People who use opioids, including heroin, may delay seeking health services due to experiences of inequitable treatment in care. Delays in accessing care can lead to worse health outcomes for the individual as well as added strain on healthcare services. Qualitative research with people who use opioids suggests that a primary reason for delayed care-seeking is the lack of timely access to opioid substitution therapy to prevent withdrawal upon hospital admission. The iHOST study seeks to address this gap by implementing a five-pronged intervention to improve OST provision in acute hospital settings. The intervention has been co-developed with people who use opioids and other key stakeholders.
This project is funded by NIHR [HSDR NIHR133022]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the DHSC.
We are a multi-disciplinary team with expertise in social science, pharmacy practice, implementation science and health economics who have a considerable track record of work in these areas.
iHOST stems from the Care & Prevent project.
The aim of Care and Prevent was to improve skin and soft tissue infection (SSTI) prevention, care and treatment for people who inject drugs.
We found that:
- High reported lifetime prevalence of SSTI: 68% (310/455)
- High proportion hospitalised for SSTI: 44% (137/310).
- SSTI severity & hospitalisation associated with time taken to access care (54% >5 days, 28% >10 days)
- Fear and experience of opioid withdrawal in hospital a primary barrier to treatment presentation & completion
Read more information on the findings.
Our qualitative data provided additional insight:
- We found that PWID are living with serious, painful health conditions and avoiding care
It was mad, like I was homeless and the right side would just randomly, out of nowhere, it would just burst with blood, like blood everywhere! Within ten seconds my entire trousers would be covered in blood. (Lee)
- When they get care: usually an emergency and instigated by someone else
My brother and my friend saw me struggling to walk to the toilet and my knee was almost trebled in size. So, they said, “If you don’t go you’re gonna die,” and it started to get really hot … I went to A&E … they were draining it and I saw the colour of the stuff was like a luminous green. (Jay)
- People are delaying care because they are worried
- Of punitive and harming intervention
“It’s being so scared at turning up at the hospital and when they’ve got an ulcer … “oh we’re going to cut your hand off” seriously, it’s scared.”
- Of being judged and stigmatised
“When you go into the A&E smelly legs, it’s ** embarrassing man, having to sit there and people looking and you know, yeah, it’s horrible.”
- Of being hospitalised and in withdrawal
“Severe pain [for 3 weeks] …then I had a fever and then eventually my girlfriend phoned the ambulance … Scared, it’s the fear of the not having drugs at the time and that sounds pathetic. …I wasn’t on the script, no.”
What is iHOST?
iHOST is an intervention that aims to improve hospital care for people who use opioids by removing barriers to opioid withdrawal management.
The iHOST intervention involves five key components co-produced by people who use opioids. Each of these five components aims to improve access to OST for all people who use opioids. The five components are:
- ‘My Meds’ patient advocacy card;
- An OST advocacy and information helpline for people who use opioids and for hospital staff;
- An e-learning training module for hospital staff;
- A ‘best practice’ hospital OST policy template; and
- A local iHOST ‘champion. Each of these intervention components has been coproduced with relevant stakeholders, including people who use opioids.
- My Meds advocacy card
The card was developed through workshops with people who inject drugs in Camden, Finsbury Park and Brixton.
“like a helping hand. Something that speeds up the time you get your Methadone in hospital.”
“We need something like that [card] to take to the hospital to say I’ve got a right to be treated with dignity”
The advocacy card is credit card sized, double sided, and generic rather than personalised. It aims to:
- Empower people on OST to feel safe to access hospital care and to disclose their medication requirements.
- Enable timely medicines reconciliation: prescriber and pharmacist contacts to be entered by the drug service
- Support patients and staff with specialised OST advocacy and information (Release helpline).
No hospital will prescribe OST on the basis of the card alone. PWUD can choose to take or refuse a card (not mandatory).
- Advocacy helpline
The advocacy helpline, run by Release, aims to ensure that patients are supported in securing their community OST, in line with the hospital policy where the caller has been admitted. The advocacy helpline will also offer advice to hospital staff.
