A prospective study of substance use and housing stability in a homeless population

Multimorbidity of mental health and substance use disorders among housed and homeless U.S. veterans

Housing can be an important social determinant of mental health, which is why it is important to understand how mental health disorders (MHDs) and substance use disorders (SUDs) cluster and vary by housing instability. This study examined rates of comorbid MHDs and SUDs among three groups of U.S. veterans: those experiencing homelessness, those in supported housing, and those independently housed. Administrative data on a national cohort of 5,402,062 veterans (including 181,131 homeless veterans and 29,166 veterans in supported housing) enrolled in the U.S. Department of Veterans Affairs (VA) healthcare system from 2021 to 2023 were analyzed. Among homeless veterans, 28.3% had a SUD diagnosis, 62.9% a MHD diagnosis, and 24.7% comorbid MHD/SUD. Among veterans in supported housing, 38.2% had a SUD diagnosis, 67.3% a MHD diagnosis, and 32.0% comorbid MHD/SUD diagnoses. Among independently housed veterans, 7.9% had a SUD diagnosis, 41.6% a MHD diagnosis, and 5.8% comorbid MHD/SUD diagnoses. Homeless veterans with comorbid MHD/SUD used significantly more outpatient, inpatient, and emergency department care than veterans in supported housing; in turn, supported housing veterans with comorbid MHD/SUD used significantly more outpatient, inpatient, and emergency department care than independently housed veterans. Among homeless veterans with comorbid MHD/SUD diagnoses, those with addiction to central nervous system (CNS) stimulants used more outpatient, inpatient, and emergency department care than those with addiction to CNS depressants. In conclusion, the psychiatric epidemiology and comorbidity of veterans varies by housing situation, and there is continued need for psychiatric treatment among homeless veterans who enter supported housing.

Addressing the complex needs of homeless youth with early psychosis and comorbid substance use: a naturalistic longitudinal study of 10 years' experience with EQIIP SOL's specialized outreach service

PURPOSE

Psychosis and substance use disorders (SUDs) are highly prevalent and often co-occurring among homeless youth. EQIIP SOL, a specialized intensive outreach program within an early intervention service, provides 3-year comprehensive care for first-episode psychosis (FEP) homeless youth, targeting psychosis, SUD, and homelessness. This study aims to examine clinical and functional outcomes, along with predictors of housing stability, among youth enrolled in the program since its inception in 2012.

METHODS

This longitudinal study examined the 3-year outcomes of all youth admitted to EQIIP SOL from 2012 to 2020. The inclusion criteria encompassed youth aged 18-30 years, diagnosed with primary psychosis and SUD and experiencing homelessness. Assessments were conducted at baseline and at 1, 3, 6, 9, 12, 15, 18, 24, and 36 months thereafter to describe housing stability, illness severity, and general functioning evolutions. Alcohol and substance use were evaluated at baseline and annually. A multivariate mixed-effects model investigated baseline predictors of housing stability.

RESULTS

Of the 177 enrolled youth, 81.4% achieved housing stability at least once, within a median of six months. Improvements in illness severity and general functioning were observed during the initial nine months, plateauing thereafter. SUDs reduced approximately by one-third; alcohol use disorder decreased by half. Older age (OR = 1.18 (1.07-1.31)), no history of chronic homelessness (OR = 2.16 (1.13-4.13)), stimulant addiction (OR = 0.51 (0.26-0.98)) and being roofless/emergency sheltered at admission (OR = 0.41 (0.19-0.88)) were associated with housing stability.

CONCLUSION

EQIIP SOL's integrated approach yields promising results, warranting replication, robust evaluation of its efficacy, and adaptation in other settings.

History of Alcohol Use Disorder and Housing Instability as Predictors of Fatigue and Mental Health Problems During the COVID-19 Pandemic

Mental health and alcohol problems are significant public health concerns amid the COVID-19 pandemic. Housing instability and symptoms of fatigue are understudied aspects of the pandemic. This study examined history of Alcohol Use Disorder (AUD), history of COVID-19 infection, and housing instability as correlates of fatigue, anxiety, and depression symptoms. Data were drawn from 250 adults enrolled in an online survey within the NIAAA COVID-19 Pandemic Impact on Alcohol Study in between April 6 and June 2 of 2022. Participants completed self-report measures of housing stability, fatigue, and mental health symptoms. Multivariable analyses controlling for age, sex, race, ethnicity, and household income were conducted. Individuals with a history of AUD reported higher mental fatigue, anxiety symptoms, and depressive symptoms when compared to those with no history of AUD. Individuals with "other" housing arrangements (not renting or owning) reported higher mental fatigue, pandemic fatigue, anxiety symptoms, and depressive symptoms relative to homeowners. Individuals who worried about not having a place to live in the past 6 months reported higher physical fatigue, mental fatigue, anxiety symptoms, and depressive symptoms when compared to individuals without housing worry. History of COVID-19 infection was neither associated with mental health nor fatigue symptoms. Housing instability, as captured by housing worry and having "other" housing arrangements, was associated with greater fatigue and mental health problems, even after controlling for household income. Housing instability uniquely contributed to mental health symptoms, warranting further research and targeted prevention and intervention efforts.

Towards a "trauma-informed spaces of care" model: The example of services for homeless substance users

While clinical practitioners have long recognized the importance of trauma-informed models of care, geographies of care scholars have been slow to engage with and address trauma in its methodologies for better understanding environments that support, or hinder, care for people. Marrying the conceptual contributions of geographies of care, trauma geographies, and geographies of addiction, this paper aims to advance the inquiry of trauma-informed spaces of care. Drawing on the example of the homeless substance user, we present a novel theoretical imperative for considering trauma on both an individual and collective level for advancing spatial interventions for healing in spaces of care.

