Health and homelessness in Scotland: research

Chapter 6: Prescriptions

In total, there were around 9.5 million prescriptions dispensed over the time period 14 January 2009 to 31 March 2015 to the 1.3 million people in the study. Many homeless people present to health services with multiple morbidity including drug or alcohol dependence, mental health and physical problems such as tuberculosis and breathing difficulties (Department of Health, 2010) ^[41] . For this reason, the study focuses on the following selection conditions:

• mental health conditions;
• alcohol dependence;
• opioid dependence and;
• the treatment of tuberculosis ( TB).

The prescriptions data for this study is a very small subset of all prescriptions (hereafter referred to as study prescriptions). This is typically less than 2% of all prescriptions in any given year. This is because these are a subset of the prescriptions for the people in the study as it does not include other prescriptions ( e.g. antibiotics and all other medicines). Also that the people in the study are a subset of all the people in Scotland. For more information on the prescriptions data see Section 2.3.6.

In this chapter we discuss the study cohorts, their dispensed prescriptions and how this relates to homelessness. How this relates to deprivation and health needs is discussed in Chapter 11.

6.1 Overview of prescriptions in the study

Accounting for one third of all people in the study, people in the EHC (Ever Homeless Cohort) accounted for 66% of study prescriptions (30% male, 36% female). Study prescriptions amongst the MDC (Non-homeless 20% Most Deprived Cohort) accounted for 26% of study prescriptions during the period (10% male, 16% female). The LDC (Non-homeless 20% Least Deprived Cohort) accounted for 8% of study prescriptions (3% male, 5% female).

Table 6.1: Number of study prescriptions dispensed by cohort, sex and type of prescription.

Type of prescription	Male			Female
	EHC	MDC	LDC	EHC	MDC	LDC
Alcohol	40,780	10,360	1,680	23,460	6,040	1,050
Opioid	588,410	95,360	3,910	332,220	47,390	1,530
Mental Health	2,180,000	878,170	271,490	3,065,080	1,457,330	478,300
Tuberculosis	1,590	1,040	540	980	880	460
Total prescriptions	2,810,773	984,933	277,615	3,421,729	1,511,635	481,337

The study prescriptions are dominated by those to treat mental health ( Table 6.1). The four different prescription types could have different activity patterns. Therefore in the following sections analysis is done focussing on each type in isolation.

6.2 Comparative prescriptions for alcohol dependence between the EHC and their controls

Accounting for one third of all people in the study, people in the EHC (Ever Homeless Cohort) accounted for 77% of prescriptions for alcohol dependence (49% male, 28% female). Prescriptions for alcohol dependence amongst the MDC (Non-homeless 20% Most Deprived Cohort) accounted for 20% of prescriptions for alcohol dependence during the period (12% male, 7% female). The LDC (Non-homeless 20% Least Deprived Cohort) accounted for 3% of prescriptions for alcohol dependence (2% male, 1% female).

Table 6.2: Number of people, number of prescriptions for alcohol dependence and the ratio of the number of prescriptions for alcohol dependence between EHC and MDC, and between EHC and LDC, by age and sex.

Age (at 31 March 2015)	Male				Female
	Number of people	Prescriptions	EHC : MDC	EHC : LDC	Number of people	Prescriptions	EHC : MDC	EHC : LDC
0 to 15	135,444	0			127,461	0
16 to 20	49,263	30			51,276	20
21 to 25	64,209	660	8.3	58.0	78,690	400	38.0	38.0
26 to 30	75,363	2,520	7.0	72.7	93,003	1,560	3.8	16.9
31 to 35	70,407	5,190	6.3	43.9	74,493	2,900	7.4	41.7
36 to 40	58,347	7,300	4.5	20.5	53,259	4,640	5.8	38.7
41 to 45	55,737	9,950	3.8	25.5	48,873	5,970	3.5	24.9
46 to 50	49,818	10,040	4.4	33.3	43,563	6,470	3.4	20.0
51 to 55	37,746	8,730	2.7	20.6	31,578	4,640	3.0	17.6
56 to 60	25,017	4,520	2.5	20.7	19,017	2,540	3.0	23.0
61 to 65	15,765	2,640	3.4	28.3	11,436	1,030	3.3	9.1
66 or over	21,591	1,240	10.6	4.8	16,203	400	7.8	6.2
All ages	658,707	52,820	3.9	24.3	648,852	30,550	3.9	22.3

In order to see how prescriptions for alcohol dependence compare in the different cohorts, ratios of prescriptions for alcohol dependence were constructed for each age band and sex ( Table 6.2).

