Setting up a drug treatment service in a COVID-protect hotel in inner London

On 23 March 2020, prime minister Boris Johnson addressed the nation on COVID-19 and told the population to stay indoors and only leave the house for limited reasons such as shopping, exercise and addressing medical needs. This announcement highlighted the plight of the UK's homeless population for whom staying at home or self-isolating whilst symptomatic, were not options. The government recognised this and had already appointed Dame Louise Casey to head a task force to address the problem. She spearheaded an ‘Everyone In’ emergency accommodation operation and on 26 March 2020, Luke Hall MP (minister for local government and homelessness) wrote to all local council leaders and requested that “these people have access to … facilities that enable them to adhere to public health guidance on hygiene or isolation, ideally single room facilities (Ministry of Housing, 2020a). Extra funding was announced and by 8 April 2020 the housing secretary Robert Jenrick MP estimated that 90% of known rough sleepers at the start of the lockdown had been offered accommodation (Ministry of Housing, 2020b).

Drug and alcohol misuse among rough sleepers is a significant problem – a recent report on homeless by the Advisory Council on the Misuse of Drugs (ACMD), estimated that up to 50% of homeless people in England may have a substance misuse problem (ACMD, 2019). In April 2020 Public Health England (PHE) issued guidance for commissioners and providers of substance misuse treatment, which recommended a move away from face-to-face work and more remote contact with clients via phone or video link (PHE, 2020). It was recognised that for new people starting drug treatment face-to-face contact would still be required but that personal protective equipment (PPE) should be worn. For clients on substitute opioid prescriptions, such as methadone and buprenorphine, the guidance highlighted the dilemma of continuing daily supervised administration of medication at local pharmacies in the face of government advice to stay at home and reduce the risk of transmission. Many pharmacies had restricted their opening hours during the lockdown and some of the larger chains had closed smaller branches. PHE suggested that more stable clients might be given up to two-weeks' worth of medication as a single take-away dose and that all clients would need to nominate someone who could collect their medication in the event of having to self-isolate.

The local council opened a COVID-Protect hotel on 6 April 2020 with the aim of housing local rough sleepers and those living in supported accommodation who were unable to self-isolate due to having shared facilities. The hotel was funded to take up to 100 residents. The project was coordinated by a third sector agency with a history of running several local hostels as well as providing support, aftercare and psychosocial interventions for people who are homeless or have substance misuse problems. The council approached local healthcare providers to set up an informal network of in-reach services to the hotel, including:

• A specialist primary care service that worked with homeless people
• An NHS specialist substance misuse treatment team
• A mental health team with expertise in working with the homeless
• The local Find and Treat team to lead on COVID-19 testing.

The local NHS provider already had experience of outreach prescribing services having set up five hostel prescribing clinics between 2006 and 2020 (Dunn et al, 2006).

This article focuses on the role of the substance misuse treatment team in the COVID-protect hotel.

The hotel

The hotel was a five-storey building in one of the borough's more affluent areas. Core staff continued to work at the hotel, including domestic and reception staff. Initially catering was outsourced but then brought back in-house and provided by the third-sector support service's chef and delivered to resident's rooms. The hotel bar was closed and alcoholic drinks had been removed from the bar itself. The large dining room was mainly used as a meeting space. A laundry service was available to residents. A couple of rooms on the ground floor were modified as improvised clinical rooms for the visiting GP, the primary care nurse and the substance misuse service. The management and support staff from the third-sector agency had a large office at the entrance of the building.

The substance misuse team

This team came from the local NHS specialist substance misuse service. Drug and alcohol services in the local borough have a somewhat complex organisational structure with drug and alcohol services commissioned through separate teams with different lead providers and the drug treatment service further split into complex and non-complex teams again with different providers. The NHS provider delivers the complex drug treatment service in partnership with a third sector provider, as well as an alcohol detox team and an alcohol assertive outreach team. The other main providers of drug and alcohol services are other third sector organisations.

Following the guidance from PHE, the local drug services needed to reduce face-to-face contact with clients and move to providing most follow-up and review appointments by phone or video link. Prescriptions were either hand-delivered or couriered directly to local pharmacies. These measures effectively reduced the daily footfall at the main treatment site from around 44 attendances per day to 11. However, with the lockdown, there was a significant increase in referrals – both self-referrals and those brought in by the local street outreach team. To illustrate this, the number of new presentations to the service between March-April 2019 was 63 but between March-April 2020 it increased to 122.

With the reduced footfall at the main service, the team were able to redeploy some staff to create the new hotel prescribing service. The core team consisted of two nurse prescribers and a doctor, but the service was very much a partnership between our staff and those of other organisations, in particular the support staff based at the hotel, a local pharmacist and a couple of volunteer drivers.

