Discussion
overdose, anxiety, substance dependence, overdosed, atrial fibrillation, deaths, trauma
ATRIAL FIBRILLATION, RECRUITMENT, NUTRITIONAL DEFICIENCIES
Despite having a reputation for being hard to reach, 128 from 130 participants were engaged, provided consent and detailed baseline information during lengthy in person assessments in one of 20 different venues.The median duration of homelessness was 23.5 years, which is approximately half the life expectancy of a person experiencing homelessness in Scotland [Heroin-assisted treatment of problem opiate use has some evidence of reduced street heroin use; however, the impact on overdose remains uncertain [The effectiveness of current care for problem drug use in people experiencing homelessness could be assessed by measures such as the number of drug-related deaths or overdoses or the number of participants presenting to emergency department with drug-related problems. Given one of the main outcomes from treatments such as OST and diazepam is to reduce harm and prevent overdose and deaths, the effectiveness of current care appears conditional on the effectiveness of these treatments for poly problem drug use. That participants repeatedly overdosed despite receiving OST and in some cases, diazepam, highlights an evidence and practice gap in the care of participants in this study, in terms of their problem drug use. In terms of established interventions, OST is proven to reduce all cause and overdose mortality in people dependent on street opioids [Difficulties associated with recruitment of people experiencing homelessness in trials may have previously limited collection of information about characteristics [“Housing First” offers permanent, self-contained housing for people experiencing homelessness, alongside wrap-around health and social care support. It is an evidenced approach to ending homelessness for people with complex needs including mental health problems [Participants had an average of two mental health problems. Medicines and other approaches have a role in the treatment of people with complex trauma and other mental health problems. Sixty-seven (50%) were in receipt of medicines for mental health problems, but none of the 128 participants were receiving any other form of specialist mental health input. While this is in keeping with previous work [Residential treatment services for drug use are scarce across Scotland [Inequities in the prescribing of diazepam may be due to clinical decision making in the light of uncertain evidence of benefit particularly in a high-risk cohort using multiple drugs who are frail. Given the high prevalence and importance of problem street diazepam use in our participants, and the congregate living conditions which bring participants into close proximity, it is likely that participants are aware of each other’s drug habits and treatments. Prescribed diazepam inequalities are unlikely to be lost on participants who already have a heightened sense of discrimination and stigmatisation and live together. Other unexplained inequities shown by these data include: variable uptake of COVID-19 vaccination; irregular registration with General Practitioners; and low levels of registration with mental health services.Health-related quality of life is regarded to be the most relevant outcome for people experiencing homelessness; health outcomes are significantly associated with quality-of-life scores [Our findings demonstrate extensive unmet health and social care needs of people experiencing homelessness post overdose. These needs are unlikely to be met by continuation of care as usual. Innovative models of care and new interventions are necessary to address the status quo, accompanied by robust, pragmatic research including qualitative research to understand the complexity and barriers and facilitators to real world implementation [The competing needs of finding safety, managing the impact of an accumulated treatment burden and self-medicating for anxiety and substance dependence may have diverted attention away from health seeking behaviour until problems became overwhelming and required ED attendance [Limitations to generalisability include most of the participants identifying as Caucasian, and recruitment from one Scottish city albeit across 20 different venues. Screening for other specific conditions, e.g. atrial fibrillation through electrocardiography or blood samples for nutritional deficiencies, did not form part of baseline assessments which limits our understanding of these and other important needs. Worldwide, proportions of people experiencing homelessness using multiple street drugs and overdosing are unclear, making generalisations based on these data difficult. There were 26,166 homelessness applications across Scotland in 2021/2022 [