Covid-19 crisis led to quicker access to homeless services, new study finds

The study found vulnerable homeless clients were moved to single occupancy accommodation at the outset of the pandemic. 

The Covid-19 crisis led to improved services and access to treatment for people who are homeless, with a new study asking why it took a global pandemic to remove barriers to harm reduction measures which had been required for years.

The research paper, called Harm reduction in the time of Covid-19: Case study of homelessness and drug use in Dublin, Ireland was just published in the International Journal of Drug Policy. It outlines the dramatic moves taken at the outbreak of the pandemic to protect those who were sleeping rough and in emergency accommodation.

According to the authors: "It is noteworthy that in the field of Irish medicine, the Covid-19 crisis facilitated a number of practice changes that had persuasive arguments in their favour prior to Covid-19, e.g. emailed prescriptions, electronic social welfare certificates, tele-consultations, etc. Why it took a pandemic to overcome barriers to seemingly obvious practice reforms is difficult to discern."

It added that longer-term, the Covid-19 experience is "a potentially important milestone in the development of national drug policies".

Vulnerable homeless clients were moved to single occupancy accommodation at the outset of the pandemic and, by early June, more than 750 symptomatic clients had been tested and screening was conducted on 450 asymptomatic residents and 165 asymptomatic staff in hostels where there had been positive cases.

More than 330 clients had been placed in isolation, rotating through a 50-bed isolation unit, and more than 500 people had been placed in shielding, of whom 340 were in newly obtained units.

Thus, the crisis appeared to demonstrate that whatever systemic factors had heretofore maintained long waiting times for OST, the Covid-19 impetus saw them removed overnight

There was just one Covid-related homeless death and the study highlighted how Dublin's infection rate of 2% compared favourably to Boston, where 10% of the homeless population got the virus and shielding units were not developed.

However, the paper points out big changes elsewhere.

Regarding opiate substitution therapy, or methadone, pre-Covid there was a 12-to-14 week wait for treatment for GMQ Medical, a primary care service for homeless people. With the virus outbreak, the HSE issued national contingency guidelines allowing for reduced waiting times and removal of caps on recruitment to treatment.

This, along with other drug treatment clinics agreeing to take on homeless patients resident in hostels in their catchment areas, meant waiting times dropped "overnight" to 2–3 days. There was more flexibility in obtaining take-away dosages, with the amount of methadone patients were allowed to take away decided on a case-by-case basis.

"Thus, the crisis appeared to demonstrate that whatever systemic factors had heretofore maintained long waiting times for OST, the Covid-19 impetus saw them removed overnight," it said.

Also prior to Covid, GMQ Medical offered BZD (Benzodiazepines) detoxes based on the national protocol, but only offered BZD maintenance in occasional cases. However, as the Covid outbreak unfolded, those with high dose BZD dependence were unlikely to remain in their accommodation, increasing the risk of infection.

"National contingency guidelines emerged recommending that patients in isolation could be offered up to 30mg daily to prevent withdrawals for the period of isolation only. In the homeless sector, over 70 people were commenced on BZD maintenance treatment."

Finally, Naloxone  — used for the complete or partial reversal of opioid overdose  — was made more widely available, with more flexibility as to who could administer it.  

The paper was written by Austin O'Carroll, the Covid-19 Clinical Lead for Homelessness in Dublin, Tony Duffin, the CEO of the Ana Liffey Drug Project, and John Collins, Director of Academic Engagement of the Austria-based Global Initiative Against Transnational Organized Crime.

Paper co-author and Clinical Lead for Homelessness in Dublin, Dr Austin O’Carroll said: “As the Covid pandemic approached there was a palpable fear amongst the homeless population and those who provided services to them. Homeless people, who have the worst health indices in the western world and who either sleep rough or live in shared accommodation, found themselves in a precipitously dangerous and vulnerable situation.

"The sector was very happily surprised by not only the low rate of infection and negligible death rate, but also by the noticeable improvement in general health and wellbeing in the homeless population. This served as a timely reminder that there are inextricable links and vicious circles between housing and health, housing and substance use and health and substance use.” 

Another co-author, Tony Duffin, CEO of Ana Liffey Drug Project, said: “Thanks to the determined effort of all those involved, during the first wave of Covid-19 in Ireland, the number of Covid infections amongst people who use drugs and who are homeless in Dublin was lower than had been anticipated.

“As highlighted by this paper, a harm reduction approach has been, and will continue to be, an important element of the public health response to Covid-19 for this cohort; it is crucial to help stop the spread of the virus and to reduce drug-related harm.” 

 The third author, Dr John Collins, Director of Academic Engagement, the Global Initiative Against Transnational Organized Crime, said: “Ireland has shown itself as a policy innovator during the Covid-19 crisis and has outperformed even best-case scenarios for mortality among homeless and drug-using populations in Dublin. 

"As some countries tentatively emerge from the first wave of Covid-19, it is important to take stock of lessons learned.

"This report highlights how Dublin’s success emerged from a variety of factors including a sense of national emergency, pragmatic and well-coordinated government policy, the provision of housing, the expansion of harm reduction services, and the bravery of front line service providers. 

These policies are replicable across the world and in many cases merely represent a reduction in barriers to service provision, rather than a radical departure from existing approaches.

"Secondly, this report highlights some long term policy lessons from Covid-19. It is clear that innovations, made under emergency conditions, should not be allowed to roll back as and when the virus recedes. 

"Covid-19 has meant that policy barriers in Ireland that may have taken years to reduce have been pushed aside in a matter of weeks. 

"If these gains are kept in place, aside from the lives saved during the Covid-19 pandemic, they will more than likely continue to save lives long into the future.”

• You can read the full research paper here.