- Training module
The e-learning training module will offer hospital staff an introduction to providing equitable care in acute care settings. The training is designed to reduce stigma against people who use opioids, and to equip hospital staff in communication and de-escalation strategies. The training aims to improve understanding of the basic therapeutics and key safety around prescribing and administering OST. The training also includes an additional component to support local iHOST champion in taking up their role.
- ‘Best practice’ policy template
The ‘best practice’ guideline will be iteratively developed over the course of the iHOST project timeline. The aim of the 'best practice' guideline is to collate available evidence with insights from stakeholder consultation to promote the timely and effective management of opioid withdrawal symptoms in hospital. Our development of the 'best practice' guideline draws from the team's review of 101 existing hospital policies across England. In addition to this review, we also conducted a review of current national guidance from governing bodies such as NICE and the Department of Health and Social Care. The final 'best practice' guideline will be approved by key professional bodies and developed through robust engagement with people who use opioids as well as hospital staff.
As the first step in the 'best practice' guideline development process, we sought to revise existing guidelines at the pilot site, UCLH. The revised guideline was authored with support from the iHOST Policy Template Working Group, assembled of partners of the iHOST study, which met regularly to workshop the guideline's key provisions. The guideline's full development was guided by an Oversight Group, convened by the iHOST team with representation from key professional bodies, to refine and vet the guideline's final recommendations through facilitated workshops and written feedback. The final ‘best practice' guideline has also been revised and signed off by three committees of UCLH (the Opioid Stewardship Committee, the Use of Medicines Committee, and the Clinical Guidelines Committee). At its core, the guideline establishes four key changes to practice: 1) removing the urine screen requirement for OST prescription; 2) increasing the starting dose for initiating OST; 3) enabling takeaway OST for people who are already on a community OST prescription; and 4) providing takeaway naloxone to all patients prescribed OST in hospital.
- iHOST champion role
The iHOST champion(s) will support implementation of the iHOST intervention package in their local hospital setting, especially with respect to the training module and policy template. The iHOST champion(s) will promote uptake of the training module and, where relevant, alert colleagues to any changes made to local hospital policy and practice around OST provision. The iHOST champion role description has been co-produced with hospital staff including nurses.
Magdalena is a sociologist in inclusion health based at LSHTM. She leads a mixed-method programme of research on health interventions for people who use heroin and crack cocaine in the UK, including through NIHR projects. She has 18 years’ experience in qualitative and participatory research with people who use drugs, holds the 2020 Society for the Study of Addiction Award for Impact on Policy and Practice and in 2022 was awarded a Membership through Distinction of the Faculty of Public Health.
Director of the UCL Institute of Epidemiology & Health Care and NIHR Senior Investigator
Andrew is the Director of the UCL Institute of Epidemiology & Health Care and NIHR Senior Investigator, has over 20 years research experience on marginalised populations leading to policy change and service improvements.
Public health specialist and researcher
Dan is a public health specialist and researcher. He is an expert in analysis of data from hospitals, GPs, and other health services. Dan is leading the quantitative evaluation of iHOST.
Viv is currently Professor of Public Health at the Public Health Institute, Liverpool John Moore University. Prior to this he worked at Public Health England, and he has held academic posts at London School of Hygiene & Tropical Medicine, Imperial College London, and the University of Birmingham. He has over 25 years’ experience of research and public health practice focused on understanding the health issues associated with drug use and the responses to these. His research has focused on the harms associated with the injection of drugs, particularly infections, and preventing drug-related deaths. His research interests also include the use of human enhancement drugs, sexualised drug use, sexual health, and the well-being of LGBT+ communities.
Senior Lecturer in Primary Care
Jenny is a Senior Lecturer in Primary Care, and has expertise in intervention development in community pharmacies including online training development, previous clinical experience in hospital pharmacy and current clinical experience in a community drug treatment team.
Roz is Director of Pharmacy for Humankind, a national substance misuse provider, has clinical and research expertise in the management of substance misuse, psychiatry and pharmacy practice in primary and secondary care settings.
Alistair is the Find and Treat lead for UCLH, co-ordinates a programme of outreach care for homeless, has published widely on inclusion health for marginalised populations and has extensive experience in operationalising public health interventions amongst vulnerable populations.
