Supporting people who use drugs

What are the effects and harms of drug use?

The use and effects of a drug on an individual can vary depending on a number of factors. There is a difference between ‘recreational use’ and ‘dependency’:

• Recreational – occasional use of drugs, usually in a social setting
• Dependence – repetitive use of drugs resulting in feeling withdrawal symptoms 

It is important that homelessness services are aware of an individual’s history, type and pattern of drug use, as this will help in ensuring that the right support can be made available. 

Some of the common harms associated with problematic drug use include:

• Dependency and addiction
• Committing crime to fund drug use
• Decrease in personal care
• Negative socio-economic circumstances
• Unstable accommodation and periods of homelessness
• Mental health problems
• Poor social networks and social isolation
• Difficulty making/keeping appointments
• Physical health complications
• Loss of life 

Therefore, it is important that an organisation has the following in place:

• Clear entry criteria, which should also be outlined in your organisation’s policy and referral document. (See example drugs policies below)
• A comprehensive assessment – to determine the type of drug(s) being used, the frequency, history of use, and type of administration (i.e. smoking, injecting, vaping, snorting).
• Risk assessments – based on the tolerance levels of your service and its set up, other people accessing the service, staff, and the individual themselves.
• Regular support sessions – to understand an individual’s journey, highlight changes in drug use, and to discuss how they might like to be supported with their substance use.
• Correct and legal policies and procedures – to ensure that people that use drugs, as well as other people accessing the service and staff, are safe and supported appropriately, and that services operate within the law.
• Good joint working arrangements – so that individuals can be supported in a holistic manner.
• Health and safety – making sure that this is regularly monitored and in line with other organisational policies and procedures, such as lone working practices. The health and safety of people who use drugs should be paramount, for example, making sure that those that use drugs are offered regular health checks, and given harm reduction advice.

How can homelessness services support people who are using drugs?

Effective care planning

It is important that the support worker builds good rapport with the individual, so that they feel comfortable in discussing and disclosing problems that they are facing, including the use of drugs. A holistic approach to care planning should include:

• Health checks (physical and mental)
• Tackling/reducing level of debt
• Exploring education and employability opportunities
• Improving social networks and relationships
• Building an increased understanding of rights and responsibilities
• Reducing or abstaining from substance use
• Improving housing resilience
• Encouraging hobbies

This should be facilitated by the staff member, with actions and goals identified and agreed by the individual. Care planning provides an excellent opportunity to discuss and, if appropriate, professionally challenge preconceptions, raise aspirations, discuss drug use and impart key harm reduction measures, as well as exploring aspects of wider community re-integration and overall wellbeing. Read our resources on strengths-based practice here.

Provide advocacy

Homelessness staff and volunteers can act as advocates for people accessing their service, ensuring that individuals are receiving the care and support that they require, particularly with external organisations. This includes making sure they are not being discriminated against and that appropriate processes and procedures are being followed.

Promote harm reduction

Harm reduction in the context of drug use refers to practical strategies and public health policies aimed at minimising the negative consequences associated with drug use, without necessarily requiring abstinence. Harm reduction approaches acknowledge that while drug use may continue, steps can be taken to reduce its harmful effects on individuals.

Examples of harm reduction strategies include:

• Needle exchange programmes: provide sterile injection equipment to people injecting drugs to prevent infections
• Naloxone distribution: Widely distributing the opioid overdose reversal drug to save lives. Read our naloxone guidance here.
• Medication-assisted treatment: Using medications like methadone or buprenorphine to treat opioid dependence.
• Drug checking services: Allow users to test substances for contaminants or potency.
• Education on safer use: Providing information on lower-risk ways to use drugs.

Overdose prevention

The use of drugs carries a risk of side effects, including overdose. An overdose can either be intentional or accidental. People who use opiates like heroin will be risking overdose each time that they use the drug, because there is no way of knowing the quality of the product until after it has been used.  Another factor in relation to opiate overdose is the person’s level of tolerance. For example, if someone has been abstinent after recently detoxing then their tolerance levels will be low, meaning that if they use again, and to a similar level that they would have used previously, they will be at greater risk of overdosing. 

Read our guidance on naloxone which includes how to spot signs of an overdose as well our information on New Psychoactive Substances.

Refer to drug treatment services

Drug treatment services can support people in controlling and eventually overcoming their addiction to drugs. Although drug treatment is not a mandatory service (i.e. there is no legal requirement to commission them), many local authorities commission drug treatment services.

Contact your local drug treatment service to find out what they offer and the referral pathways to use. If you are finding it difficult to find out who your local service provider is, contact your local public health team, who are based within your local authority and have responsibility for commissioning drug treatment services. 

Embrace partnership working 

There will be a range of services and organisations operating within your area that will be of value in collaborating with, in order to most effectively support people who use drugs. By proactively searching for them (based on the needs of the group of people accessing your service) and encouraging and supporting access, there will be joint ownership of care. It is important to ensure that your service is co-ordinating and monitoring these pathways on an ongoing basis. 

Some examples of the type of services that you should consider approaching include:

• Drug and alcohol treatment services
• Local volunteer centres
• Primary and secondary care services 
• Education and training providers 
• Mutual aid and peer support groups
• Employment support services
• Local government departments
• Welfare assistance services
• Debt support agencies 
• Housing support services 

Staff should be encouraged to make strong links with external services and organisations. Perhaps consider inviting external organisations into your service to deliver presentations to staff and people accessing the service on a regular basis, to share information on what is on offer.

Drug treatment pathways and options

If a person wants treatment to tackle their drug addiction, they are entitled to NHS care in the same way as anyone else with a health problem. A GP is often a starting point. The GP can either initiate treatment themselves or refer to a specialist drug treatment service. Alternatively, a direct pathway can be created from another service (such as a homelessness service) to the local drug treatment service. 

