Substance consumption and intoxication patterns in a medically supervised overdose prevention program for people experiencing homelessness

Abstract

Background: Opioid overdose is a leading cause of death among homeless individuals. Combining psychoactive substances with opioids increases overdose risk. This study aimed to describe intoxication patterns at a drop-in space offering medical monitoring and harm reduction services to individuals who arrive intoxicated and at risk of overdose. Methods: We examined data from visits to the Supportive Place for Observation and Treatment at Boston Health Care for the Homeless Program between January 1, 2017 and December 31, 2017. We used k-means cluster analysis to characterize intoxication patterns based on clinically assessed sedation levels and vital sign parameters. Multinomial logistic regression analysis assessed demographic and substance consumption predictors of cluster membership. Linear and logistic regression models examined associations between cluster membership and care outcomes. Results: Across 305 care episodes involving 156 unique patients, cluster analysis revealed 3 distinct intoxication patterns. Cluster A (26.6%) had mild sedation and normal vital signs. Cluster B (44.5%) featured greater sedation with bradycardia and/or hypotension. Cluster C (28.9%) was comparable to cluster B but with the addition of hypoxia. Self-reported consumption of non-opioid sedatives prior to arrival was common (63.3% of episodes) and predicted membership in cluster B (aOR 2.75, 95% CI 1.40, 5.40) and cluster C (aOR 3.38, 95% CI 1.48, 7.70). In comparison to cluster A episodes, cluster C episodes were longer (mean 4.8 vs. 2.3 hours, p < 0.001) and more likely to require supplemental oxygen (27.3% vs. 2.5%, p < 0.001). Few episodes required hospital transfer (4.7%) or naloxone (1.0%). No deaths occurred. Conclusions: In a medically supervised overdose monitoring program, reported use of non-opioid sedatives strongly predicted more complex clinical courses and should be factored into overdose prevention efforts. Low-threshold medical monitoring in an ambulatory setting was sufficient for most episodes, suggesting a role for such programs in reducing harm and averting costly emergency services.

Keywords:

• Homelessness
• harm reduction
• substance use disorder
• overdose prevention

Acknowledgment

The authors thank Yuchiao Chang, PhD, for her input on the statistical analysis.

Disclosure statement

Dr. Baggett receives royalties from UpToDate for authorship of a topic review on homeless health care. Ms. Racine and Drs. Wishik, Gaeta, and O’Connell have no financial disclosures. No potential conflict of interest was reported by the author(s).

Author contributions

GW, JMG, MWR, and TPB conceived of the study design. MWR assembled the dataset for analysis. TPB and MWR led the data analysis, and all authors participated in interpreting the findings. GW, MWR, and TPB led the writing. All authors critically revised the manuscript and approved the final version.