Organizational and patient factors associated with positive primary care experiences for veterans with current or recent homelessness

OBJECTIVE

To identify organizational service features associated with positive patient ratings of primary care within primary care clinics tailored to accommodate persons with ongoing and recent experiences of homelessness (PEH).

DATA SOURCES AND STUDY SETTING

PEH receiving primary care in 29 United States Veterans Health Administration homeless-tailored clinics were surveyed about their primary care experience using the validated Primary Care Quality-Homeless (PCQ-H) survey. Characteristics of the clinics were assessed through surveys of clinic staff using a new organizational survey developed through literature review, site visits, statistical analysis, and consensus deliberation.

STUDY DESIGN

Cross-sectional examination of patients' ratings of care based on surveys of patients, and of clinic characteristics, analyzed with Classification and Regression Tree (CART) analysis, a form of machine learning.

DATA COLLECTION METHODS

Patient surveys (n = 3394) were obtained from a random sample of enrolled patients by both mail and telephone by an external survey contractor. Staff (n = 52 from 29 clinics) were interviewed by telephone.

PRINCIPAL FINDINGS

This analysis identified service features that impact patient experience favorably, including aspects of patient-centeredness, team identity, strong external leadership support, and service that reach beyond traditional primary care clinic confines. Results varied according to the patient experience scale analyzed. Individual characteristics of PEH, such as degree of social support, general health, and unsheltered status, were also correlated with how they rate care.

CONCLUSIONS

Organizational characteristics correlate with ratings of primary care from patients with recent and ongoing homelessness. Primary care programs serving homeless individuals can assure better care based on who they hire, how they foster team identity, what services they provide, and the strength of leadership support to protect a homeless-focused mission.

Safer-use strategies in the context of harm-reduction treatment for people experiencing homelessness and alcohol use disorder

BACKGROUND

Two, randomized controlled trials found harm-reduction treatment for AUD (HaRT-A) improves alcohol outcomes for adults experiencing homelessness. HaRT-A, which neither requires nor precludes abstinence, entails tracking alcohol-related harm, harm-reduction goals, and safer-use strategies. This secondary dual study qualitatively describes this last component, safer-use strategies, and their quantitative association with treatment outcomes.

METHODS

Participants were people who experienced homelessness and AUD and were enrolled in the active HaRT-A treatment arms in 2 randomized control trials (Trial 1 N = 86; Trial 2 N = 208). Trial 1was a 2-arm study with randomization to HaRT-A or services as usual. Trial 2 was a 4-arm study combining HaRT-A and extended release naltrexone. In HaRT-A sessions, participants received a list of 3 categories of safer-use strategies (i.e., buffering alcohol's effects on the body, changing the manner of drinking to be safer and healthier, and reducing alcohol use). Mixed methods were used to qualitatively describe safer-use strategies implemented and quantitatively test their association with alcohol outcomes (i.e., peak quantity, frequency, alcohol-related harm).

RESULTS

In Trial 1, but not Trial 2, participants committed to more safer-use strategies across time, which was associated with reductions in alcohol frequency over the past 30 days. In both trials, participants committing to reducing alcohol consumption drank on a quarter fewer days overall, and in Trial 2, experienced 15 % less alcohol-related harm. In Trial 1, participants who committed to changing the manner of drinking were heavier drinkers overall, and although they showed significant reductions in alcohol-related harm, their reduction rate was slower than for participants who selected other strategies. In Trial 2, strategies to buffer alcohol's effects were associated with a monthly 14 % decrease of alcohol-related harm.

CONCLUSION

This study replicated prior findings that people experiencing homelessness and AUD regularly adopt strategies to reduce alcohol-related harm. The implementation of safer-use strategies was favorably associated with alcohol outcomes, but specific associations differed by trial and outcome. Discussion of safer-use strategies appears helpful; however, further research is needed to firmly establish how this HaRT-A component works.

Improving Traumatic Stress with Justice-Impacted Women and Women Experiencing Homelessness: A Pilot Study of Narrative Exposure Therapy

OBJECTIVE

We sought to investigate the feasibility, acceptability, and impact of a brief, manualized trauma-focused intervention aimed at improving PTSD symptoms in persons with complex PTSD, Narrative Exposure Therapy (NET).

DESIGN

Using a mixed methods approach, we tested the feasibility, acceptability, and impact of NET in a sample of trauma-affected women in traumatogenic circumstances: justice-impacted women in prison and women experiencing homelessness in a shelter. We quantitatively assessed data using a single sample, pre-/post-intervention design. We qualitatively assessed self-described symptom change and opportunities for intervention adaptation using a content analysis approach.

METHODS

Sixteen trauma-affected participants completed the intervention protocol. NET interventionists included one nurse practitioner, one registered nurse, and one nursing student. All NET participants attended pre-/post-intervention visits and active NET sessions. In-depth interviews were conducted at pre- and post-intervention, alongside a diagnostic battery.

RESULTS

NET was both highly feasible and acceptable among participants. Participants significantly improved on the intervention-specific outcome of PTSD symptoms, as well as somatic symptom burden, with large effect sizes. Participants also improved on subjective self-described symptom change. Participants offered recommendations regarding opportunities to enhance population-specific intervention acceptability.

CONCLUSIONS

Results from this pilot study are consistent with previous evidence demonstrating that NET facilitates improvements in women with traumatic stress. Findings of high feasibility, acceptability, and impact supports the use of NET in JW and WEH. Integrating participant recommendations to optimize acceptability may further support scalability and reach of NET. Replication with a larger sample and within a randomized controlled design is required to definitively determine effectiveness.

