The voluntary agency Novas Initiatives is the largest provider of homeless accommodation in the Mid-West area. McGarry House was opened by Novas in 2002 in Limerick city and provides homeless accommodation for 30 individuals and long-term supported housing for 37 individuals. In recent years the staff have observed a change in the profile of their residents, with escalating and more chaotic drug use: between May 2012 and November 2013 the staff responded to 34 overdose incidents. 

In response to this, Novas commissioned a research project in order to gain a better understanding of the problem of overdose in McGarry House and to assess their responses to such incidents.1 The aim of the research was to: 1) understand the experience of overdose among residents and staff; 2) understand the risk-taking behaviour of the residents; and 3) identify ways to improve knowledge and reduce the risk of overdose and increase effective bystander response. 

A mixture of qualitative and quantitative methods was used: semi-structured interviews with 15 staff and 15 residents; an on-line survey of 20 staff; a postal survey of four GPs; focus groups with staff, residents and professional stakeholders; and a systems review of the policies and procedures. The small sample size was identified as a limitation by the authors, with 50% of residents, nine key stakeholders and four (out of the 15 GPs invited) taking part in the research. Recall bias may also have been an issue in the case of participants who may have used drugs, particularly benzodiazepines, which can affect memory. 

Profile of residents

Of the 114 people who lived for a time in McGarry House in the course of 2012, 11% were aged under 21 years, and almost half (48%) were aged under 30 years. The percentage of residents presenting with drug use issues had risen from 17% in 2010 to 27% in 2012. 

Of the 15 residents who participated in the study, almost all had an extensive history of both illicit drug use (heroin, street methadone, crack cocaine, street benzodiazepines and Z-drugs, novel psychoactive drugs) and licit drug use (alcohol, prescribed methadone, benzodiazepines and Z drugs). Over half (8, 58%) reported that they injected frequently. 

Experience of overdose:

• 73% (11) had ever overdosed.
• 93% (14) had witnessed another person overdosing in the past year.
• 85% (17) of staff had been on shift when an overdose occurred.

Of those who overdosed: 

• 100% (11) had overdosed in the past year.
• 91% (10) reported benzodiazepines as the most common drug involved in their overdose.
• 82% (9) had overdosed more than once.
• 82% (9) reported heroin involvement in their overdose.
• 72% (8) of overdoses involved more than one drug.
• 64% (7) were with someone when they overdosed.
• 46% (5) reported alcohol involvement in their overdose.
• 36% (4) had overdosed in the six months prior to the interview.

One of the themes to come from the study was that, while residents were at high risk of overdose, participants expressed ambivalence about the extent of their risk. Of those who discussed this, many felt it was unlikely that they would overdose again, or were not concerned about the risk or worried about overdosing. This was despite the fact that over half of residents interviewed felt that overdose was an inevitable or unavoidable part of drug use. Almost all agreed that they could reduce their overdose risk; however, the perceived degree of difficulty in doing this varied between residents. 

Of the residents who had witnessed an overdose, the majority reported carrying out appropriate emergency responses, e.g. checking level of consciousness, breathing and pulse. However, some reported carrying out interventions which were not effective or potentially harmful: walking the person around (risk of fall and injury); putting the person in the bath (risk of drowning); and injecting with salt water. Four participants stated that they were concerned about calling an ambulance for fear of personal consequences if the gardaí also arrived. 

More than half of the residents interviewed felt that they knew ‘very little’ or ‘some’ about the causes of overdose, but 87% were interested in taking part in overdose prevention training, including provision of naloxone. 

The researchers also noted that while McGarry House promoted a low-threshold ethos, e.g. by providing safe disposal bins for needles, some residents still worried about negative consequences if they disclosed their drug use. 

Another theme emerging from the research related to interagency prevention and response. The external agencies acknowledged the vital role of McGarry House in overdose prevention and were keen to develop interagency protocols and structures. At the time of the research, Novas was working with the HSE to improve interagency co-ordination, with a focus on providing clarity around maintaining confidentiality while striving to prevent overdose. Another example of interagency work was liaison with the ambulance service in order to speed up processes and improve communication. 

Two themes emerged in relation to the challenges McGarry House staff faced in responding to overdose. While there was very much a ‘coping culture’ there was a need to ensure effective support for staff, and for further development of confidence, capacity and learning opportunities. 

One of the particular issues raised by staff concerned pregnant women who had continued to use drugs, some intravenously, during their pregnancies (in the period before the research was conducted). The staff reported this as extremely stressful (indeed, one woman had given birth in the hostel) and, while pregnancy does not increase the risk of overdose, the consequences of any overdose has implications for both the woman and her unborn child. 

The recommendations made in the report are summarised below.

• Develop a peer education programme for residents on understanding risks, prevention and management of overdose.
• Provide consistent harm reduction information that is agreed at an interagency level.
• Update overdose policy which can be reviewed as required. Review the client risk assessment form.
• Train staff in additional effective overdose prevention interventions, e.g. motivational interviewing and cognitive behavioural therapy to address the ambivalence to overdose risk expressed by some clients.
• Continue to work to, and promote with residents, an evidence-based low-threshold approach.
• Clearly communicate to residents that their personal information is treated confidentially and only shared for risk management.
• In consultation with staff, develop and provide appropriate supports to staff in the event of an overdose.
• Explore, with other agencies, the opportunities for a naloxone distribution programme.
• Develop and formalise interagency protocols to improve communication and information sharing in relation to overdose, with the HSE and emergency services in particular.
• Develop person-centred assessment training in collaboration with the Homeless Persons Centre in Limerick city to improve information gathering of risk factors from residents.
• Improve understanding with GPs and pharmacists by developing a standard information letter which explains the role of McGarry House in overdose prevention.
• Support the development of an interagency response to care for pregnant women who use drugs, e.g. employment of a regional drug-liaison midwife.

1. Dermody A, Gardner C, Quigley M and Cullen W (2013) Heads up: preventing and responding to overdose in McGarry House, Novas. Limerick: Novas Initiatives. www.drugsandalcohol.ie/22183