Peer worker with UCLH Find and Treat
Adrian is a peer worker with UCLH Find and Treat. He has lived experience of OST, has received research training from MH, has experience in interviewing PWUO about hospital care access and will act as PPI lead.
Niamh is Executive Director of Release, has extensive legal, advocacy and drug policy experience.
Mike is a Consultant physician in Infectious Diseases and Acute Medicine, and Clinical Director, Division of Infection, UCLH, and Hon Associate Professor in the Clinical Research Dept at LSHTM, has led and published on improving diagnosis in vulnerable populations in acute hospital and primary care settings, and leads the Inclusion Health Strategic Forum at UCLH.
Consultant in Infectious Diseases
Penny is a Consultant in Infectious Diseases, with a special interest in emerging infections, HIV, blood borne viruses and working to improve medical care delivery for patients who use opioids.
Ann-Marie is Emergency Medicine Consultant and Clinical Director for Emergency and Acute Medicine at Tertiary Major Trauma Centre and will be the clinical project lead for the Staffordshire hospital site.
Andrew is the Founder of Exchange Supplies a social enterprise developing equipment, information, and training to reduce drug related harm.
Public Health Physician/Research Fellow
Adam is a Public Health Physician and a Research Fellow at the University of Bristol and the London School of Hygiene and Tropical Medicine. He has research interests in the ethical and empirical arguments for different drug policy and harm reduction approaches and improving healthcare services for underserved populations who use drugs.
Nerissa is a Research Assistant at the London School of Hygiene & Tropical Medicine. She is supporting the research activities on the iHOST project.
Marisha Wickremsinhe is a bioethicist and qualitative researcher. Marisha leads the guideline development process for the iHOST study in her role as Research Fellow. Alongside Magdalena and Bean, she also conducts qualitative research for the iHOST study as part of the project's process evaluation.
The Advisory Board
- Professor Anne Whittaker (Chair)
- Professor Sir John Strang
- Professor Peter Vickerman
- Dr Monica Desai
- Dr Tom Yates
- Dr Thomas Brothers
- Dr Chris Ford
- Dr Caitlin MacLeod
- Mr Peter Simonson (PPI member)
- Dr Chris Hallam (PPI member)
- Ms Erin O'Mara (PPI member)
Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence
Magdalena Harris, Adam Holland, Dan Lewer, Michael Brown, Niamh Eastwood, Gary Sutton, Ben Sansom, Gabby Cruickshank, Molly Bradbury, Isabelle Guest & Jenny Scott
BMC Medicine volume 20, Article number: 151 (2022)
Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care
Social Science & Medicine Volume 260, September 2020, 113183
‘Care and Prevent’: rationale for investigating skin and soft tissue infections and AA amyloidosis among people who inject drugs in London
M Harris, R Brathwaite, Catherine R McGowan, D Ciccarone, G Gilchrist, M McCusker, K O'Brien, J Dunn, J Scott, V Hope
Harm Reduction Journal Volume 15, Article number: 23 (2018)
Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK
Talen Wright, Vivian Hope, Daniel Ciccarone, Dan Lewer, Jenny Scott, Magdalena Harris
PLoS One. 2020 Jul 14;15(7):e0235350
Magdalena Harris 2022
- What is iHOST?
Improving Hospital Opioid Substitution Therapy (iHOST) is an intervention that aims to improve hospital care for people who use opioids by removing barriers to opioid withdrawal management. The project will co-produce, test and evaluate an intervention to make access to opioid substitution therapy (OST) timelier, more effective, and patient centred.
The iHOST intervention involves five key components:
- 'My Meds' patient advocacy card;
- An OST advocacy and information helpline for people who use opioids and for hospital staff;
- An e-learning training module for hospital staff;
- A 'best practice' hospital opioid substitution therapy policy template; and
- A local iHOST 'champion.
Each of these intervention components has been co-produced with relevant stakeholders, including people who use opioids.
- Why is this study important?
