It seems that reports from the Advisory Council on the Misuse of Drugs (ACMD) are, as the old adage has it, like buses. There are none for ages, then three come along at once.
Earlier this month, the ACMD published a report on custody-community transitions, two days later they issued a report on the needs of older opiate users and five days after that they published a report on – Drug-related harms in homeless populations and how they can be reduced — the subject of this blog post.
This report finds that there is increased risk of problematic drug use associated with people who experience homelessness. There is a higher rate of drug-related deaths, infections among people who inject drugs, and multiple morbidities. People who experience homelessness and use substances have particularly complex circumstances and additional risks which require intensive long-term support.
The ACMD recommends an integrated health, social care, and community care approach to the recovery and housing needs of people who are homeless and says such an approach should include a focus on safe, stable housing and evidence-based harm reduction initiatives.
The main findings of the report are:
- Drug using homeless populations suffer a lack of social connectedness and their personal safety is at greater risk. In addition, a high proportion of people who are homeless and who have drug use issues have experienced multiple adverse childhood experiences (ACEs). The implementation of Universal Credit, the pursuit of localism and the lack of affordable housing add to the risk of homelessness amongst drug users.
- People who are homeless and numbers who are rough sleeping have increased substantially with some variation across the UK since 2010. Whilst the problems are proportionally greater in inner city and urban areas it is also clear that the issue has become increasingly prevalent in rural areas.
- The needs of people who are homeless, particularly rough sleepers, are not well met by mainstream benefit, health and social care and some drug services.
- Drug use patterns and trends vary across the UK with different areas showing higher prevalence for some substances than others – for example, synthetic cannabis use in Manchester, Newcastle and Cardiff, but a high proportion of injecting heroin users who have been homeless in Glasgow.
- There is a higher rate of drug-related deaths among homeless populations compared with the general population.
- There has been a rise in serious bacterial infections amongst injecting drug users and there is evidence that homeless populations are over represented in these infected groups. In addition, levels of HIV and HCV in drug users who are homeless are high. In Scotland there are high levels of long-term conditions such as chronic obstructive pulmonary disease (COPD) among homeless drug users.
- Harm reduction work within the homeless and drug use sectors in the UK utilises a holistic, pragmatic and supportive approach to encourage individuals to consider and reduce the harms related to their substance-using behaviour. Evidence-based Harm Reduction models in the UK include assertive outreach programmes, education, counselling, health promotion, peer support, user fora, needle exchange schemes, administration of Naloxone and opioid substitute prescribing. There is international evidence to support the effectiveness of ‘safe injecting sites’ to engage with and maintain contact with highly marginalised target populations and to prevent overdose deaths.
The ACMD makes five principal recommendations:
- Housing policies, strategies and plans across the UK should specifically address the needs of people who use drugs and are experiencing homelessness by: recommending evidence-based housing provisions, such as Housing First; enabling collaboration across departments and agencies to ensure these interventions have a chance to succeed.
- Services at a local level must be tailored to meet the specific needs of substance users who are currently experiencing, or have recently experienced, homelessness – including evidence-based and effective harm reduction and substance use treatment approaches with the capacity, resource and flexibility to reach them. Services need to consider people who are experiencing multiple and complex needs and adopt psychologically-informed approaches.
- Substance use, mental health and homelessness services to use evidence-based approaches such as integrated and targeted services, outreach, and peer mentors to engage and retain homeless people in proven treatments such as opiate substitution treatment.
- Service providers should be aware of the levels of stigma experienced by people who are homeless and are engaged in substance use treatment or who choose not to engage due to the experiences of stigma and oppression they have had. Respect, choice, dignity and the uniqueness of the person should be at the core of the design and delivery of the service provision in respect of substance use and homelessness services.
- The workforce in substance use and other services which have contact with the homeless need to have skills in dealing with complexity and in retaining homeless drug users in treatment.