Planning and implementing community-based drug checking services in Scotland: a qualitative exploration using the consolidated framework for implementation research.

BACKGROUND: Drug checking services (DCS) provide harm reduction support and advice to individuals based on chemical analysis of submitted substances of concern. Whilst there are currently no DCS in Scotland, community-based services are being planned in three cities. METHODS: In this paper, we report qualitative findings based on interviews with 43 participants, focused on perceptions of DCS and their implementation. Participants were relevant professionals, those with experience of drug use, and family members of those with experience of drug use. The Consolidated Framework for Implementation Research (CFIR) was used to inform data collection and analysis. We report findings under nine constructs/themes across the five CFIR domains. RESULTS: Participants noted the importance of DCS being implemented in low-threshold, trusted services with a harm reduction ethos, and outlined a range of further service design considerations such as speed of testing, and information provided through the analysis process. In relation to the 'inner setting', a key finding related to the potential value of leveraging existing resources in order to expand both reach and effectiveness of drug trend communication. The approach of local and national police to DCS, and the attitudes of the public and local community, were described as important external factors which could influence the success (or otherwise) of implementation. Bringing together a range of stakeholders in dialogue and developing tailored communication strategies were seen as ways to build support for DCS. Overall, we found high levels of support and perceived need for DCS amongst all stakeholder groups. CONCLUSIONS: Our findings present initial implementation considerations for Scotland which could be further explored as DCS are operationalised. Further, our focus on implementation contexts is relevant to research on DCS more generally, given the minimal consideration of such issues in the literature.

"It would really support the wider harm reduction agenda across the board": A qualitative study of the potential impacts of drug checking service delivery in Scotland.

Drug checking services (DCS) enable individuals to voluntarily submit a small amount of a substance for analysis, providing information about the content of the substance along with tailored harm reduction support and advice. There is some evidence suggesting that DCS may lead to behaviour and system change, with impacts for people who use drugs, staff and services, and public health structures. The evidence base is still relatively nascent, however, and several evidence gaps persist. This paper reports on qualitative interviews with forty-three participants across three Scottish cities where the implementation of community-based DCS is being planned. Participants were drawn from three groups: professional participants; people with experience of drug use; and affected family members. Findings focus on perceived harm reduction impacts of DCS delivery in Scotland, with participants highlighting the potential for drug checking to impact a number of key groups including: individual service users; harm reduction services and staff; drug market monitoring structures and networks; and wider groups of people who use and sell drugs, in shaping their interactions with the drug market. Whilst continued evaluation of individual health behaviour outcomes is crucial to building the evidence base for DCS, the findings highlight the importance of extending evaluation beyond these outcomes. This would include evaluation of processes such as: information sharing across a range of parties; engagement with harm reduction and treatment services; knowledge building; and increased drug literacy. These broader dynamics may be particularly important for evaluations of community-based DCS serving individuals at higher-risk, given the complex relationship between information provision and health behaviour change which may be mediated by mental and physical health, stigma, criminalisation and the risk environment. This paper is of international relevance and adds to existing literature on the potential impact of DCS on individuals, organisations, and public health structures.

Development of an intervention to manage benzodiazepine dependence and high-risk use in the context of escalating drug related deaths in Scotland: an application of the MRC framework.

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.

'It's not going to be a one size fits all': a qualitative exploration of the potential utility of three drug checking service models in Scotland.

BACKGROUND: Scotland currently has the highest rates of drug-related deaths in Europe, so drug checking services are being explored due to their potential role in reducing these deaths and related harms. Drug checking services allow individuals to submit presumed psychoactive drug samples for analysis, and then receive individualised feedback and counselling. This paper explores participants' views on the advantages and challenges of three hypothetical service models, to inform future service delivery in Scotland. METHODS: Semi-structured interviews were conducted with 43 people: 27 professional stakeholders, 11 people with experience of drug use, and five family members across three cities. Vignettes were used to provide short descriptions of three hypothetical service models during the interviews. Interviews were audio-recorded, transcribed and analysed using thematic analysis. RESULTS: Participants identified advantages and challenges for each of the three potential service models. The third sector (not-for-profit) model was favoured overall by participants, and the NHS substance use treatment service was the least popular. Participants also noted that multiple drug checking sites within one city, along with outreach models would be advantageous, to meet the diverse needs of different groups of people who use drugs. CONCLUSIONS: Drug checking services need to be tailored to local context and needs, with a range of service models being possible, in order to meet the needs of a heterogeneous group of people who use drugs. Addressing issues around stigma, accessibility, and concerns about the potential impact of accessing drug checking on access to and outcomes of drug treatment, are essential for successful service delivery.

Feasibility and Acceptability of an Overdose Prevention Intervention Delivered by Community Pharmacists for Patients Prescribed Opioids for Chronic Non-Cancer Pain.

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.

Making community pharmacies psychologically informed environments (PIE): a feasibility study to improve engagement with people using drug services in Scotland.