The UK has highest rate of drug-related deaths in the European region and people who use drugs are at high risk of morbidity and mortality (1). Our research and international evidence shows that fear of opioid withdrawal is a barrier to timely hospital presentation and treatment completion among people who use illicit opioids, such as heroin, and/or who receive opioid substitution therapy (OST). Opioid Substitution Therapy (OST) is a medication-assisted intervention where patients are prescribed opioids such as methadone to alleviate symptoms of withdrawal, reduce drug use and help provide stability (2). There are an estimated 260,000 illicit opioid users in England (3) and over 140,000 people in England are on treatment (4). This is an ageing population, vulnerable to premature death, illness and infectious disease (5). People who use opioids have complex health needs and the rate of hospital admission in this population is several times greater than people of the same age in the general population (5).
Poor opioid withdrawal management, including breaks in continuity of care between community and hospital OST provision, can lead to discharge against medical advice, which is associated with emergency readmission in the following month (6). 1 in 14 opioid-related deaths in England happens in the two weeks after the hospital discharge (7).
Hospital-based interventions for the highly marginalised population of people who use illicit opioids, are therefore crucial.
- Where can I find more detailed information on the study?
The protocol is a document which outlines the plans for the study. This document describes the background, rationale, research methods, how the intervention will be delivered and the types of analysis that will be conducted to evaluate the study.
- What ethical approvals does the study have and is it registered?
This research has been approval by the NHS Health Research Authority, with details available for improving hospital OST. The study has been granted ethical approval by London - Camden & Kings Cross Research Ethics Committee (Reference: 22/LO/0370) and the London School of Hygiene and Tropical Medicine Ethics Committee (Reference: 27895)
The NHS Health Research Authority is a regulatory body that approves health and social care research, mostly in England, but also works closely with the other countries in the UK to provide a UK-wide system. Any research project that involves recruitment of NHS patients, staff, premises, resources (pharmacy, radiology or laboratories) or data/tissue in England must go through the HRA approval process, including ethical approval where appropriate.
The research is registered on the ISRCTN registry.
The ISRCTN registry is a primary clinical trial registry recognised by WHO and ICMJE that accepts all clinical research studies (whether proposed, ongoing or completed), providing content validation and curation and the unique identification number necessary for publication.
A systematic review on "How can access to opioid agonist therapy be improved in acute hospital settings?" is being conducted as part of this research. The review is registered on PROSPERO.
PROSPERO is an international database of prospectively registered systematic reviews of health and social care related research. See more information about the database. A systematic review is a piece of research that aims to identify, select and synthesis all research published on a particular question or topic. Systematic reviews follow a strict design that is planned in advance and this plan could be reproduced by another team of researchers.
- I would like to raise a concern about this research, who do I contact?
If you would like to make a formal complaint, you can do this by contacting the LSHTM Research Governance and Integrity Office at RGIO@lshtm.ac.uk or call 020 7927 2626.
- How can I find out the progress of this research?
The progress of the project, preliminary findings and research results will be reported in a variety of places including at external and publicly available methods such as conference presentations, peer-reviewed publications and community presentations. These will be made available on the outputs section of this website.
The progress of this research will also be shared at hospital sites that this intervention is being conducted in.
- Who is the funder, and how do they decide what to fund?
The National Institute for Health Care and Research (NIHR) is funding this research. NIHR is the nation's largest funder of health and care research, spending £1 billion from the Department of Health and Social Care on research every year.
NIHRs work focuses on early translational research, clinical research and applied health and social care research. NIHR work in partnership with the NHS, universities, local government, other research funders, patients and the public, to fund, enable and deliver world-leading health and social care research that improves people's health and wellbeing and promotes economic growth.
Find out more information on NIHR fund research. Patients, members of the public, users of social care services and carers can get involved at all stages of NIHR research funding. Find out more about how to be involved.
This research comes under the research call for "19/165 HS&DR Injuries, accidents and urgent and emergency care" and started on March 2022 and is expected to finish in February 2025. The project reference for this is HSDR NIHR133022. The views expressed are those of the research team and not necessarily those of the NIHR or the DHSC.
- Who is conducting this research?