The EHC have more prescriptions for alcohol-dependence

In total, the EHC has almost four times the number of prescriptions for alcohol-dependence compared with MDC (3.9 times for males and for females) and over 20 times the number of prescriptions for alcohol dependence compared with LDC (24 times for males, 22 times for females).

For each age and sex breakdown, the EHC have more prescriptions for alcohol-dependence

Compared to the controls in the MDC or LDC, the ratio of prescriptions for alcohol dependence is always greater than one (minimum ratio is: 2.5, EHC : MDC at 56–60 years).

EHC aged 21–25 years have the most prescriptions for alcohol dependence compared with their controls

Unlike [many] other ratio variations with age seen in the study, the ratios do not tend to increase with age to a maximum and then decline again. Here we see that the highest ratios are for the youngest ages (the EHC: MDC ratios for those aged 21 to 25 years are 8.3 for males and 38.0 for females. Compared to the LDC, the ratios are even more stark: 58.0 for males and 38.0 for females). This appears to be driven by the LDC and the MDC having very few prescriptions for the younger age groups. The ratios for EHC : MDC increases again above 60 years, although this is not seen in the ratios EHC : LDC.

6.3 Comparative prescriptions for opioid dependence between the EHC and their controls

Accounting for one third of all people in the study, people in the EHC (Ever Homeless Cohort) accounted for 86% of prescriptions for opioid dependence (55% male, 31% female). Prescriptions for opioid dependence amongst the MDC (Non-homeless 20% Most Deprived Cohort) accounted for 13% of prescriptions for opioid dependence during the period (9% male, 4% female). The LDC (Non-homeless 20% Least Deprived Cohort) accounted for 0.5% of prescriptions for opioid dependence (0.4% male, 0.1% female).

Table 6.3: Number of people, number of prescriptions for opioid dependence and the ratio of the number of prescriptions for opioid dependence between EHC and MDC, and between EHC and LDC, by age and sex.

Age (at 31 March 2015)	Male				Female
	Number of people	Prescriptions	EHC : MDC	EHC : LDC	Number of people	Prescriptions	EHC : MDC	EHC : LDC
0 to 15	135,444				127,461
16 to 20	49,263	150	14.0		51,276	210
21 to 25	64,209	4,610	8.2	410.0	78,690	9,490	12.4
26 to 30	75,363	35,820	14.4	127.9	93,003	47,720	13.4	276.6
31 to 35	70,407	134,990	10.3	214.9	74,493	99,110	9.7	198.7
36 to 40	58,347	189,230	6.1	161.9	53,259	98,470	6.4	257.0
41 to 45	55,737	168,600	5.0	117.1	48,873	68,900	4.9	519.6
46 to 50	49,818	102,980	5.0	225.0	43,563	39,220	5.6	207.1
51 to 55	37,746	37,330	4.3	93.9	31,578	13,050	4.4	58.2
56 to 60	25,017	10,140	5.4	213.0	19,017	3,540	5.7	26.5
61 to 65	15,765	3,140	6.9	20.2	11,436	1,360	3.8	107.0
66 or over	21,591	710	2.5	24.5	16,203
All ages	658,707	687,680	6.2	150.5	648,852	381,140	7.0	217.1

In order to see how prescriptions for opioid dependence compare in the different cohorts, ratios of prescriptions for opioid dependence were constructed for each age band and sex ( Table 6.3).

The EHC have much more prescriptions for opioid dependence

In total, the EHC has over six times the number of prescriptions for opioid dependence compared with MDC (6.2 times for males, 7.0 times for females) and over 150 times the number of prescriptions for opioid dependence compared with LDC (150 times for males, 217 times for females).

For each age and sex breakdown, the EHC have more prescriptions for opioid dependence

Compared to the controls in the MDC or LDC, the ratio of prescriptions for opioid dependence is always greater than two (minimum ratio is: 2.5, EHC : MDC at 66+ years). The EHC: MDC ratios are highest amongst those aged under 35 years and this is true for both males and females.

6.4 Comparative prescriptions for mental-health between the EHC and their controls

Accounting for one third of all people in the study, people in the EHC (Ever Homeless Cohort) accounted for 63% of prescriptions for mental-health (26% male, 37% female). Prescriptions for mental-health amongst the MDC (Non-homeless 20% Most Deprived Cohort) accounted for 28% of prescriptions for mental-health during the period (11% male, 17% female). The LDC (Non-homeless 20% Least Deprived Cohort) accounted for 9% of prescriptions for mental-health (3% male, 6% female).