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).

Patient, family members and community pharmacists' views of a proposed overdose prevention intervention delivered in community pharmacies for patients prescribed high-strength opioids for chronic non-cancer pain: An explorative intervention development study.

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.

The Potential for Managed Alcohol Programmes in Scotland during the COVID-19 Pandemic: A Qualitative Exploration of Key Areas for Implementation Using the Consolidated Framework for Implementation Research.

People experiencing homelessness and alcohol dependence are at increased risk of a range of harms, including from COVID-19. Managed Alcohol Programmes (MAPs) are an alcohol harm reduction intervention specifically for this group. In this paper we report on qualitative findings of a mixed methods study investigating the potential utility of MAPs during the COVID-19 pandemic in Scotland. Interviews, conducted with 40 participants, explored potential views of implementing MAPs during the pandemic. Theoretically, we drew on the Consolidated Framework for Implementation Research (CFIR) to inform data collection and analysis. Six themes were identified which mapped onto three CFIR domains: perceptions of MAPs and the evidence base; necessary components of MAPs; changing culture of alcohol harm reduction; MAPs as a moral and ethical grey area; addressing a service gap; and securing buy-in and partnership working. Participants were generally positive about MAPs and viewed them as a key intervention to address a service gap. Several necessary components were identified for successful implementation of MAPs. Securing buy-in from a range of stakeholders and partnership working were deemed important. Finally, MAPs require careful, long-term planning before implementation. We conclude that MAPs are needed in Scotland and require long-term funding and appropriate resources to ensure they are successful.

Negotiating an Illicit Economy in the Time of COVID-19: Selling and Buying Dilemmas in the Lives of People Who Use Drugs in Scotland.

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.

A Realist Review of How Community-Based Drug Checking Services Could Be Designed and Implemented to Promote Engagement of People Who Use Drugs.

With rising numbers of drug-related deaths in the UK and globally, exploration of interventions that seek to reduce drug-related harm is essential. Drug checking services (DCS) allow people to submit drug samples for chemical analysis and receive feedback about the sample, as well as harm reduction advice. The use of DCS is often linked to festival and/or nightlife settings and to so-called 'recreational' drug use, but research has also shown the potential of community-based DCS as an intervention serving more varied demographics of people who use drugs, including more marginalised individuals and those experiencing drug dependence. Whilst there is a growing evidence base on the effectiveness of drug checking as a harm reduction intervention, there is still limited evidence of the underlying mechanisms and processes within DCS which may aid implementation and subsequent engagement of people who use drugs. This presents a challenge to understanding why engagement differs across types of DCS, and how best to develop and deliver services across different contexts and for different populations. To explore the contexts and mechanisms which impact engagement in community-based DCS, a realist review was undertaken to synthesise the international evidence for the delivery and implementation of DCS. There were 133 sources included in the review. From these sources the underlying contexts, mechanisms, and outcomes relating to DCS implementation and engagement were developed and refined into seven programme theories. The findings of this review are theoretically novel and hold practical relevance for the design of DCS, with implications for optimisation, tailoring, and implementing services to reach individuals in different settings.

Exploring how greenspace programmes might be effective in supporting people with problem substance use: a realist interview study.

BACKGROUND: Greenspace programmes are health projects run outside in nature, typically with the aim of improving mental health. Research suggests that programmes may also be effective in supporting people with problem substance use (PSU), but there is limited understanding of the key components that make them successful for this client group. Previous work has claimed that a realist-informed intervention framework for greenspace programmes for mental health could be transferable to programmes that support people with PSU, and that this could provide insight into the causal processes within programmes. However, this claim is yet to be explored in depth. The aim of this study was to further test, refine, and consolidate the proposed framework to show how greenspace programmes could support people with PSU. METHODS: Using a realist approach, 17 participants (8 programme staff; 9 wider stakeholders) were interviewed about contexts, mechanisms, and outcomes (CMOs) relative to greenspace programmes for mental health and PSU. Semi-structured interviews were used since they facilitated exploration of the proposed framework but were flexible enough to allow identification of new CMOs for framework refinement. Interviews were audio-recorded, fully transcribed, and analysed inductively and deductively against the proposed framework. RESULTS: Findings supported the proposed framework and indicated that greenspace programmes support people with poor mental health and PSU due to: feelings of escape; space to reflect; physical activity; self-efficacy; feelings of purpose; relationships; and shared experiences. However, data showed that programmes must also consider: explicit intervention focus to ensure adequate support for clients; existing challenges with funding and stakeholder buy-in; and the impact of COVID-19. Findings allowed development of a refined framework that shows how greenspace programmes can support people with PSU. CONCLUSION: The findings of this project are theoretically novel and have practical relevance for those designing greenspace programmes by providing recommendations on how to optimise, tailor, and implement future interventions. Findings could be particularly relevant for academic researchers, multidisciplinary health professionals, and for those working in the third sector, developing and delivering greenspace programmes for people to improve their mental health and to support them with PSU.