In the first phase of the service, a minimum of two prescribing staff attended the hotel daily, seven days a week. This enabled us to respond rapidly to the changing needs of the clientele, for example, new admissions, clients falling off prescriptions, emerging mental health issues, dose adjustments to prescribed medication and the monitoring of alcohol detoxes.

Getting to and from the hotel, which was about 1.5 miles away from the main drug service and transporting controlled drugs from the pharmacy to the hotel posed a logistic challenge. This was resolved by travelling to the pharmacy and the hotel by car. The local authority had granted some of our staff temporary parking permits to facilitate outreach work. Either one of the nurse prescribers drove or we used one of two volunteer drivers. When travelling by car staff wore PPE and kept the windows open. Staff remained in PPE throughout the hotel visits.

Assessments

New clients with substance misuse problems were identified daily by in-house support staff and seen by the NHS prescribing staff for assessment in a private room that had been adapted for semi-clinical purposes. It had had all furniture removed apart from a desk and chairs to facilitate infection control and enable staff to maintain the 2-metre rule. New assessments were usually undertaken by the doctor. Equipment was available on site to measure blood pressure, undertake urine drug testing, take breathalyser readings, provide needle/syringe exchange, take-away naloxone and supplies of PPE. This clinical room was also used to undertake reviews of clients, especially those with emerging mental health problems.

Although there was some remote access to our electronic client records, notes were written up at the main site after the visit. Prescriptions were also generated at the main site using our prescribing software, kept in a separate folder for the hotel and delivered to the pharmacy by hand.

The residents

During April/May 2020, the hotel housed 93 residents and between April and December, a total of 112 residents had passed through the hotel. In relation to our hotel prescribing service, at its peak, there were 28 residents in treatment with a total of 35 prescribing clients passing through the programme.

The in-house support staff encouraged all residents to register with the in-house GP service on admission to the hotel as well as apply for benefits. They made referrals to specialist teams where needs were identified. Although we did not collect any data on non-prescribed residents, with whom we were not working, it was clear that many had significant problems with alcohol or stimulants and/or had mental or physical health problems.

In relation to clients requiring substitute opioid treatment, there were two main groups:

• Existing service users already engaged with treatment
• New clients starting treatment – some of whom had had previous treatment episodes with us and others who were completely new to our service.

Table 1 summarises the key characteristics of all 35 residents we worked with between April and December 2020.

For residents who were opiate dependent, but not already on substitute opioid therapy, the writers aimed to start substitute opioid medication on the same day as the patient's initial assessment. As prescriptions were usually generated in advance, using prescribing software at the main treatment base, these prescriptions had to be hand-written using FP10s that were stored securely on-site. These were then taken to a nearby pharmacy where the medication was dispensed, brought back to the hotel by a member of staff and administered to the client under direct observation.

From the hotel opening in April until early December 2020, only one resident contracted COVID-19 and this person probably caught the virus before moving into the hotel. The resident was temporarily moved to another hotel that specialised in the management of COVID-19 positive cases and stayed there for 10 days before returning to the local hotel. No other resident or member of staff tested positive for the virus between April and December 2020.

There were no drug-related deaths at the hotel but two residents, who were not part of the prescribing programme, and not known to be drug users, died between April and October – one by hanging and another was a sudden and unexpected death. One of the prescribing clients, who was evicted from the hotel after assaulting another resident, died some weeks later.

Over 80% of clients were still in treatment when the project ended in December 2020 and the majority had been housed in hostels or in temporary accommodation.

Medication management

In normal circumstances, clients attend pharmacies near to where they live. This client group would ordinarily have been attending daily and having their substitute opioid medication supervised at the pharmacy. To comply with government advice, the team did not want clients having to leave the hotel every day and go to a pharmacy. Instead, a local pharmacy was approached who were already doing some home and hostel deliveries for clients with physical health problems and asked if they would provide all the medication for the hotel – they agreed to take on this role.

The initial plan was that the pharmacist would dispense the medication daily, put it in individually labelled containers, deliver it to the hotel and give it to the clients to take. However, there were immediate problems with clients congregating in the reception area of the hotel when the pharmacy technician arrived, not taking their medication when given and reports by staff of bottles of methadone being found in clients' rooms. So within a matter of days, procedures were changed so that NHS prescribing staff, who had an existing relationship with most clients, collected the medication at the pharmacy, transported it by car to the hotel and administered it under direct observation to clients at the doors of their rooms. At the start of the programme Sunday's doses and bank holiday doses were left in a locked box in the client's room but again we had to start supervising these doses too due to concerns that some were not being taken and were possibly being diverted.

The NHS provider had a controlled drugs cabinet installed in the support staff office at the hotel. We developed a standard operating procedure for storing and administering controlled drugs and put together a training package for support staff to supervise clients' medication. This training was provided by our lead pharmacist and our nurse prescribers. This allowed the NHS prescribing staff to reduce the number of days that they attended the hotel and started gave support staff closer involvement in the clients' substitute opioid treatment.