The multidisciplinary team working on this project represents advocates from national charities, clinicians and academics. Find out who is in the team.
The lead researcher (Principal Investigator) is Magdalena Harris who is based at the London School of Hygiene and Tropical Medicine. Magdalena leads a mixed-method programme of research on health intervention for people who use opioids in the UK, including through NIHR projects. She has 20 years' experience in qualitative and participatory research with people who use opioids.
- How will you know if the intervention makes a difference?
There will be a few ways of understanding if this intervention has made a difference. The outcomes, which are the markers expected to change as a result of the intervention, are measured quantitatively (through hospital data sets at local hospital site and nationally across England) and qualitatively (through interviews, focus groups and observations with participants across the intervention).
There are two primary outcomes: Discharge Against Medical Advice (DAMA) and Emergency hospital readmission within 28 days of discharge.
There are four further secondary outcomes: Reported inpatient illicit drug use; Time between admission; prescription of Opioid Substitution Therapy (OST) and receipt of OST; OST dose; Provider knowledge and attitudinal change
We will also seek to understand what parts of the intervention were key to these changes, what aspects were less important and how this differs according to the context of the intervention site. This will help us refine and develop the intervention further.
- Where are you carrying the study out? (What sites are you working with to test and evaluate iHOST?)
The three participating hospitals are: University College London Hospital, St James's University Hospital in Leeds and Royal Stoke University Hospital in Staffordshire. These sites have been selected to represent different geographical contexts and all experience a high proportion of people who use drugs accessing accident and emergency and acute inpatient admissions.
The drug treatment services participating in London are situated in boroughs close to University College London Hospital. These are Better Lives Islington, Better Lives Seven Sisters, Westminster Turning Point and the Margarete Centre, Camden and Islington Foundation Trust.
The main drug treatment services participating in Leeds and Stoke are operated by Humankind: Staffordshire Treatment and Recovery Service (STARS), Forward Leeds.
The charity Release are providing the helpline.
- Where do people get the cards and how are they expected to work?
'My Meds' patient advocacy cards will be provided to clients on Opioid Substitution Therapy (OST) at the drug treatment intervention sites. For London these are: Better Lives Islington, Better Lives Seven Sisters, Westminster Turning Point and Margarete Centre.
The My Meds cards have a dual function:
- To empower people to access hospital and alert hospital providers to their needs for OST
- To enable hospital providers to conduct medicine reconciliation without delay
The card includes the advocacy helpline number for further assistance or information. The three hospitals that are participating in this intervention (University College London Hospital, St James's University Hospital in Leeds and Royal Stoke University Hospital in Staffordshire) are not expected to provide OST based on being shown this card alone.
- Who can access the helpline and how is it expected to work?
Anyone can access the helpline. It has been designed to support patients and staff in hospitals with OST provision who engage with the three participating hospitals of this intervention: University College London Hospital, St James's University Hospital in Leeds and Royal Stoke University Hospital in Staffordshire.
The helpline will be staffed by patient advocates who have a significant understanding of Opioid Substitution Therapy OST and, as partners in the project, have an understanding of the hospital's guidelines for patients accessing these medications, which may assist clinical staff.
The hospital helpline, advertised on the 'My Meds' card, is expected to operate between 10am and 6pm. The helpline number can be texted to organise a call back in operating hours. Details will be taken and Release staff will contact the relevant medical team and hospital pharmacist involved in the patients care, as well as liaising with the community drug services responsible for the patient's prescription.
The advocacy helpline is run by Release and aims to ensure that patients are supported in securing their community Opioid Substitution Therapy (OST), in line with the hospital policy where the caller has been admitted. Release has been providing advocacy and legal support to people who use drugs for over 50 years.
- Will this intervention be available across the NHS?
The intervention is currently only being conducted in the three participating sites: University College London Hospital, St James's University Hospital in Leeds and Royal Stoke University Hospital. After the iHOST intervention has been evaluated the team will make any changes or tweaks required, and dependent on the findings, will recommend it is implemented at scale across NHS acute hospital Foundation Trusts.
- What is the role of the drug treatment services?
