Holistic health and social care outreach for people experiencing homelessness with recent non-fatal overdose: the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx (PHOENIx after overdose) pilot randomised controlled trial

Problem

The large and growing public health crises of drug related death disproportionately impacts people experiencing homelessness, who are already severely disadvantaged because of multiple exclusion, intersecting physical and mental health problems and adverse social circumstances. There are no ‘off the shelf’ interventions known to prevent overdose, delay emergency service contacts or improve other health outcomes in people experiencing homelessness at high risk of fatal overdose.

Approach

Multicentre pilot RCT (with accompanying process and economic evaluations) of an assertive outreach intervention delivered by pairs of NHS Independent prescriber pharmacists and third sector homelessness workers (Simon Community Scotland or Marie Trust) (PHOENIx). Operating under the governance of specialist Homelessness Health Service GPs in Glasgow, Pharmacists assess health, treat, prescribe and refer to other health care while Third sector workers assess and address welfare benefits, housing, social prescribing. Patients set their priorities during visits every 2 weeks for 7 months. Participants are homeless with a history of at least one non-fatal overdose in the previous 6 months. Independent researchers collect baseline data before randomisation to either PHOENIx plus Usual Care (UC) or UC; follow-up at 6 and 9 months. Our aim is to inform a subsequent definitive RCT by achieving progression criteria: recruitment of ≥100 participants within 4 months;≥ 80% participants with data collected (at baseline and follow up); ≥60% receiving the intervention; and ≥60% remaining in the study at 6 and 9 months. Secondary outcomes include rates and time to: overdose; hospitalisations; emergency department attendance; treatment uptake for physical health, mental health and problem drug use; health related quality of life; frailty and treatment burden (workload of self-management and impact on well-being).

Findings

128/130 eligible participants were recruited from 20 Glasgow homeless venues between May and September 2021. Mean age 42 years (SD 8.4); 71% male. At baseline, participants used a median of 3(IQR 2-4) illicit drugs, street valium being the most widely used street drug (87%). Participants had overdosed 3.2(SD 3.2) times in the 6 months prior to recruitment, despite 90% receiving prescribed opioid substitution treatment and 10% receiving prescribed diazepam. Participants had a mean of 2.2(SD 1.3) mental health problems and 5.4(SD 2.5) physical health problems; 50% in treatment for physical and mental health problems. 62 allocated to PHOENIx, 66 to UC. Seven participants were withdrawn due to protocol violation soon after randomisation; 12 lost capacity or died. At 6 and 9 months, 96/113(85%) and 88/109(81%) received in-person follow up (mean 9.6(SD 1.9) months per participant. 113/113(100%) and 109/109(100%) respectively, had data collected from clinical records. 60/62(97%) PHOENIx group participants received at least one in-person consultation with mean of 14.9(SD 9.9) per patient.

Consequences

Progression criteria were met. Health/social care outcomes will be available in July, to inform research and practice for the UK's most destitute citizens.