Housing Insecurity and Other Syndemic Factors Experienced by Black and Latina Cisgender Women in Austin, Texas: A Qualitative Study

Austin, Texas emerged as one of the fastest-growing cities in the U.S. over the past decade. Urban transformation has exacerbated inequities and reduced ethnic/racial diversity among communities. This qualitative study focused on housing insecurity and other syndemic factors among Black and Latina cisgender women (BLCW). Data collection from 18 BLCW using in-depth interviews guided by syndemic theory was conducted three times over three months between 2018 and 2019. Four housing insecurity categories emerged: (a) very unstable, (b) unstable, (c) stable substandard, and (d) stable costly. Participants who experienced more stable housing, particularly more stable housing across interviews, reported fewer instances of intimate partner violence (IPV), less substance use, and a reduced risk of acquiring HIV. Results identified the importance of exploring housing insecurity with other syndemic factors among BLCW along with determining structural- and multi-level interventions to improve housing circumstances and other syndemic factors. Future research should explore these factors in other geographic locations, among other intersectional communities, and among larger sample sizes and consider using a mixed methods approach.

Eye Disease Prevalence and VF-14 Validation Among Patients Experiencing Homelessness and Presenting for Ophthalmic Examination in Baltimore, Maryland

Purpose

The coronavirus disease 2019 (COVID-19) pandemic is projected to drive 1.5 million Americans toward homelessness, adding to the 3.5 million currently affected. Homelessness poses both socioeconomic and public health challenges because housing status is a social determinant of health. Given ophthalmic health's importance in daily functioning, we characterized ophthalmic disease and vision-related quality of life (VRQOL) among a population experiencing homelessness in Baltimore, Maryland.

Methods

Questionnaires, including a Visual Function Index-14 (VF-14) for measuring VRQOL, were administered among patients seeking eye examinations at Health Care for the Homeless (HCH) from October 2018 to March 2020.

Results

One hundred sixty-two participants were enrolled in this study. The average age was 53 years. Participants' most common vision concerns were blurry vision (70%) and desire for glasses (52%). Best corrected visual acuity (BCVA) measurements revealed significant vision loss (18%, P < 0.001). Physicians mostly diagnosed refractive error (77%), cataracts (36%), glaucoma/glaucoma suspect (25%), and dry eye (24%). Nearly half were referred to additional ophthalmic care (46%). VRQOL trends reflected functional vision categories (P = 0.042 and P = 0.021). The 1:1 VRQOL and BCVA comparison showed correlation (rho = -0.3, P < 0.001). Cronbach's alpha demonstrated VF-14 reliability (alpha = 0.92).

Conclusions

We find high ophthalmic disease prevalence within a population experiencing homelessness. Comparison to studies worldwide reveals healthcare disparities despite healthcare system differences, suggesting a need for more targeted solutions. VF-14 is valid and reliable in assessing those experiencing homelessness. Intragroup VRQOL comparisons may reveal subgroup needs. It is imperative that future studies continue monitoring those experiencing homelessness.

Translational Relevance

Validation of VF-14 will allow future studies to utilize this patient-oriented metric within populations experiencing homelessness.

The association between housing stability and perceived quality of life among emerging adults with a history of homelessness

Many cities across the United States are experiencing homelessness at crisis levels, including rises in the numbers of unhoused emerging adults (18-25). Emerging adults experiencing homelessness may be at higher risk of experiencing negative outcomes, given that being unhoused increases risk for a variety of behaviors. To better understand the current living circumstances of emerging adults with a history of homelessness, as well as their perceptions about associations between housing stability and quality of life (QOL), we conducted 30 semi-structured in-depth interviews with individuals recruited from drop-in centers for youth experiencing homelessness. At the time of recruitment n=19 were stably housed and n=11 were unstably housed. Two coders analyzed these data inductively and deductively, using pre-identified domains and open coding. Coding reliability was assessed. Three main themes emerged, each with subthemes: 1) Housing quality (neighborhood safety, convenience, housing unit characteristics); 2) QOL before stable housing (physical and mental wellbeing, social wellbeing, and other determinants of QOL, such as encounters with law enforcement); and 3) Changes in QOL after stable housing (same subthemes as for pre-housing stability QOL). Findings indicated a pattern of perceived relationships between housing stability, housing quality, built and social environments, and QOL in the context of emerging adults who experienced or continued to experience homelessness. However, results were mixed with regards to the perceived effects of housing stability on alcohol and other drug use. Taken together, results indicate several areas of challenge, but also highlight opportunities to facilitate improvements in QOL among vulnerable emerging adults who experience homelessness.

A Longitudinal Study of Suicidality in a Homeless Population Sample

OBJECTIVE

Little research has been conducted on the timing of the onset and course of suicidality relative to the timing of the onset and temporal status of homelessness. Therefore, this longitudinal study investigated suicidal ideation and plans and suicide attempts in a homeless population in relation to housing attainment, psychiatric disorders, and substance use/disorders.

METHOD

Prospective longitudinal follow-up data were collected from a representative sample of literally homeless adults in St. Louis (N = 255) using the Diagnostic Interview Schedule/Homeless Supplement, the Composite International Diagnostic Interview-Substance Abuse Module, and urine drug screens. Associations among suicidal symptom variables, housing status, psychiatric/substance use disorders, and substance use were examined at baseline and longitudinally.

RESULTS

Lifetime prevalence of suicidal ideation/plan and suicide attempts in this homeless population were much higher than in the general population. Onset of suicidal symptoms had typically preceded onset of homelessness. Few individuals experienced suicidal ideation/plans or attempted suicide during this study, and even fewer experienced new suicidal symptoms after baseline. Securing stable housing during the study follow-up was associated with lower rates of suicidal ideation/plans.

CONCLUSIONS

This study's findings contradict assumptions that the high prevalence of suicidal symptoms in homeless populations can be explained by the difficulties and miseries of homelessness. Psychiatric illness, substance abuse, and psychosocial factors associated with homelessness may be direct contributors to suicidal symptoms and thus represent strategic intervention targets.HIGHLIGHTSMost suicidality reported at baseline first emerged long before first homelessnessAfter baseline, few reported new suicidal symptoms or had active suicidal symptomsSignificantly fewer reports of suicidal ideation/plans over time were found in those with the most stable housing outcome.