Drug treatment services provide health care and support for people who are concerned about their use of drugs. In terms of the iHOST intervention, drug treatment services will hold a stock of 'My Meds' patient advocacy cards for people who use their service and receive OST.
The 'My Meds' card prototype was co-produced with people who use drugs and refined in collaboration with a variety of stakeholders, including drug treatment service providers. We have consulted drug treatment providers CGL, Turning Point, Humankind and NHS addiction services regarding implementation feasibility.
London Making Every Contact Count provides a list of community drug treatment services across London. Drug treatment services can be found at a national level.
Opioid Substitution Therapy (OST)
- What is opioid substitution therapy (OST)?
Opioid Substitution Therapy (OST) is a medication-assisted intervention where patients are prescribed opioids such as methadone to alleviate symptoms of withdrawal, reduce drug use and help provide stability.
OST is approved by National Institute for Health and Care Excellence (NICE) for the treatment of opioid dependence. The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. (1)
OST reduces the risk of all-cause mortality, including from opioid overdose, and reduces the risk of blood-borne virus transmission, including HIV and hepatitis C (2).
How is it prescribed?
Methadone is usually prescribed once-daily, with the initial daily dose of 20–30 mg that is later increased. Most methadone patients receive 60–120 mg of methadone per 24 hours, but some need higher doses.
How does OST work in a hospital setting?
When people who use heroin and other opiates are admitted to hospital, they usually need prompt medication e.g. opioid substitution therapy (OST) to prevent drug withdrawal. This is regardless of whether they are on a prescription for OST or not.
In hospital, the purpose of OST provision is to:
Prevent opioid withdrawal symptoms, Enable treatment of presenting medical condition(s), Reduce risk of self-management of withdrawal using illicit opioids in hospital, and Reduce risk of discharge against medical advice.
People who use opioids need access to OST in hospital to not only prevent withdrawal symptoms and a loss of tolerance, but also to ensure their wellbeing and ability to stay in hospital. Failure to offer opioid substitution therapy can contribute to decreased tolerance, thereby putting the patient at risk of fatal overdose upon discharge.
- Opioid withdrawal is just like the flu, isn't it?
A common misconception is that symptoms of opioid withdrawal are relatively mild. However, people who use drugs report that experiences of opioid withdrawal are intolerable and far more significant than 'flu-like' symptoms. The fear of opioid withdrawal can be highly distressing and precede the actual onset of physical withdrawals. Rising panic and distress can be alleviated by knowing that withdrawals will be treated in a timely manner before they become severe.
In this project, we promote trusting people who use drugs, and trusting their accounts of opioid withdrawal symptoms.
Hospital experiences for people who use drugs
- Will more people go to hospital to access drugs?
We want people to attend the hospital. The United Kingdom (UK) has the largest reported population of people who use non-prescribed opioids in Europe. The rate of emergency hospital admission in this population is several times greater than people of the same age in the general population, with most admissions relating to long-term health conditions, injuries and bacterial infections. Delays to seeking treatment are common and many admissions result in discharge against medical advice. Patients who leave hospital prematurely are more likely to be readmitted and have higher risk of death. Hospital discharge is a particularly risky time for people who use heroin as they may leave hospital in an unfamiliar neighbourhood and use drugs in public places, often while unwell and with reduced opioid tolerance, which are all risk factors for overdose.
People who inject drugs are often living with serious and painful health conditions but avoid care. Our research has found that people often delay care because they are worried about a health intervention that might harm them, but are particularly concerned about being judged and experiencing opioid withdrawal while hospitalised.
Some people are concerned that people who use drugs will come to hospital just to access OST. However, people who use drugs have greater access to drugs outside of the hospital rather than within it. People do not attend hospital to access drugs. Opioid substitution therapy helps manage the symptoms of withdrawal and does not lead to a euphoric effect.
- I am interested in reading more on this topic, what do you recommend that is freely accessible?
The academic publications below, which are freely accessible, are a good place to start.
They present the experiences of people who use drugs and the policies hospitals have on opioid substitution therapy.
- Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care
- Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence
Please contact firstname.lastname@example.org if you would like to find out more or have publications sent to you.