02 November, 2020
The following is a summary of outcomes from the period of 24/3/20 – 24/6/20, from Lynne Drysdale a nurse prescriber who worked within the Edinburgh Access Practice during the covd19 pandemic delivering medically assisted treatment to those experiencing homeless. Lynne has worked as a nurse within the access practice for 12 years and is passionate about collaborative engagement within marginalised groups that promotes choice, rapid access to treatment that fosters autonomy and empowerment.
Often marginalised and stigmatised, the recent lockdown brought many challenges for vulnerable people who experience homelessness. Many had no access to accommodation and were temporarily housed in hotels where meals were provided and social distancing implemented. For those with opiate dependency and not engaged in OST the challenges faced were further magnified. The most vulnerable people are generally the most chaotic and as such have trouble navigating the complex welfare system. Consequently one of the only ways to fund substance dependency is by street begging which was prohibited throughout lockdown which added to the disruptions in supply of illicit drugs and restrictions on travel meant that untreated opiate dependency wasn’t only problematic for the individual but also, from a public health and criminal justice perspective, an issue for wider society also.
As a non medical prescriber and both a registered mental health nurse and general nurse, with many years experience in substance misuse, assertive outreach was identified as the best approach to engaging people into treatment. Off I went with a rucksack containing injecting equipment and bins, foil, naloxone, urine dip toxicology, disposable cups, PPE, EAP registration forms and IAC forms, a pen and prescription pad and a trauma informed attitude. This holistic, harm reduction approach enabled me to prescribe in unprecedented circumstances within a risk aware context. Whilst a priority was containing covid19, it was still crucial not to contribute to an increase in drug related deaths/harm.
OST was initiated in 17 patients aged between 22 and 45 years. The majority were male and this not only mirrors the gender split in homelessness statistics in Scotland but also is representative of drug related death figures. 35% were registered with EAP, assessed and issued with prescriptions all on the same day.
It is essential for me to take a trauma informed, non-judgemental, open approach and to acknowledge client autonomy and responsibility for their treatment. Many later through emotional touch points reported they found this empowering as previous experiences of treatment were described as patronising and authoritarian. The majority had symptoms of complex trauma going back to childhood and although resilient, they lacked alternative coping strategies and protective factors. It was also paramount to be aware of resistance to care which traumatised people paradoxically view as authority and in some cases, synonymous with abuse.
Good partnership working was essential as both 3rd sector outreach and hostel staff were able to identify people not engaged in OST and signpost them. 70% of those initiated onto treatment came via that route and these good relationships continue as concerns re high risk clients are shared. We also set up a drop-in style clinic within the Salvation Army Centre in Niddire Street (Edinburgh) which had a duel role of follow up appointments and initiation of treatment. A good outcome for me personally was seeing one man on outreach who was still trying to obtain funds by begging on Princes St. I was given information regarding him from street outreach and as such was able to locate him on his begging pitch and offer support at the time and place of his need. Another being a female I had heard about who was camping with her partner in a graveyard as they felt this was the best way to avoid covid but they had unmet complex needs.
Many of the clients we support present with chaotic, complex lives. It is rare that they use only one substance and most also have a co-occurring alcohol, benzodiazepine’s or crack dependency. Many also present with physical problems such as COPD and CVD. It was important to think “outside the box” while also having an acute awareness of new and shifting risk factors. Due to fear of spreading covid, community pharmacies stopped supervising methadone and dispensing was changed to three times weekly. This brought its own concerns as very chaotic people were given large amounts of Methadone potentially to takeaway. As we know evidence shows that NFO/DRD is more likely in first 4 weeks of Methadone initiation so Buprernorphine was our treatment of choice. If no obvious withdrawals were observed at the time of assessment, discussion around precipitated symptoms and the clients understanding of this was paramount. If the client was opposed to Buprernorphine we would still initiate Methadone and I always utilising a trauma informed approach to enable an open and honest discussion around drug use and consequently reduce the risk of drug related harm.
The availability of injecting equipment, including foil and safer injecting advice enhanced discussions around safety and many opted to smoke heroin rather than inject after a comprehensive, informed choice was presented to them. Everyone was offered and took naloxone meaning that a holistic service could be provided in order to reduce risk as much as possible.
Taking the service to the person
Only 11% of new starts were assessed in a traditional clinic setting and 89% were located and assessed elsewhere utilising assertive outreach and previously mentioned strong partnership links. As soon as hotel premises were established at the very beginning of the lockdown and as people were being booked in, initiation of OST was commenced utilising a harm reduction approach. Hotel reception staffs were trained in administering THN and Streetwork overseeing the management of the hotel were all trained and had supplies. The staff from the Salvation Army proved invaluable as they escorted people to drop-in outreach clinic and alerted me to residents not on OST who I managed to engage within the hostel. The most satisfying moments was the above mentioned assessment for and initiation via hand written prescription of OST on a back street off Princes St (urine sample obtained and dipped up a hidden close!) and commencing a prescription in a graveyard (urine sample obtained behind a crypt).
17 people remain not only engaged in OST but are also accessing wider primary healthcare. Three people are currently being treated for hepC whilst one is undertaking assessment. There were no incidents of NFO which is often cited as a concern in discussions around same day presentation and prescribing and interestingly this was unaffected by treatment choice.
This supports the benefits of a robust, holistic harm reduction based approach underpinned by frank trauma informed patient-centred ethos which recognises client autonomy and responsibility. I would contend that this is essential in same day prescribing in a chaotic cohort with complex needs.
Covid lead to a relaxation in prescribing rules which in turn allowed the introduction of innovative ways of working. It highlighted same day presentation and prescribing in practice in a complex, chaotic cohort which is recommended by WHO 2014. It also demonstrated that if anything there was a greater awareness and evaluation of risk.
The importance of good, strong partnership working was identified as essential as well as the need to further develop assertive outreach as a model of care for hard to reach marginalised people as it provides a route into wider primary care and public health initiatives such as hep C treatment.
Patients reported they were appreciative of the autonomy and responsibility afforded to them regarding their treatment which they found empowering.
Though this is just a snapshot of a response to a crisis, it is hoped this test for change will form the blueprint for a future project around reducing drug related harm and engaging hard to reach homeless people utilising an assertive outreach, trauma-informed approach.
As a nurse this was a frightening yet exciting and innovative period. From a wider perspective I hope that this snapshot will contribute to new ways of thinking about how in Scotland we implement the MAT standards and, in time, reduce drug related harm.
A poster visualisation of this initiative is available here