Respiratory infectious disease outbreaks among people experiencing homelessness: a systematic review of prevention and mitigation strategies

PURPOSE

People experiencing homelessness (PEH) are at increased risk of respiratory infections and associated morbidity and mortality. To characterize optimal intervention strategies, we completed a systematic review of mitigation strategies for PEH to minimize the spread and impact of respiratory infectious disease outbreaks, including COVID-19.

METHODS

The study protocol was registered in PROSPERO (#2020 CRD42020208964) and was consistent with the preferred reporting in systematic reviews and meta-analyses guidelines. A search algorithm containing keywords that were synonymous to the terms "Homeless" and "Respiratory Illness" was applied to the six databases. The search concluded on September 22, 2020. Quality assessment was performed at the study level. Steps were conducted by two independent team members.

RESULTS

A total of 4468 unique titles were retrieved with 21 meeting criteria for inclusion. Interventions included testing, tracking, screening, infection prevention and control, isolation support, and education. Historically, there has been limited study of intervention strategies specifically for PEH across the world.

CONCLUSIONS

Staff and organizations providing services for people experiencing homelessness face specific challenges in adhering to public health guidelines such as physical distancing, isolation, and routine hygiene practices. There is a discrepancy between the burden of infectious diseases among PEH and specific research characterizing optimal intervention strategies to mitigate transmission in the context of shelters. Improving health for people experiencing homelessness necessitates investment in programs scaling existing interventions and research to study new approaches.

Econometric Issues in Prospective Economic Evaluations Alongside Clinical Trials: Combining the Nonparametric Bootstrap With Methods That Address Missing Data

Prospective economic evaluations conducted alongside clinical trials have become an increasingly popular approach in evaluating the cost-effectiveness of a public health initiative or treatment intervention. These types of economic studies provide improved internal validity and accuracy of cost and effectiveness estimates of health interventions and, compared with simulation or decision-analytic models, have the advantage of jointly observing health and economics outcomes of trial participants. However, missing data due to incomplete response or patient attrition, and sampling uncertainty are common concerns in econometric analysis of clinical trials. Missing data are a particular problem for comparative effectiveness trials of substance use disorder interventions. Multiple imputation and inverse probability weighting are 2 widely recommended methods to address missing data bias, and the nonparametric bootstrap is recommended to address uncertainty in predicted mean cost and effectiveness between trial interventions. Although these methods have been studied extensively by themselves, little is known about how to appropriately combine them and about the potential pitfalls and advantages of different approaches. We provide a review of statistical methods used in 29 economic evaluations of substance use disorder intervention identified from 4 published systematic reviews and a targeted search of the literature. We evaluate how each study addressed missing data bias, whether the recommended nonparametric bootstrap was used, how these 2 methods were combined, and conclude with recommendations for future research.

Development and validation of the housing instability scale

Despite increasing attention to the importance of examining factors that impact housing instability and homelessness, the field lacks a validated scale of housing instability. The current study examined the reliability and validity of a seven-item scale that measures housing instability. Data were taken from a larger study which implemented the Domestic Violence Housing First model across five domestic violence agencies in the Pacific Northwest. A total of 406 participants were interviewed every six months over a period of two years. A Spanish version of the scale was administered to Spanish-speaking participants. Results provide an overview of the psychometric functioning of the scale and support its utility in assessing housing instability and homelessness. Specifically, the scale demonstrated concurrent and predictive validity, and showed evidence of scalar equivalence over time and across both language and locality. The current scale is therefore a succinct and psychometrically sound measure of housing instability which can be used moving forward to track housing instability in English and Spanish speakers, as well as in urban and rural settings.

Discrimination, Substance Use, and Mental Health among Sexual and Gender Minority Adults Accessing Day Shelter Services

BACKGROUND

Sexual and gender minority (SGM) adults are overrepresented in the population of individuals experiencing homelessness, and high rates of substance use are common in this group. Plausibly, poor mental health and discrimination may contribute to substance use among SGM adults experiencing homelessness. This study described participant characteristics, and the interrelations among sociodemographic variables, substance use, mental health, and discrimination experiences among 87 SGM adults seeking services at a day shelter in Oklahoma City, OK. Discrimination experiences were characterized by race (White vs. non-White), sex (female vs. male), sexual identity (heterosexual vs. sexual minority), and gender identity (gender conforming vs. gender minority).

METHODS

Participants reported their past 30-day tobacco (cigarette/cigarillos, alternative tobacco products [ATP]), alcohol, and marijuana use, as well as everyday and lifetime major discrimination experiences, substance use problems, depression, anxiety, and post-traumatic stress disorder (PTSD). Independent samples t-tests examined differences in discrimination based on substance use and mental health.

RESULTS

Participants had high rates of tobacco and marijuana use, substance use problems, depression, anxiety, and PTSD. Over 80% reported experiencing everyday or lifetime major discrimination. Depression and PTSD were associated with ATP use, and anxiety was associated with alcohol use. All mental health variables were associated with substance use problems and everyday discrimination. Depression was associated with lifetime major discrimination.

CONCLUSIONS

SGM adults accessing shelter services frequently experienced discrimination and poor mental health, and substance use was common. Future research should examine the causal impact of discrimination on mental health and substance use among SGM adults experiencing homelessness.

