficult. Harm reduction services can be useful in reducing risks. Approaches delivered by people who have had similar experiences (peers) are also promising. Some research has highlighted the importance of trusting relationships with service staff. More research is needed on how all of these should work with people who are homeless and who use substances. This study consisted of four 'Peer Navigators' providing practical and emotional support to a group of people who are homeless and use substances to help improve their quality of life and health. The Peer Navigators had similar past experiences. The Peer Navigators were hired, and worked with around 15 'participants' each, for 212 months. They were based in third-sector homelessness residential and outreach services in Scotland and England. The Peer Navigators developed relationships with participants. They worked with (and often accompanied) them to access services, such as substance use treatment, health care, housing and welfare/benefits. The Peer Navigators had access to a small budget to pay for essentials, including food and bus fares. The relationship between the Peer Navigators and participants was most important, so the Peer Navigators spent time getting to know and listening to them. The aim was to understand if this intervention could be delivered to individuals experiencing these challenges. This study was not designed to know if the intervention worked; a larger study is needed for that. Despite some challenges, the participants were able to make positive changes to their lives, and they valued working with their Peer Navigator. The Peer Navigators enjoyed their roles and staff generally supported the intervention. The next step is to conduct more research to assess if this intervention can make a difference.
Asunto(s)
Personas con Mala Vivienda , Trastornos Relacionados con Sustancias , Estudios de Factibilidad , Humanos , Calidad de Vida , Trastornos Relacionados con Sustancias/terapia , Encuestas y CuestionariosRESUMEN
Against a backdrop of high levels of drug related harms in Scotland, this research aimed to inform training development to aid the upskilling of the workforce to support people who use drugs and are involved in transactional sex. Sixteen qualitative interviews were conducted with participants recruited across four health board areas and a range of services covering sexual health and/or harm reduction. Interviews explored initiation, frequency, and the nature of transactional sex; drug use, and experience of services. A thematic analysis was undertaken. Vulnerability was a key emerging theme when discussing drug use, sexual behavior, and service use. Vulnerability increased risk of a range of harms from sexual assault to injecting harms and overdose. Participants were often, but not always, introduced to drugs and transactional sex by someone who had power over them or was more experienced in drug use and/or sex. High risk drug use was evident in terms of polydrug use, consuming large quantities of drugs, sharing crack pipes/injecting equipment. There is a need for information and services to reduce the risk of harm from drugs, sexual violence, and unprotected sex as well as non-judgmental, trauma aware services. The workforce needs to be skilled to recognize and manage these potentially complex syndemics.
Asunto(s)
Infecciones por VIH , Preparaciones Farmacéuticas , Abuso de Sustancias por Vía Intravenosa , Reducción del Daño , Humanos , Conducta Sexual , Abuso de Sustancias por Vía Intravenosa/epidemiología , Sexo InseguroRESUMEN
BACKGROUND: For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that the development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. METHODS: The study used mixed methods to assess the feasibility, acceptability and accessibility of a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning, for people experiencing homelessness and problem substance use. Four Peer Navigators were employed to support individuals (n = 68 total, intervention participants). They were based in outreach services and hostels in Scotland and England. Qualitative interviews were conducted with intervention participants, Peer Navigators and staff in services, and observations were conducted in all settings. Quantitative outcomes relating to participants' substance use, physical and mental health, and quality of the Peer Navigator relationship, were measured via a 'holistic health check' with six questionnaires completed at two time-points. RESULTS: The intervention was found to be acceptable to, and feasible and accessible for, participants, Peer Navigators, and service staff. Participants reported improvements to service engagement, and feeling more equipped to access services independently. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling trusting, authentic, and meaningful relationships to be developed. Some challenges were experienced in relation to the 'fit' of the intervention within some settings. Among participants there were reductions in drug use and risky injecting practices. There were increases in the number of participants receiving opioid substitution therapy. Overall, the intervention was positively received, with collective recognition that the intervention was unique and highly valuable. While most of the measures chosen for the holistic health check were found to be suitable for this population, they should be streamlined to avoid duplication and participant burden. CONCLUSIONS: The study established that a peer-delivered, relational harm reduction intervention is acceptable to, and feasible and accessible for, people experiencing homelessness and problem substance use. While the study was not outcomes-focused, participants did experience a range of positive outcomes. A full randomised controlled trial is now required to assess intervention effectiveness. TRIAL REGISTRATION: Study registered with ISRCTN: 15900054.
Asunto(s)
Personas con Mala Vivienda , Trastornos Relacionados con Sustancias , Estudios de Factibilidad , Reducción del Daño , Humanos , Calidad de Vida , Trastornos Relacionados con Sustancias/terapiaRESUMEN
Drug-related deaths have increased significantly in Scotland in recent years, with a much greater percentage increase in deaths among women than among men. We undertook a mixed-methods project to identify explanations for this trend, comprising three parallel methodological strands: (i) an analysis of available routine data, including drug treatment data, death registrations, and surveys of people using needle exchanges; (ii) thematic analysis of interviews and focus groups with professional stakeholders and (iii) secondary analysis of interviews with women who use drugs. Results indicated that the observed trend is likely to reflect multiple, interacting causes. Potential contributors identified were: ageing; changing patterns of substance use; increasing prevalence of physical and mental health co-morbidities; changing relationships and parenting roles; changes to treatment services and wider health and social care provision; unintended consequences or poor implementation of recovery-oriented practice; and changes in the social security system. Policy responses to rising drug-related death rates require a gender-informed approach, recognising the commonalities and differences between men and women who use drugs; the diversity of experiences within each gender; and the intersections between gender and other forms of inequality, such as poverty.
RESUMEN
People who experience homelessness and alcohol dependency are more vulnerable than the general population to risks/harms relating to COVID-19. This mixed methods study explored stakeholder perspectives concerning the impact of COVID-19 and the potential utility of introducing managed alcohol programmes (MAPs) in Scotland as part of a wider health/social care response for this group. Data sources included: 12 case record reviews; 40 semi-structured qualitative interviews; and meeting notes from a practitioner-researcher group exploring implementation of MAPs within a third sector/not-for-profit organisation. A series of paintings were curated as a novel part of the research process to support knowledge translation. The case note review highlighted the complexity of health problems experienced, in addition to alcohol dependency, including polysubstance use, challenges related to alcohol access/use during lockdown, and complying with stay-at-home rules. Qualitative analysis generated five subthemes under the theme of 'MAPs as a response to COVID-19': changes to alcohol supply/use including polysubstance use; COVID-19-related changes to substance use/homelessness services; negative changes to services for people with alcohol problems; the potential for MAPs in the context of COVID-19; and fears and concerns about providing MAPs as a COVID-19 response. We conclude that MAPs have the potential to reduce a range of harms for this group, including COVID-19-related harms.