Last month, the research roundup provided you with an overview of articles looking at concerning deprescribing (Robertson, 2022). This month, we will review articles looking at prescribing in the homeless population. The first article looks at prescription data from specialist homelessness general practices. The second article looks at opioid replacement therapy in a homeless population, while the final paper reviews a pharmacist outreach and non-medical prescribing service for homeless people.
Medicines prescribing for homeless persons: analysis of prescription data from specialist homelessness general practices
This article, published in the International Journal of Clinical Pharmacy aimed to investigate the prescribing of medicines to homeless persons who present to specialist homelessness primary care practices and compares the data with the general population (Khan et al, 2022). The research team collected information from prescribing datasets over 12 months between April 2019 and March 2020. The data of interest was the prescription of medications from 20 pre-selected British National Formulary paragraphs which related to the most commonly prescribed medications in England to the general population. The data from specialist homeless persons' general practices covered 15 practices across England from city areas. This was a broad spread across counties, but five were in London. The data extracted was then compared with the general population during the same time and also with the most deprived and least deprived populations in England. The main outcome measure reported was the number of medicines prescribed per 1000 people in key disease areas. These included drugs prescribed across a range of mental health conditions including substance dependence, drugs in gastrointestinal conditions, respiratory and cardiovascular conditions and diseases of the endocrine system. The analysis consisted of prescriptions for 20 572 people. The results revealed a significantly higher prescribing of drugs in opioid dependence compared to the general population with around 1297 items per 1000 people in the homeless practices and 15.7 in the general population. A marked increase was also seen in drugs for psychosis in the homeless population. This difference was even more marked when compared to the population from the least deprived areas of England. Conversely, prescribing for some other long-term conditions, especially of the cardiovascular system and thyroid hormones, was markedly lower in the homeless population. The authors conclude that most prescribing activities in the homeless population relate to mental health conditions and substance misuse. They acknowledge that other long-term conditions that overlap with homelessness may be underdiagnosed and under-managed. Finally, they suggest that the wide variations in data across practices need further investigation.
Long-acting depot buprenorphine in people who are homeless: views and experiences
This article, published in the Journal of Substance Abuse Treatment, aimed to explore the views of homeless people who are dependent on opioids or opiates, whether these be prescribed or obtained illicitly, on a variety of opioid replacement therapies (Matheson et al, 2022). This range included methadone liquid, sublingual/wafer buprenorphine and long-acting buprenorphine depot injections. This study was qualitative in nature and used focus groups as well as one-to-one interviews in its methods. A total of nine participants in three focus groups were recruited and there were 20 participants in the one-to-one interviews. Recruitment was across Scotland and Wales through organisations working with the homeless. These included the Territorial Salvation Army, Simon Community in Scotland and the Kaleidoscope group in Wales. Some participants were recruited through recovery programmes. The focus groups took place in November and December 2020 via Zoom due to COVID-19 restrictions, with individual interviews conducted between January and May 2021 by either Zoom or telephone. The research team sought to gather information and views on the range of opioid replacement therapies including experiences, perceptions, acceptability and utility. The results presented include a demographic background of participants showing more men than women participated and all had experienced mental health issues and interaction within the criminal justice system including prison time. All participants had used opioid replacement therapies and gave their views on the types they had the experience with and expressed preferences. They reported long-acting buprenorphine being valuable in the management of their opioid use and gave them some freedom from daily dispensing and giving them some control over their lives. The research team identified crucial themes for those experiencing homelessness: emotions, trust and time. They conclude that care providers should be mindful of this shift and make it central to shared decision-making, information provision and support when prescribing long-acting preparations.
Improving the health of people experiencing homelessness with recent drug overdose: rationale for and design of the Pharmacist and Homeless Outreach worker Engagement Non-medical Independent prescribing Rx (PHOENIx) pilot randomised controlled trial
This article published online as a preprint prior to peer review is a rapid communication of this new research study. It is important to therefore be aware that this should not be used to guide clinical practice but the study design and findings are of interest in the area of prescribing for the homeless as the number of persons experiencing homelessness is on the increase (Lowrie et al, 2022). This paper notes that other research has determined that the incidence of homelessness is associated with mental health issues, substance misuse, physical health deterioration and premature death. This paper specifically looks at homeless people who have recently experienced a drug overdose. The paper presents the proposal of a pilot randomised controlled trial looking to ascertain if a collaborative health and social care intervention is potentially beneficial to this group of patients. They describe the PHOENIx trial (Pharmacist and Homeless Outreach worker Engagement Non-medical Independent prescribing Rx) which was formed by staff working for charities engaged with the homeless in Scotland concerned with the morbidity and mortality of drug use in this population. There will be a detailed collection of health and social care information to form a baseline before the commencement of the randomisation of identified participants to either care as the usual arm of the trial or care as usual plus visits from a prescribing pharmacist and a homeless outreach worker. This will be measured over a 6–9 month period. The intended primary outcome measures are number and rate of presentations to the emergency department for overdose. The plan is to progress to a full randomised control trial recruiting upwards of 100 participants within 4 months with an aim to maintain retention in the study at 6-9 months at over 60%. Other possible outcome measurements include hospitalisation, treatment uptake and self-reported measures from participants. Semi-structured interviews will be conducted as a follow-up to explore the future implementation of the outreach programme and interventions to ascertain reasons for overdose and any protective factors that prevent it. The trial will also explore the economics of this intervention as well as facilitators and barriers. This could be a landmark study in this population and will aim to seek input from people normally excluded from randomised control trials. The pilot trial has already received ethical approval.
Conclusion
Prescribing in any marginalised group or population is often difficult and with little research to support interventions. As the homelessness problem grows worldwide, more research is needed to support safe prescribing practice in this area and validate the effectiveness and need for specific service for persons experiencing homelessness. Key areas to target appear to be mental health services, drug and alcohol misuse and the effective diagnosis and management of long-term conditions.