Trends and age-related characteristics of substance use in the hospitalized homeless population

ABSTRACT

We aimed to examine trends and characteristics of substance use (opioid, cocaine, marijuana, and heroin) among hospitalized homeless patients in comparison with other hospitalized patients in 3 states.This was a cross-sectional study, based on the 2007 to 2015 State Inpatient Data of Arizona, Florida, and Washington (n = 32,162,939). Use of opioid, cocaine, marijuana, heroin, respectively, was identified by the International Classification of Diseases, 9th Revision. Multi-level multivariable regressions were performed to estimate relative risk (RR) and 95% confidence intervals (CI). Dependent variables were the use of substances (opioid, cocaine, marijuana, and heroin), respectively. The main independent variable was homeless status. The subgroup analysis by age group was also conducted.Homeless patients were associated with more use of opioid (RR [CI]), 1.23 [1.20-1.26], cocaine 2.55 [2.50-2.60], marijuana 1.43 [1.40-1.46], and heroin 1.57 [1.29-1.91] compared to other hospitalized patients. All hospitalized patients including those who were homeless increased substance use except the use of cocaine (RR [CI]), 0.57 [0.55-0.58] for other patients and 0.60 [0.50-0.74] for homeless patients. In all age subgroups, homeless patients 60 years old or older were more likely to be hospitalized with all 4 types of substance use, especially, cocaine (RR [CI]), 6.33 [5.81-6.90] and heroin 5.86 [2.08-16.52] in comparison with other hospitalized patients.Homeless status is associated with high risks of substance use among hospitalized patients. Homeless elderly are particularly vulnerable to use of hard drugs including cocaine and heroin during the opioid epidemics.

Predictors of change in housing status over 12 months among individuals using emergency shelters, temporary housing or permanent housing in Quebec, Canada

Homelessness is an ongoing societal and public health problem in Canada and other countries. Housing services help homeless individuals along the transition towards stable housing, yet few studies have assessed factors that predict change in individual housing trajectories. This study identified predictors of change in housing status over 12 months for a sample of 270 currently or formerly homeless individuals using emergency shelters, temporary housing (TH) or permanent housing (PH) resources in Quebec. Participants recruited from 27 community or public organisations were interviewed between January and September 2017, and again 12 months later. Sociodemographic variables, housing history, health conditions, service use and client satisfaction were measured. Directors and programme coordinators from the selected organisations also completed a baseline questionnaire measuring strictness in residential codes of living/conduct, interorganisational collaboration and overall budget. Independent variables were organised into predisposing, enabling and needs factors, based on the Gelberg-Andersen Behavioral Model. Multilevel logistic regressions were used to test associations with the dependent variable: change in housing status over 12 months, whether positive (e.g. shelter to TH) or negative (e.g. PH to shelter). Predictors of positive change in housing status were as follows: residing in PH, being female, having children (predisposing factors); having consulted a psychologist, higher frequency in use of public ambulatory services (enabling factors); and not having physical illnesses (needs factor). The findings support strategies for helping this clientele obtain and maintain stable housing. They include deploying case managers to promote access to public ambulatory services, mainly among men or individuals without children who are less likely to seek help; greater use of primary care mental health teams; the establishment of more suitable housing for accommodating physical health problems; and reinforcing access to subsidised PH programmes.

The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis

BACKGROUND

Homelessness continues to be a pressing public health concern in many countries, and mental disorders in homeless persons contribute to their high rates of morbidity and mortality. Many primary studies have estimated prevalence rates for mental disorders in homeless individuals. We conducted a systematic review and meta-analysis of studies on the prevalence of any mental disorder and major psychiatric diagnoses in clearly defined homeless populations in any high-income country.

METHODS AND FINDINGS

We systematically searched for observational studies that estimated prevalence rates of mental disorders in samples of homeless individuals, using Medline, Embase, PsycInfo, and Google Scholar. We updated a previous systematic review and meta-analysis conducted in 2007, and searched until 1 April 2021. Studies were included if they sampled exclusively homeless persons, diagnosed mental disorders by standardized criteria using validated methods, provided point or up to 12-month prevalence rates, and were conducted in high-income countries. We identified 39 publications with a total of 8,049 participants. Study quality was assessed using the JBI critical appraisal tool for prevalence studies and a risk of bias tool. Random effects meta-analyses of prevalence rates were conducted, and heterogeneity was assessed by meta-regression analyses. The mean prevalence of any current mental disorder was estimated at 76.2% (95% CI 64.0% to 86.6%). The most common diagnostic categories were alcohol use disorders, at 36.7% (95% CI 27.7% to 46.2%), and drug use disorders, at 21.7% (95% CI 13.1% to 31.7%), followed by schizophrenia spectrum disorders (12.4% [95% CI 9.5% to 15.7%]) and major depression (12.6% [95% CI 8.0% to 18.2%]). We found substantial heterogeneity in prevalence rates between studies, which was partially explained by sampling method, study location, and the sex distribution of participants. Limitations included lack of information on certain subpopulations (e.g., women and immigrants) and unmet healthcare needs.

CONCLUSIONS

Public health and policy interventions to improve the health of homeless persons should consider the pattern and extent of psychiatric morbidity. Our findings suggest that the burden of psychiatric morbidity in homeless persons is substantial, and should lead to regular reviews of how healthcare services assess, treat, and follow up homeless people. The high burden of substance use disorders and schizophrenia spectrum disorders need particular attention in service development. This systematic review and meta-analysis has been registered with PROSPERO (CRD42018085216).

TRIAL REGISTRATION

PROSPERO CRD42018085216.

Differences in housing transitions and changes in health and self-determination between formerly homeless individuals

Background

To reduce homelessness, it is important to gain a better understanding of the differences between homeless people who remain in institutions and those who gain and can sustain independent housing. This longitudinal study explores differences in housing transitions and differences in changes in health and self-determination between formerly homeless people still living in institutions 2.5 years later and those now living in independent housing in the Netherlands.

Methods

This study mapped the housing transitions of 263 participants from when they entered the social relief system (SRS) to 2.5 years later when they were in independent housing or institutions. These individuals were compared at the 2.5-year mark in terms of gender, age and retrospectively in terms of duration of homelessness. They were also compared with regard to changes in psychological distress, perceived health, substance use and self-determination.