Please note that, to enter a specialist drug treatment service, an individual must be registered with a GP in the area.

Community drug treatment

Community drug treatment services normally operate from a central base, but can also deliver services from satellite clinics, such as GP surgeries. The frequency that someone will need to attend will depend upon their individual circumstances. 

Initial appointment

At the first appointment for drug treatment, staff will ask about drug use. They will also ask about work, family and housing situation. A urine or saliva sample may be taken and analysed. Staff will talk through all of the treatment options and agree a treatment plan for the individual to sign. They can also explain local support groups for the individual and their families or carers. A keyworker will be allocated, who will provide support throughout the treatment journey.

What does drug treatment involve?

This depends on the personal circumstances and what substances the person is addicted to. The keyworker will work with the individual to plan the right treatment support for them.  Treatment options may include:

• Talking therapies - such as cognitive behavioural therapy (CBT), help to see how thoughts and feelings affect behaviour. These can be delivered on a one-to-one, or group basis
• Treatment with medicines - if there is a dependency to heroin or another opioid drug, a substitute drug may be offered, such as methadone or buprenorphine. This means people can get on with treatment without having to worry about withdrawing or buying street drugs.
• Please note that medication is titrated, meaning that the desired dosage may take time to be achieved as there is usually a lower starting dose that is gradually increased until the individual is comfortable with the dose and is not feeling withdrawal symptoms. Individuals may be asked to take medication in front of a staff member (supervised consumption) until they have abstained from illicit use.
• Medication is either provided directly from the drug treatment premises, or from a local Pharmacy.
• Detoxification (detox) – for people who want to stop taking opioid drugs like heroin completely. Detox can be offered in the community, in a primary care setting (hospital in-patient) or within a residential rehab environment. Please note that certain criteria must be met in order to consider this as an option, which is usually decided by a multi-disciplinary panel made up of drug treatment senior staff and local authority commissioners.
• Shared Care – this is when treatment is transferred to primary care settings and delivered jointly by a professional from the drug treatment service and a GP.
• This option is available once the individual has achieved stability with their treatment regime and heavily reduced or abstained from any illicit drug use.

Family members, friends and professionals can be added to the individual’s confidentiality agreement, so that information on treatment progress can be discussed, but note that this is only if the individual agrees. 

Through and aftercare

Individuals who are progressing with treatment should be supported in engaging in positive activity at every conceivable opportunity. For people who have managed to successfully complete drug treatment, it is just as important that there is a comprehensive plan after they leave the treatment service. This may be directed by the drug treatment service, but ultimately it is up to the individual to decide what they would like to do in order to preserve and sustain their long-term recovery. 

Some of these options include:

• Volunteering
• Undertaking qualifications
• Building bridges with family members, or non-drug using friends
• Engaging with mutual aid and self-support groups
• Entering abstinence-based recovery housing
• Employability activities 
• Finding a hobby or taking up a sport
• Leisure/social activities

If your service has a number of individuals either accessing drug treatment or that have successfully completed treatment, you may want to consider a setting up a ‘Recovery Support Group’, so that people can discuss their individual experiences with their peers in a safe and therapeutic environment.

Needle exchange programmes

Needle exchange programmes or NSPs are free, harm reduction, social programmes that allow people who inject drugs intravenously, to obtain sterile injecting equipment. NSPs can be delivered by specialist services (such as drug treatment services) or in community settings (mostly Pharmacies). Homelessness services can work with drug treatment services to deliver needle exchange in hostel/day centre settings.

People accessing the service should be offered a range of equipment, such as different sized syringes and needles, sterile cups, vitamin C sachets, condoms, filters, sharps boxes and other essential equipment.  The person using drugs is encouraged to access drug treatment (if not already doing so) and other health related matters can be discussed with the lead pharmacist or dispensing staff. Consultation rooms should always be used to discuss confidential matters and to dispense the equipment.

Developing a peer support/volunteer programme

There is great merit in providing involvement opportunities for individuals with lived experience of addiction within homelessness services. If done correctly (and resourced where possible), an effective peer support programme can add value to the reputation of an organisation, its governance and performance. 

The involvement of people with lived experience will add additional credibility with people accessing the service and embrace the therapeutic value of one individual with lived experience of addiction helping another, which can lead to positive outcomes for all involved.

A vibrant peer support/volunteer programme can play a role in supporting individuals, gaining feedback through consultation, raising awareness, representing the organisation, setting up new initiatives and gaining a much deeper understanding of the issues that people accessing the service are facing. 

Here are some practical tips for setting up a programme:

• Ensure ‘buy in’ from key individuals within the organisation (e.g. trustees, managers and people accessing the service)
• Convene a meeting with prospective peer supporters
• Create, review and/or update the organisational volunteer and expenses policies 
• Highlight at least one lead staff member
• Provide regular supervision to peer supporters
• Develop a needs analysis and professional development regime
• Ensure that the peer supporters' activity is monitored and recorded
• Promote the programme as part of staff and service user inductions
• Ensure that peers are invited to attend team/management meetings and have a dedicated agenda item for feedback.

Further resources

• Listen to Series 4 of Homeless Links ‘Going Beyond’ Podcast which discusses approaches to supporting people experiencing homelessness who are using drugs and/or alcohol. The episodes cover the prevalence of use, harm reduction techniques, women’s use of substances, drug use in supported accommodation and barriers to engagement with treatment services.
• Example drug policies: Free to download below are template drug policies which have been developed specifically for the homelessness sector. There is also an introductory document on ‘how to write your drugs policy’ which includes the Organisational Drug Aims Identification Tool (ODAIT), which organisations should use to assess which level of tolerance will be most effective for them.