Social science inspires researchers to create much needed system and service change for people who are homeless with substance use problems

Dr Hannah Carver, Lecturer in Substance Use, Faculty of Social Sciences, University of Stirling

Dr Tessa Parkes, Director of the Salvation Army Centre for Addiction Services and Research, Faculty of Social Sciences, University of Stirling

The Covid-19 pandemic has been hard for us all, but let’s consider how much harder it has probably been for people experiencing homelessness and problem substance use. For them, the coronavirus can be particularly dangerous because following public health advice is challenging when you’re also managing underlying health conditions, and dealing with poor living conditions, financial pressures and historic, and potentially current, experiences of violence and trauma. In Scotland, however, we have witnessed inspiring initiatives spearheaded by partnerships across our third sector, statutory organisations, and NHS alike, dedicated to protecting vulnerable people from the coronavirus.

Housing those without homes

People who are homeless are at much higher risk of contracting, becoming ill, or dying from, coronavirus. This highlights the significance of providing housing to those who experience homelessness during a pandemic. At the very beginning of the lockdown in Scotland, hotels and student accommodation were made available for those living on the streets. The Scottish Government also made £350 million available to organisations working with people who were homeless. These policies have meant that almost every person was housed, albeit temporarily, during the initial lockdown period. Experiences across the UK suggest that this rapid housing of people was not without its challenges, with particular concerns about people leaving temporary accommodation in the middle of the pandemic because it was not able to support them with complex challenges like poor mental health and substance use problems. Simply providing housing was not enough.

Taking a harm-reduction approach

Harm reduction approaches for those experiencing problem drug use include a wide range of services and policies. In a blog written by Lauren Gibson, a specialist pharmacist working in Edinburgh, the wide range of services developed specifically for people who were homeless during the pandemic was highlighted. This included the rapid ‘scaling up’ of access to opioid substitution therapy, delivery of methadone prescriptions by newly mobilised volunteers including medical students, new avenues for naloxone distribution including using peers with experience of drug use, blood borne virus testing, and ambitious assertive outreach. People were able to access opioid substitution treatment the very same day they saw a health practitioner, rather than having to wait days or weeks. They didn’t even need to attend health clinics to do so. Staff went to them.

Extending initiatives to support people with problem alcohol use

When the pandemic came, we witnessed no equivalent ‘scaling up’ of harm reduction responses for people dependent on alcohol, however. While many organisations provided essential detailed clinical guidance for those with problem alcohol use, a focus on detoxification and managing withdrawal was not necessarily applicable for those with very specific needs, such as people who are homeless. Abstinence-based treatment programmes, which expect people to stop drinking, are difficult to comply with. Detoxification is simply impractical, and possibly unethical, for somebody without safe and secure accommodation. In some areas, detoxification was suspended, meaning that people who wanted this option could not access it. Additionally, the medical model of problem alcohol treatment means harm reduction may be considered as lying outside the remit of many practitioners.

Alcohol harm reduction approaches are therefore vital, but conventional harm-reduction measures such as i) offering information and advice about safer drinking, ii) provision of population-level approaches such as drinking guidelines, iii) restrictions on advertising, and iv) minimum unit pricing, are less effective for people experiencing homelessness. We do, however, have some evidence-based ideas about what might help people experiencing homelessness during the pandemic and beyond.

Managed Alcohol Programmes, or MAPs for short, support individuals to control their alcohol use and reduce harm gradually, whilst also providing access to a range of housing, health and social supports. MAPs were developed in Canada, where alcohol harm reduction approaches are more established. While none currently exist in Scotland, The Simon Community are setting one up in Glasgow. Based on the findings of our recent research on the potential of MAPs in Scotland, we believe that MAPs are likely to be important as a response to Covid-19. We are specifically exploring this in our current study funded by Scotland’s Chief Scientist Office,  which reports at the end of this year.

Data from our 2019 study shows that those who would be eligible for MAPs are not only at risk of alcohol withdrawal and associated health problems, but also at risk of experiencing a drug-related death. Almost half of our participants used drugs as well as alcohol, and use of more than one drug was also common. Scotland has the highest rate of drug-related deaths in Europe. Our study also showed high rates of physical and mental health problems. In a meta-ethnography we recently conducted on what people who are homeless want and need from substance use treatment services, we highlight that the way in which substance use treatment services are delivered is more important to those needing help, than the type of treatment or intervention. Treatment was considered by clients to be effective when it provided a facilitative service environment, compassionate and non-judgemental support, time, choices, and opportunities to (re)learn how to live.

Social science as a way to think about contemporary problems

Social science has helped us to think about the challenges we have discussed in this blog. We have been inspired by Tim Rhodes’ risk environment framework which highlights the influence of both micro and macro environments on risk-taking behaviour. Factors such as social norms, peer groups, economic factors, and the legal status of a substance, can all influence how risky use is. Lack of safe and suitable housing, the use of illicit drugs or non-beverage alcohol alongside alcohol, and a lack of appropriate harm reduction services, all put someone at much higher risk of alcohol-related harm.

Cameron Duff’s enabling places builds on Rhodes’ framework suggesting that particular social, material, and affective resources are needed for environments to be considered enabling, and for interventions to be successful. Indeed, Managed Alcohol Programmes have been described as such enabling places for those who experience homelessness and problem alcohol use, providing safe places for people to manage use without the expectation of abstinence.

Merrill Singer’s syndemic theory describes the clustering of a range of vulnerabilities which arise from harmful social conditions. The combination of homelessness, substance use, and both mental and physical health problems highlight the complex vulnerabilities affecting this group and the structures, such as healthcare services, that too often reinforce, rather than actively reduce, barriers.

As this blog has demonstrated, while we have made some progress, we still have much to do to support those living with the complex challenges in the context of the Covid-19 pandemic and beyond. Problem alcohol and drug use, and the mental distress that often lies behind this use, requires full attention in a pandemic response. It must be front and centre, alongside a focus on providing for people’s physical needs such as safe housing.

Application of social science, such as the approaches described here, drive us to take a structural rather than individual lens to understanding the nature of social and health problems, and consequent remedies. By understanding the macro as well as micro factors that influence people’s use of alcohol and drugs, and the resources available to them, we look far wider for levers of change. Taking a structural analysis avoids blaming individuals for their problems which is still, unfortunately, far too common. Its enables clarity on how systems and services need to work better together and change to improve individual outcomes. It encourages us to view individuals as survivors of very difficult lives and stark inequalities, as hugely resilient in the face of adversity, and as experts on their lives and what they need to be safe and well.

This article first appeared on the Campaign for Social Science blog, on 3 September 2020.

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