Magdalena is an Associate Professor and Sociologist in Inclusion Health at LSHTM. She leads a mixed-method programme of research on health interventions for people who use heroin and crack cocaine in the UK, has lived experience of injection drug use and is an honorary consultant in Inclusion Health at UCLH.

Background
Inadequate opioid withdrawal management in hospital is a barrier to timely presentation and completion of care for people who use heroin and other opioids. Stigma can compound the stress of withdrawal leading to discharge against medical advice. The NIHR-funded iHOST project aims to improve opioid substitution therapy (OST) provision in NHS hospitals. Our formative review of NHS hospital substance dependance policies identified wide variation in practice, barriers to timely OST provision and use of stigmatizing language.
Methods
The iHOST intervention comprises five components: an advocacy card; helpline; staff training; champion role; and policy guideline. Here we report the development of the policy guideline. We worked in collaboration with a London hospital to revise their local guidance. Two groups were convened to workshop (key stakeholders, including people who use drugs) and oversee (key organizational representatives) the policy revision. We sought NHS Trust committee approvals to enact the guidance into practice.
Results
Key changes included: 1) removal of requirements for urine drug tests prior to OST prescription, identified as causing significant delays to management; 2) increasing the standard initiation dose of methadone from 10mg to 20mg, with the former considered too low to adequately address patients’ needs; 3) increasing the maximum OST dose permitted on day one when suitable expertise is available; 4) introducing takeaway OST to enable continuity of care for patients discharged out of hours; 5) introducing naloxone provision on discharge.
Conclusion
Our revised policy guidance has addressed discriminatory barriers to timely withdrawal management. Notably, this London hospital will be one of the first in England to provide naloxone on discharge, crucial at a time of heightened overdose risk. We demonstrate that policy change, in collaboration with community stakeholders, is possible and can be the first step in a broader transformation of hospital care for people who use drugs.