Specialist Homeless and Primary Care Perspective

1. Specialist Homeless and Primary Care Perspective Dr Nigel Hewett Leicester Homeless Primary Health Care Service. Dawn Centre LE2 0JN GP and PCT Clinical Lead for Drugs and Alcohol

2. We are at the same point now with regard to alcohol treatment services as we were 15-20 years ago with drug treatment services.

3. Male, 27, cause of death not listed. Male, 42, alcoholic found dead in disused house. Male, 46, found dead in ditch, depression and alcoholism. Male, 44, burned to death in disused house. Male, 44, status asthmaticus. Male, 34, hepatic renal and pulmonary failure due to paracetamol poisoning and that he did kill himself by taking an overdose. Male, 41coronary thrombosis (diabetes and self neglect. Male, 30, methadone poisoning, having purchased a bottle of methadone he ingested and caused his own death. Male, 53, acute alcohol poisoning (found dead on a bench) Female, 18, inhalation of butane gas. Male, 39, acute haemorrhagic pancreatitis. Male, 27, hypothermia and high blood levels of diazepam. Male, 57, Alcoholic, epilepsy. The Leicester Homeless Death List.

4. Male, 34, haematemesis due to alcoholic liver disease. Male, 20, dihydrocodeine poisoning. Male, 41, methadone, cyclizine and diazepam poisoning. Male, 36, morphine poisoning following heroin injection. Male, 42, acute left ventricular failure due to coronary atheroma. Male, 28, fatal heroin overdose. Male, 17, methadone toxicity. Male, 23, multiorgan failure, heroin misuse. Male, 22, acute methadone poisoning, found in bin shed, Dover Street. Male, 22, heroin OD, found in toilet in Oxford. Male, 74, myocardial infarction due to ischaemic heart disease due to smoking. Male, 31, heroin overdose with alcohol in night shelter. Male, 51, acute left ventricular failure due to coronary atheroma (chronic alcoholic). Male, 45, collapsed and died outside night shelter, bronchopneumonia, cirrhosis, chronic alcohol abuse. Male, 42, septic shock, bronchopneumonia, hiv infection, chronic alcoholic. Male 43, stabbed to death. Male, 29, acute pulmonary oedema. Male, 31, heroin addict, alcoholic. The Leicester Homeless Death List.

5. Female, 36, bronchopneumonia due to self neglect. Male, 34, picked up by police taken to lri where died. Male, 21, Fatal misuse of heroin. Male, 26, heroin od, Male, 29, heroin poisoning. Male, 43, L pneumonia, alcoholic liver disease. Male, 36, drug and alcohol intoxication, found dead in ns. Male, 43, Pulmonary oedema, alcohol and codeine excess. Male, 39, HepC positive, chronic alcoholic, heroin od. Male, 29, suspension by ligature – suicide in prison. The average age at death for these 114 patients is 41 years. Alcohol is implicated as a cause of death for 45%. Accidental overdose of drugs of abuse is implicated as a cause of death for 28%. Deliberate suicide is implicated for 7%. The Leicester Homeless Death List.

6. PMS pilot established Outreach service now covers five direct access hostels, night shelter & two drop-ins. 1107 patients registered in last year. 8680 Doctor and nurse consultations. Contraception services enhanced to include condom provision. 80% cervical cytology rate. Acupuncture treatment for musculoskeletal conditions introduced. Vaccination rates increased, e.g. 136 patients vaccinated against hepB. 96 treatments for heroin dependence commenced. RCGP audit awarded highest possible grade of “outstanding” for our treatment programme for drug misuse in primary care. Clinical care enhanced by significant event analysis, audits of standards of care, prescribing trends and mortality data. Summary 2000 to 2005.

7. Homeless Primary Care Drug Treatment in Leicester Today. • Full time drug worker since 2004 • Continue to accept chaotic alcohol and poly drug using, groin injecting, dual diagnosis patients without waiting list. • Flexible drop-in service, within clear boundaries. • Audits – 2004, 85% had 3 doses hepB vaccine • 2004, methadone audit dose range 30ml to 140ml, average maximum dose 72ml • 2005 shared care introduced, numbers in treatment increased from average 31, to 59. • 06/07 73 patients treated in 98 treatment episodes • 81% retention rate at 12 weeks • 100% screened for blood borne viruses. • 07/08 85% retention rate, average maintenance dose 67ml, 92.2% vaccinated against hepatitis A and B

8. Non medical prescribing & extended role of drug worker. • Non-medical prescribing introduced in 2007, now used for majority of patients (currently 61 out of 63) • Minor illness treatment, blood testing, vaccinations all directly provided by drug worker, supported by primary care team • Active involvement in inter-agency care, chairing single homeless MDT • Community alcohol detoxification protocol for drug patients with alcohol dependence

11. Homeless Community Detox Protocol • If there is an immediate, urgent need for detoxification in this client group- such as vomiting, acute jaundice, haematemesis or other severe physical health problems, or symptoms of Delerium Tremens, then in-patient treatment as a medical emergency is the only safe option • There is also some evidence that repeated cycles of abrupt withdrawal and relapse may increase the risk of fits with subsequent withdrawal episodes – so a failed detox may be worse than no detox at all. Repeated failed detoxes may also reinforce the expectation of treatment failure, and reduce the possibility of successful engagement in the future. • However, we are frequently consulting with chaotic and damaged patients who are desperate to overcome their alcohol dependence. They are able to access our drop-in based service, but are too chaotic to engage with appointment based secondary care alcohol services. Many patients present in the early stages of withdrawal, having decided themselves to attempt to withdraw, without medical support if necessary. It is also important to consider that there is no risk free option, the average age at death for homeless patients in Leicester is 41 with nearly half of all deaths in this group attributed to alcohol. Consequently, not intervening leaves the patient at continuing high risk of death.

12. Audit of Community Alcohol Detoxification for Homeless Patients • All 19 patients treated in 12 months June 07 to July 08 to allow for 6 month outcome assessment • Age range 28 to 55, average 40, 2 F, 17 M. • 47% had SADQ score recorded (majority had dosage regime decided on clinical assessment) • Of those recorded, 33% had SADQ score in moderate range (15-30) • And 66% had SADQ score in severe or very severe range (31-60)

13. Alcohol Detox Outcomes • 12 (63%) had Pabrinex (B vitamin IM injections) • 12 of 19 (74%) completed 8 day course • 3 (16%) remained continuously dry • 1 immediately lost to follow up, of remaining 15 average duration to relapse 34 days, range 2 to 120 days. • 6 month outcome 8 (42%) dry (3 continuous plus 5 dry again after relapse) • Another 3 significantly reduced consumption, 5 the same, 3 lost to follow up. • So at 6 months 11 (58%) significant improvement

14. Near Future • Full time primary care based alcohol worker for homeless people starting 09/10 • Hospital employed alcohol liaison specialist nurse -in place now, most posted anticipated • Community alcohol liaison worker (Comm. Alcohol Team post) recruitment soon

15. Not so near future • Lets acknowledge the reality that most patients do not fit into tidy categories of drug dependence or alcohol dependence • The majority of the cases we see have poly substance misuse issues and usually accompanying mental and physical illness. • Has to be holistic response (addressing physical and mental health as well as substances) - primary care is the only setting trained and experienced to provide this • Aspire to GP facilitated, primary care based substance misuse service. Substance misuse worker in every practice willing to address not just drugs and alcohol, but drugs or alcohol in primary care setting