Retrospective evaluation of a low-threshold multicomponent healthcare pathway for people who use drugs in Tayside, Scotland: an observational cohort study

Abstract Background We implemented a nurse-led multicomponent pathway in Tayside (Scotland) delivering integrated care and referral through three six-monthly visits within harm reduction settings for People Who Use Drugs (PWUD), who experience high multimorbidity and mortality. We examined pathway uptake and subsequent outcomes, and compared probability of overdose and fatality in this group relative to those in conventional support services. Methods We conducted a retrospective observational cohort study to examine pathway uptake and subsequent outcomes. We undertook matched (on sex and age) logistic regression analyses, adjusted for opioid agonist therapy, to compare odds of overdose and mortality between those who received healthcare via the pathway and a comparison group drawn from other substance use support services. Results From 17 August 2021 to 31 August 2024, 150 PWUD received healthcare via the pathway. Polydrug use was disclosed by 142 (95%), with a mean of 7 (SD: 3) substances used. Re-engagement was 98/142 (69%) at visit two and 53/97 (55%) at visit three. There was substantial physical and mental health morbidity. In the pathway group, there were 74 non-fatal overdoses (26.49 [20.80–33.26] per 100PY) and eight overdose fatalities (2.86 [1.24–5.65] per 100PY). In the comparison group, there were 78 non-fatal overdoses (13.61 [10.75–16.98] per 100PY) and eight overdose fatalities (1.39 [1.06–2.75] per 100PY). This corresponded to higher odds of non-fatal ( a OR 2.50, 1.55–4.02, p = .001) but not fatal overdose ( a OR 1.82, 0.66–4.97, p = .245) in the pathway group. Conclusion Our findings suggest that a co-located holistic care pathway can maintain repeated contacts for various health interventions in a previously disengaged group of PWUD. Despite higher probability of non-fatal overdose there was no detectable excess mortality likelihood in the pathway group, which is plausibly consistent with the focus on enhanced care. Such approaches present practitioners with the opportunity to maintain repeated contact with PWUD whilst addressing unmet health needs that contribute to inequalities in outcomes. Whilst interpretation is limited by attrition, inconsistent assessment, and observational design, the findings highlight ongoing harms and support the scaling of integrated holistic care pathways alongside other interventions. Future research might explore the optimisation, sustainability, and relational aspects of such pathways.