Challenges for drug checking services in Scotland: a qualitative exploration of police perceptions.

BACKGROUND: The impact of policing practices on the engagement of people who use drugs (PWUD) with harm reduction services is well evidenced. Although the police have traditionally taken an enforcement role in responding to drug use, it is increasingly clear that they can play an important part in multiagency delivery of harm reduction interventions. Despite this, there have been no studies exploring police officer perceptions of drug checking services (DCS), which provide analytical testing of client drug samples alongside harm reduction support and advice. METHODS: Semi-structured interviews were conducted with 10 police officers to explore the policing and legal challenges which could be encountered in the delivery of DCS in Scotland. RESULTS: Participants expressed general support for DCS and described this support as part of a wider organisational shift towards public health-oriented policing. Participants also discussed different potential approaches to the policing of areas surrounding DCS including: formal limits on police presence around the service and/or stop and search powers in relation to personal possession; the effective decriminalisation of personal possession within a specified boundary around the service; and informal agreements between local divisions and DCS outlining expected policing practices. Any formal limitation on the capacity of police officers to respond to community concerns was viewed as problematic and as having the potential to erode public confidence in policing. Participants also highlighted the potential for frontline officers to utilise discretion in ways which could undermine public health goals. Legislative change, or national strategic guidance from relevant stakeholders, was seen as a means of providing 'cover', enabling local divisions to support the operation of drug checking. CONCLUSIONS: Despite a small sample of participants, this study summarises key challenges to be addressed in the implementation and operation of DCS in Scotland, and more widely. The paper concludes with suggested opportunities to develop approaches to policing that can facilitate rather than impede implementation and operation of these services.

'Why would we not want to keep everybody safe?' The views of family members of people who use drugs on the implementation of drug consumption rooms in Scotland.

BACKGROUND: People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy. METHODS: Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to 'family' was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique. RESULTS: Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care. CONCLUSIONS: Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond.

Drug Consumption Rooms and Public Health Policy: Perspectives of Scottish Strategic Decision-Makers.

There is widespread support for the introduction of Drug Consumption Rooms (DCRs) in Scotland as part of a policy response to record levels of drug-related harm. However, existing legal barriers are made more complex by the division of relevant powers between the UK and Scottish Governments. This paper reports on a national, qualitative study of key decision-makers in both local and national roles across Scotland. It explores views on the political barriers and enablers to the adoption of Drug Consumption Rooms and the potential role of these facilities in the wider treatment system. It also considers approaches to evidence, especially the types of evidence that are considered valuable in supporting decision-making in this area. The study found that Scottish decision-makers are strongly supportive of DCR adoption; however, they remain unclear as to the legal and political mechanisms that would make this possible. They view DCRs as part of a complex treatment and support system rather than a uniquely transformative intervention. They see the case for introduction as sufficient, on the basis of need and available evidence, thus adopting a pragmatic and iterative approach to evidence, in contrast to an appeal to traditional evidence hierarchies more commonly adopted by the UK Government.

Stress and Wellbeing during the COVID-19 Pandemic: A Mixed-Methods Exploration of Frontline Homelessness Services Staff Experiences in Scotland.

Staff working in homelessness services often find the work rewarding yet challenging, and the sector experiences high levels of staff burnout and staff turnover. During the COVID-19 pandemic, staff working in these services faced particularly stressful working conditions. This study explored the experiences of stress and wellbeing among those working in frontline homelessness service roles during the early stages of the pandemic in Scotland. Semi-structured interviews were conducted with 18 participants, 11 of whom completed the Maslach Burnout Inventory (MBI). Qualitative data were analysed using Framework Analysis in NVivo, informed by the Revised Transactional Model of occupational stress and coping. MBI data were analysed using descriptive statistics. The COVID-19 pandemic positively and negatively impacted participants' lives and roles. Organisational culture acted as a magnifying glass for pre-pandemic practices: for some, the pandemic brought teams and staff closer together, creating a better working environment. For others, it led to fragmentation and frustration. Participants discussed coping strategies and recommendations for the future to protect staff wellbeing. Quantitative data suggested that participants were not experiencing burnout, although some were at heightened risk. Future research should explore the longer-term impact of the pandemic on homelessness service staff outcomes.

The impact of COVID-19 on access to harm reduction, substance use treatment and recovery services in Scotland: a qualitative study.

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.

Assessing the feasibility, acceptability and accessibility of a peer-delivered intervention to reduce harm and improve the well-being of people who experience homelessness with problem substance use: the SHARPS study.

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.

A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study.

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.

Exploring the Potential of Implementing Managed Alcohol Programmes to Reduce Risk of COVID-19 Infection and Transmission, and Wider Harms, for People Experiencing Alcohol Dependency and Homelessness in Scotland.

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.