Table 6.4: Number of people, number of prescriptions for mental-health and the ratio of the number of prescriptions for mental-health between EHC and MDC, and between EHC and LDC, by age and sex.

Age (at 31 March 2015)	Male				Female
	Number of people	Prescriptions	EHC : MDC	EHC : LDC	Number of people	Prescriptions	EHC : MDC	EHC : LDC
0 to 15	135,444	20,840	1.4	2.4	127,461	8,570	1.4	1.5
16 to 20	49,263	26,340	1.7	2.7	51,276	44,200	2.0	3.2
21 to 25	64,209	119,350	2.6	5.4	78,690	243,130	2.9	5.7
26 to 30	75,363	242,120	3.4	8.7	93,003	483,500	2.9	8.1
31 to 35	70,407	381,420	3.9	12.6	74,493	615,650	2.9	10.1
36 to 40	58,347	465,850	3.4	11.9	53,259	633,170	2.4	9.1
41 to 45	55,737	542,510	2.7	11.4	48,873	737,560	2.1	7.2
46 to 50	49,818	504,660	2.4	9.5	43,563	763,440	1.8	6.2
51 to 55	37,746	399,340	2.0	7.5	31,578	601,520	1.7	5.7
56 to 60	25,017	259,350	1.7	6.1	19,017	375,470	1.6	5.2
61 to 65	15,765	172,210	1.7	5.1	11,436	221,710	1.6	4.5
66 or over	21,591	195,680	1.4	2.7	16,203	272,850	1.4	2.7
All ages	658,707	3,329,660	2.5	8.0	648,852	5,000,710	2.1	6.4

In order to see how prescriptions for mental-health compare in the different cohorts, ratios of prescriptions for mental-health were constructed for each age band and sex ( Table 6.4).

The EHC have more prescriptions for mental-health

In total, the EHC has almost over double the number of prescriptions for mental-health compared with the MDC (2.5 times for males, 2.1 for females) and over 6 times the number of prescriptions for mental-health compared with the LDC (8.0 times for males, 6.4 times for females).

For each age and sex breakdown, the EHC have more prescriptions for mental-health

Compared to the controls in the MDC or LDC, the ratio of prescriptions for mental-health is always greater than one (minimum ratio is: 1.4, EHC : MDC at 0–15 and 66+ years).

EHC people aged 31–35 years have the most prescriptions for mental-health compared with their controls

The ages at which the peak ratios occur are similar for males and females. For males EHC : LDC peaks at 3.9 at 31–35 years, and EHC : MDC peaks at 12.6 at 31–35 years. For females EHC : LDC peaks at 2.9 at 21–35 years, and EHC : MDC peaks at 10.1 also at 31–35 years.

6.5 Comparative tuberculosis prescriptions between the EHC and their controls

Accounting for one third of all people in the study, people in the EHC (Ever Homeless Cohort) accounted for 47% of tuberculosis ( TB) prescriptions (29% male, 18% female). TB prescriptions amongst the MDC (Non-homeless 20% Most Deprived Cohort) accounted for 35% of TB prescriptions during the period (19% male, 16% female). The LDC (Non-homeless 20% Least Deprived Cohort) accounted for 18% of TB prescriptions (10% male, 8% female).

Table 6.5: Number of people, number of TB prescriptions and the ratio of the number of TB prescriptions between EHC and MDC, and between EHC and LDC, by age and sex.

Age (at 31 March 2015)	Male				Female
	Number of people	Prescriptions	EHC : MDC	EHC : LDC	Number of people	Prescriptions	EHC : MDC	EHC : LDC
0 to 15	135,444	230	1.8	14.0	127,461	150	0.9	3.0
16 to 20	49,263	50	1.0	2.0	51,276	60	1.0	1.0
21 to 25	64,209	200	1.3	2.3	78,690	150	0.9	3.0
26 to 30	75,363	290	1.2	1.7	93,003	320	1.4	2.5
31 to 35	70,407	340	1.4	1.4	74,493	340	1.4	1.9
36 to 40	58,347	330	1.2	2.0	53,259	230	0.9	2.3
41 to 45	55,737	330	1.1	3.8	48,873	270	0.7	3.3
46 to 50	49,818	350	2.2	7.3	43,563	250	1.0	2.0
51 to 55	37,746	300	1.2	3.5	31,578	200	1.6	5.5
56 to 60	25,017	210	2.6	4.3	19,017	110	1.5	0.5
61 to 65	15,765	210	2.2	6.5	11,436	50	1.0	2.0
66 or over	21,591	350	1.9	1.9	16,203	190	2.0	1.1
All ages	658,707	3,170	1.5	2.9	648,852	2,320	1.1	2.1

In order to see how TB prescriptions compare in the different cohorts, ratios of TB prescriptions were constructed for each age band and sex ( Table 6.4).