Results

Two and a half years after entering the SRS, 81% of participants were independently housed and 19% still lived in institutions. People in institutions had a longer lifetime duration of homelessness, were more often men, and their number of days of alcohol use had decreased significantly more, whereas independently housed people had shown a significant increase in their sense of autonomy and relatedness.

Conclusion

Formerly homeless people living in independent housing and in institutions show few health-related differences 2.5 years after entering the SRS, but changes in autonomy and relatedness are distinctly more prevalent, after the same period of time, in those who are independently housed.

Housing, Relationships, and Substance Use among Formerly Incarcerated Females

The need for housing is an important concern for most women about to be released from prison, especially by those that need substance use treatment. This study explored the association between housing settings, relationships, and substance use. Two hundred adult females that had endorsed previous incarceration within the past two years participated in the initial baseline study. This study used multi-level modeling to analyze if housing settings and/or relationships within a living condition are associated with substance use. Results indicated that participants in homeless, and mutual settings used substances significantly more than participants in their own house or apartment. Participants that were in controlled, residential and transitional settings used significantly less than those living in their own house or apartment. Living with parents, family, or sexual partner significantly increased substance use. Utilizing these results to plan housing arrangements before women are released from correctional facilities may be beneficial for substance use recovery. Currently, there is no literature that directly measures the relationship between distinct housing settings, as well as the relationships that exist within them and substance use.

Combining behavioral harm-reduction treatment and extended-release naltrexone for people experiencing homelessness and alcohol use disorder in the USA: a randomised clinical trial

BACKGROUND

The rate of alcohol-related mortality in people experiencing homelessness and alcohol use disorder is high and necessitates accessible and effective treatment for alcohol use disorder. However, typical abstinence-based treatments do not optimally engage this population. Recent studies have shown that harm-reduction treatment, which does not require abstinence, but instead aims to incrementally reduce alcohol-related harm and improve health-related quality of life, is acceptable to and effective for this population. The aim of this study was to test the efficacy of combined pharmacological and behavioural harm-reduction treatment for alcohol use disorder (HaRT-A) in people experiencing homelessness and alcohol use disorder.

METHODS

This randomised clinical trial was done at three community-based service sites (low-barrier shelters and housing programmes) in Seattle (WA, USA). Eligible participants were adults (aged 21-65 years) who met the DSM-IV-TR criteria for alcohol use disorder and who experienced homelessness in the past year. Participants were randomly assigned (1:1:1:1) by permuted block randomisation, stratified by site, to receive either HaRT-A plus intramuscular injections of 380 mg extended-release naltrexone (XR-NTX; HaRT-A plus XR-NTX group); HaRT-A plus placebo injection (HaRT-A plus placebo group); HaRT-A alone (HaRT-A alone group); or community-based supportive services as usual (services-as-usual control group). Patients assigned to receive HaRT-A attended sessions at baseline (week 0) and in weeks 1, 4, 8, and 12. XR-NTX and placebo injections were administered in weeks 0, 4, and 8. During the study, participants, interventionists, and investigators were masked to group assignment in the two injection arms. All participants were invited to follow-up assessments at weeks 4, 8, 12, 24, and 36. The primary outcomes were self-reported alcohol use quantity (ie, alcohol quantity consumed on peak drinking occasion, as measured with the Alcohol Quantity Use Assessment questionnaire) and frequency (measured with the Addiction Severity Index), alcohol-related harm (measured with the Short Inventory of Problems-2R questionnaire), and physical and mental health-related quality of life (measured with the Short Form-12 survey). Using piecewise growth modelling and an intention-to-treat model, we compared the effects of the three active treatment groups with the services-as-usual control group, and the HaRT-A plus XR-NTX group with the HaRT-A plus placebo group, over the 12-week treatment course and during the 24 weeks following treatment withdrawal. Safety analyses were done on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT01932801.

FINDINGS

Between Oct 14, 2013, and Nov 30, 2017, 417 individuals experiencing homelessness and alcohol use disorder were screened, of whom 308 were eligible and randomly assigned to the HaRT-A plus XR-NTX group (n=74), the HaRT-A plus placebo group (n=78), the HaRT-A alone group (n=79), or the services-as-usual control group (n=77). Compared with the services-as-usual control group, the HaRT-A plus XR-NTX group showed significant improvements from baseline to 12 weeks post-treatment across four of the five primary outcomes: peak alcohol quantity (linear B -0·48 [95% CI -0·79 to -0·18] p=0·010; full model Cohen's d=-0·68), alcohol frequency (linear B -4·42 [-8·09 to -0·76], p=0·047; full model Cohen's d=-0·16), alcohol-related harm (linear B -2·22 [-3·39 to -1·06], p=0·002; full model Cohen's d=-0·56), and physical health-related quality of life (linear B 0·66 [0·23 to 1·10], p=0·012; full model Cohen's d=0·43). Compared with the services-as-usual control group, the HaRT-A plus placebo group showed significant improvements in three of the five primary outcomes: peak alcohol quantity (linear B -0·41 [95% CI -0·67 to -0·15] p=0·010; full model Cohen's d=-0·23), alcohol frequency (linear B -5·95 [-9·72 to -2·19], p=0·009; full model Cohen's d=-0·13), and physical health-related quality of life (linear B 0·53 [0·09 to 0·98], p=0·050; full model Cohen's d=0·35). Compared with the services-as-usual control group, the HaRT-A alone group showed significant improvements in two of the five primary outcomes: alcohol-related harm (linear B -1·58 [95% CI -2·73 to -0·42] p=0·025; full model Cohen's d=-0·40) and physical health-related quality of life (linear B 0·63 [0·18 to 1·07], p=0·020; full model Cohen's d=0·41). After treatment discontinuation at 12 weeks, the active treatment groups plateaued, whereas the services-as-usual group showed improvements. Thus, during the post-treatment period (weeks 12 to 36), the services-as-usual control group showed greater reductions in alcohol-related harm compared with both the HaRT-A plus XR-NTX group (linear B 0·96 [0·24 to 1·67], p=0·028; full model Cohen's d=0·24) and the HaRT-A alone group (linear B 1·02 [0·35 to 1·70], p=0·013; full model Cohen's d=0·26). During the post-treatment period, the services-as-usual control group significantly improved on mental health-related quality of life compared with the HaRT-A alone group (linear B -0·46 [-0·79 to -0·12], p=0·024; full model Cohen's d=-0·28), and on physical health-related quality of life compared with the HaRT-A plus XR-NTX group (linear B -0·42 [-0·67 to -0·17], p=0·006; full model Cohen's d=-0·27), the HaRT-A plus placebo group (linear B -0·42 [-0·69 to -0·15], p=0·009; full model Cohen's d=-0·27), and the HaRT-A alone group (linear B -0·47 [-0·72 to -0·22], p=0·002; full model Cohen's d=-0·31). For all other primary outcomes, there were no significant linear differences between the services-as-usual and active treatment groups. When comparing the HaRT-A plus placebo group with the HaRT-A plus XR-NTX group, there were no significant differences for any of the primary outcomes. Missing data analysis indicated that participants were more likely to drop out in the services-as-usual control group than in the active treatment groups; however, primary outcome findings were found to be robust to attrition. Participants in the HaRT-A plus XR-NTX, HaRT-A plus placebo, and HaRT-A alone groups were not more likely to experience adverse events than those in the services-as-usual control group.