Partnership working

On a typical day, when the prescribing staff arrived at the hotel in the morning, they would have a handover from the support service manager and hear about any problems or issues that had arisen in the last 24 hours, be told of any new admissions, residents who had gone AWOL, been admitted to hospital, or in a small number of cases been evicted from the hotel for violent behaviour. At the end of our medication round, staff would feedback any concerns raised by clients and inform staff of any changes made to treatment plans. Where we identified physical health problems, staff liaised directly with the on-site primary care nurse or GP.

If there were mental health concerns the team doctor – who was a consultant psychiatrist – assessed clients and formulated an initial management plan, which might mean managing the condition within the team or making a referral to the crisis team or the mental health in-reach team. Mental health workers to do further assessments, support clients with emerging mental health problems and liaise with specialist mental health services.

A recurrent problem was residents developing dental abscesses but unable to access dental services which had all but ceased operating except for emergencies. In these circumstances, the team felt obliged to prescribe antibiotics and non-opioid painkillers to clients to manage this painful condition.

Commissioners and local councillors took a keen interest in the project and were given regular telephone and email feedback and visited the hotel to see how the teams were working together and get feedback directly from staff and residents. Some of the residents appeared on local news programmes talking about their experiences at the hotel.

The service would not have worked without the input of a local pharmacist who went above and beyond the call of duty to ensure that medication supplies were uninterrupted and were prepared and dispensed safely.

The local hepatology service took the opportunity to start hepatitis C treatment for seven residents who all successfully completed treatment during their stay at the hotel or shortly afterwards.

The only unwelcome visitors were a contingent from the far-right Britain First organisation who turned up unannounced one weekend demanding to know if the hotel was being used to house ‘immigrants’.

Conclusions and reflections

In general residents were overwhelmingly positive about their experiences at the hotel and had much more direct contact with staff and healthcare professionals than they would have done prior to the pandemic. Several took the opportunity to re-engage with treatment for neglected health conditions, such as leg ulcers and diabetes, whilst others sought to address long-standing mental health problems. Three residents decided to try detoxing from alcohol and another from methadone. The transformation that many residents underwent during their stays was inspirational.

Most professional colleagues were very supportive of the programme but some did express concern that staff might be putting ourselves at risk of contracting or spreading the virus by going into the hotel each day. However, recommendations were followed as closely as possible in terms of wearing PPE and maintaining social distance. All staff who participated in the prescribing service were subsequently tested for the COVID-19 antibody and none was positive.

Although it was anticipated that there would be problems with drug dealing and diversion of prescribed medication, managing it was an issue. For prescribed medications, it was ensured that all methadone and buprenorphine doses were supervised 7 days a week, but other medications such as Diazepam, Chlordiazepoxide, Pregabalin were more difficult to control. It is impossible to say whether there was any more diversion of medication in the hotel than there would have been out in the community – it may simply have been that it was more visible to us. There is existing research suggesting that up to 28% of clients in substitute opioid treatment programmes save their medication, 14% give it to someone else and 5% sell it (Haskew et al, 2008). The support staff did have to evict a small number of residents where problematic illicit drug-dealing and associated behaviours were persistent.

The problem of crack cocaine use became strikingly apparent to staff, especially on days when benefit payments had been made. Some clients would be overactive, overtalkative, disinhibited and paranoid – making it hard to enforce social distancing. Crack cocaine use would often continue despite significant physical health consequences, such as acute exacerbations of asthma or COPD that necessitated repeated hospitalisation and acute psychotic episodes.

Many of the COVID-Protect hotels across the UK closed after the first lockdown but this local authority secured additional funding to keep the hotel open until December 2020 after which it was handed back to council staff to manage the small residual population until they too had been resettled.

This multiagency way of working with specialist services providing in-reach to complex clients in a residential setting was such a success that the council and its commissioners were interested in the possibility of replicating this model on a smaller scale to continue after the pandemic has passed.

Key Points

• In April 2020, an Inner London Borough set up a COVID-Protect hotel to house around 100 homeless people
• Local health and social care services provided wrap-around, inreach support and treatment
• Substitute opioid therapy was provided to 35 individuals between April and December 2020
• To minimise medication diversion, opioid therapy was provided under direct observation at the door of residents' rooms seven days a week
• 84% of clients had been retained in substitute opioid therapy by the time the COVID-Protect hotel closed.

CPD reflective questions

• How were the health and social care needs of homeless people met in your local area during the COVID-19 lockdown?
• What measures did your local drug treatment service take to reduce the risk of COVID-19 transmission for service users on supervised opioid therapy?
• How can staff working in a COVID-protect hotel minimise the risk of viral transmission?
• What measures might need to be put in place to reduce the risk of diversion of controlled drugs in a COVID-Protect hotel?