The EHC have more TB prescriptions

In total, the EHC has more TB prescriptions compared with the MDC (1.5 times for males, 1.1 for females) and over double the number of TB prescriptions compared with the LDC (2.9 times for males, 2.1 times for females).

For each age breakdown for males, the EHC have more TB prescriptions

Compared to the controls in the MDC or LDC, the ratio of TB prescriptions for males is always greater or equal to one (minimum ratio is: 1.0, EHC : MDC at 16–20). However, for four age groups, females had lower ratios of TB prescriptions in the EHC compared to the MDC.

There is no discernible structure relating the TB ratios to age

With there being so few TB prescriptions when breaking down by age, sex and cohort, there is no apparent age trend in the ratios that is clear above the noise.

6.6 Prescriptions for mental health relative to the date of first homelessness assessment: Once-Only and Repeat Homelessness

Mental-health prescriptions account for the large majority of prescriptions in the study prescription data, and will be the focus of this section. In order to explore the relationship between homelessness and prescriptions for mental-health, this section compares the timing of prescriptions with the date of first homelessness assessment ( Figures 6.1 and 6.2). Detail on this method is described in full in Section 2.10.

The ratios of prescriptions for mental-health for Repeat EHC are higher than for Once-only EHC. The following points apply for both sexes:

Mental-health prescription ratios increase up to the peak earlier for Repeat EHC

For once-only EHC the ratios begin to increase toward the peak at around 6–12 months before the date of first assessment. For Repeat EHC the increase begins around two years before first assessment.

The peak mental-health prescription ratio is higher for Repeat EHC

The peak around the date of first homelessness assessment is larger for the repeat EHC than for the once-only EHC. For males the once-only ratio increases from around 7 to around 11 (around a 50% increase), while the repeat ratio increases a greater amount from around 8 to around 16 (it doubles). For females the once-only ratio increases from around 5.5 to around 8.5 (around a 50% increase), while the repeat ratio increases a greater amount from around 7 to around 12 (around a 70% increase).

The ratio falls back to pre-homelessness levels only for once-only EHC

For the once-only EHC, by around three years following the assessment date (for males, around two years for females) the ratio has reduced to around the level it was at two years prior to the assessment date.

This contrasts with the repeat EHC ratio, which remains above the ratio value immediately prior to the peak, for the remainder of the period.

Figure 6.1: Ratio of mental health prescriptions for once-only homelessness to the controls in the LDC for those homeless people, by sex, against the time difference between the first assessment and the attendance date.

Figure 6.2: Ratio of mental health prescriptions of repeat homelessness to the controls in the LDC for those homeless people, by sex, against the time difference between the first assessment and the attendance date.

6.7 Summary

The EHC have more prescriptions than the control cohorts, especially for opioid and alcohol dependence. There are more prescriptions for mental health too. For TB there was little difference between the EHC and the MDC. Besides TB, the EHC have more prescriptions for each age and sex breakdown.

EHC aged 21–25 years have the most prescriptions for alcohol dependence compared with their controls. Furthermore, unlike other ratio variations, the ratios do not tend to increase with age to a maximum and then decline again. Instead, the ratios decline with age, suggesting these issues tend to be more skewed towards younger age groups.

EHC people aged 31–35 years have the most prescriptions for mental-health compared with their controls

It is clear that there is evidence to support each of the four research questions:

• A gradually worsening condition prior to the date of first assessment that results in excess prescriptions, occurs prior to homelessness.
• Also for some people the (first) homelessness episode is associated with some crisis with a health activity component, as observed by a prescription peak around that time. Both these effects are greater among those who go on to have multiple homelessness episodes, suggesting that these situations and crises sometimes precede not just homelessness, but repeat homelessness especially.
• The larger ratios after the first assessment date for those who have multiple homelessness episodes could be due to: further crises around the time of those later episodes, long-term effects of the earlier underlying condition, crises or homelessness itself.
• Lastly, people who go on to become homeless appear to have more prescriptions, even several years prior to their first homeless assessment. This could be a result of the EHC having an even higher proportion of individuals than the MDC affected by factors associated with deprivation.