INTERPRETATION

Compared with existing services, combined pharmacological and behavioural harm-reduction treatment resulted in decreased alcohol use and alcohol-related harm and improved physical health-related quality of life during the 12-week treatment period for people experiencing homelessness and alcohol use disorder. Although not as consistent, there were also positive findings for behavioural harm-reduction treatment alone. Considering the non-significant differences between participants receiving HaRT-A plus placebo and HaRT-A plus XR-NTX, the combined pharmacological and behavioural treatment effect cannot be attributed to XR-NTX alone. Future studies are needed to further investigate the relative contributions of the pharmacological and behavioural components of harm-reduction treatment for alcohol use disorder, and to ascertain whether a maintenance treatment approach could extend these positive outcome trajectories.

FUNDING

National Institute on Alcohol Abuse and Alcoholism.

Jail and Emergency Department Utilization in the Context of Harm Reduction Treatment for People Experiencing Homelessness and Alcohol Use Disorder

People experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, Harm Reduction Treatment for Alcohol (HaRT-A) was developed together with people with the lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. The parent RCT showed that HaRT-A precipitated statistically significant reductions in alcohol use, alcohol-related harm, AUD symptoms, and positive urine toxicology tests. This secondary study tested HaRT-A effects on more distal, 6-month pre-to-posttreatment changes on jail and emergency department (ED) utilization. People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: (a) collaborative tracking of participant-preferred alcohol metrics, (b) elicitation of harm-reduction and QoL goals, and (c) discussion of safer-drinking strategies. Administrative data on jail and ED utilization were extracted for 6 months pre- and posttreatment. Findings indicated no statistically significant treatment group differences on 6-month changes in jail or ED utilization (ps > .23). Exploratory analyses showed that 2-week frequency of alcohol use was positively correlated with number of jail bookings in the 12 months surrounding their study participation. Additionally, self-reported alcohol-related harm, importance of reducing alcohol-related harm, and perceived physical functioning predicted more ED visits. Future studies are needed to further assess how harm-reduction treatment may be enhanced to move the needle in criminal justice and healthcare utilization in the context of larger samples, longer follow-up timeframes, and more intensive interventions.

Make Mission Impossible Feasible: The Experience of a Multidisciplinary Team Providing Treatment for Alcohol Use Disorder to Homeless Individuals

AIM

People experiencing homelessness are often excluded from treatment programs for alcohol use disorder (AUD). The goal of this study was to describe the impact of a multidisciplinary treatment program on alcohol consumption and social reintegration in individuals with AUD experiencing homelessness.

METHODS

Thirty-one individuals with AUD experiencing homelessness were admitted to an inpatient unit for 5-6 days for clinical evaluation and to treat potential alcohol withdrawal syndrome. A group of volunteers, in collaboration with the Community of Sant'Egidio, provided social support aimed to reintegrate patients. After inpatient discharge, all patients were followed as outpatients. Alcohol intake (number drinks/day), craving and clinical evaluation were assessed at each outpatient visit. Biological markers of alcohol use were evaluated at enrollment (T0), at 6 months (T1) and 12 months (T2).

RESULTS

Compared with T0, patients at T1 showed a significant reduction in alcohol consumption [10 (3-24) vs 2 (0-10); P = 0.015] and in γ-glutamyl-transpeptidase [187 (78-365) vs 98 (74-254); P = 0.0021]. The reduction in alcohol intake was more pronounced in patients with any housing condition [10 (3-20) vs 1 (0-8); P = 0.008]. Similarly, compared with T0, patients at T2 showed significant reduction in alcohol consumption [10 (3-24) vs 0 (0-15); P = 0.001], more pronounced in patients with any housing condition [10 (3-20) vs 0 (0-2); P = 0.006]. Moreover, at T2 patients showed a significant reduction in γ-glutamyl-transpeptidase [187 (78-365) vs 97 (74-189); P = 0.002] and in mean cell volume [100.2 (95-103.6) vs 98.3 (95-102); P = 0.042].

CONCLUSION

Patients experiencing homelessness may benefit from a multidisciplinary treatment program for AUD. Strategies able to facilitate and support their social reintegration and housing can improve treatment outcomes.

Association of Problematic Alcohol Use and Food Insecurity among Homeless Men and Women

Food insecurity results from unreliable access to affordable and nutritious food. Homeless adults are particularly vulnerable to both food insecurity and problematic alcohol use. The current study examined the link between problematic alcohol use and food insecurity among homeless adults. Participants (N = 528; 62.7% men; M_age = 43.6 ± 12.2) were recruited from homeless-serving agencies in Oklahoma City. Problematic alcohol use was measured using the Alcohol Quantity and Frequency Questionnaire and the Patient Health Questionnaire. The latter used DSM-IV diagnostic criteria to assess probable alcohol use dependence/abuse. Heavy drinking was considered >7 drinks (women) and >14 drinks (men) per week. Food insecurity was measured with the USDA Food Security Scale-Short Form. The link between alcohol problems and food insecurity was examined with logistic regression analyses controlling for sex, age, education, income, and months homeless. Overall, 28.4% of the sample had probable alcohol dependence, 25% were heavy drinkers, and 78.4% were food insecure. Probable alcohol dependence and heavy drinking were correlated at 0.53 (p < 0.001). Results indicated that heavy drinking (OR = 2.12, CI_.95 = 1.21, 3.73) and probable alcohol dependence/abuse (OR = 2.72, CI_.95 = 1.55, 4.77) were each associated with increased odds of food insecurity. Food insecurity and problematic alcohol use are major issues among homeless populations; this study suggests they are associated. Future research is needed to shed light on potential causal mechanisms and on whether alcohol may take precedence over eating or food purchases.

A qualitative exploration of substance misuse among homeless women in Addis Ababa, Ethiopia

BACKGROUND

Substance use among homeless people is higher compared to the general population. In some studies, reported rates of problematic drug use among the homeless vary, with estimates ranging from 25 to 70%. There is a common perception that substance abuse and homelessness are linked, but there is considerable debate about the direction of the relationship. Despite observations of high levels of substance use among the homeless population in Addis Ababa, there are limited studies to date conducted on the topic. This study aims to explore the factors associated with onset of substance use and its continued use, patterns of substance use and its social and health consequences among female residents of a shelter in Addis Ababa, Ethiopia.

METHODS

A qualitative study was conducted in 2019. In-depth interviews were conducted on 14 study participants who were selected purposively. The qualitative data analysis software QDA Miner 5.0.30 was used for data processing and analysis.

RESULTS

Four major thematic areas were identified and they comprised the categories under which sub-themes were identified and coded. The major segments or categories included the following: reasons for the onset of substance use after becoming homeless, experiences of substance use and reasons for continued use, the harms which resulted on them from substance use, and the means of obtaining supply of the substances.

CONCLUSION

Factors related to life on streets were strong reasons for onset of substance use, as well as for its continued use. Homeless women suffered untimely death, addiction, and ill health from use of substances; however, they gave priority to obtaining substances than any other thing, and used every means to grab a supply of the substances.

Reducing Drinking Among People Experiencing Homelessness: Protocol for the Development and Testing of a Just-in-Time Adaptive Intervention

Background

Adults who are homeless are more likely to have alcohol use disorders (AUDs) compared with domiciled adults. Although AUD treatments are commonly available, many factors (eg, transportation limitations and inability to schedule appointments) contribute to low treatment completion rates and low success rates of these interventions among adults experiencing homelessness. Most adults who are homeless own mobile phones; however, no interventions have been developed that use mobile devices to deliver and support AUD interventions for this population. Mobile phone–based AUD interventions may reduce barriers that have limited the use and utility of traditional interventions.

Objective

The aim of this study is to (1) identify variables (eg, affect, stress, geolocation, and cravings) that predict drinking among homeless adults (phase I), (2) develop a mobile intervention that utilizes an algorithm to identify moments of risk for drinking and deliver treatment messages that are tailored to the individual’s current needs in real time (phase II), and (3) pilot test the intervention app (phase III).

Methods

In phase I, adults experiencing homelessness with an AUD (N=80) will complete baseline, equipment, 2-week, and 4-week follow-up visits in person. Participants will be prompted to complete five daily ecological momentary assessments on a study-provided smartphone for 28 days. The smartphone app will collect GPS coordinates every 5 min for the entire 28-day study period. Participants will wear a transdermal alcohol sensor that will objectively measure alcohol use. In phase II, we will use phase I data to develop an algorithm that identifies moments of heightened risk for drinking and develop treatment messages that address risk factors for drinking. Phase III will pilot test the intervention in 40 adults experiencing homelessness with AUD.

Results

This project was funded in June 2018. IRB approval was obtained in October 2018, and data collection for phase I began in February 2019. Phase III data collection is expected to conclude in 2020. To date, 80 participants have consented to the study, and data analysis for phase I will begin in early 2020.

Conclusions

This research will highlight intervention targets and develop a novel intervention for understudied and underserved adults experiencing homelessness with AUD.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15610

Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder

BACKGROUND

People experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, harm reduction treatment for alcohol (HaRT-A) was developed together with people with lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. A three-month, two-arm randomized controlled trial was conducted to test the initial efficacy of HaRT-A compared to a services-as-usual control condition.

METHODS

People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Self-reported alcohol use, alcohol-related harm, motivation, and QoL as well as urinary ethyl glucuronide were assessed over a 3-month follow-up. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: a) collaborative tracking of participant-preferred alcohol metrics, b) elicitation of harm-reduction and QoL goals, and c) discussion of safer-drinking strategies.

RESULTS

Compared to control participants, HaRT-A participants reported significantly greater increases in confidence to engage in harm reduction and decreases in peak alcohol use, alcohol-related harm, AUD symptoms, and positive urinary ethyl glucuronide tests (ps < .05). Findings were inconclusive regarding group differences on QoL (ps > .12).

CONCLUSION

A low-barrier, low-intensity, patient-driven, harm-reduction approach has at least short-term efficacy in improving AUD outcomes in this population. Future studies are needed to establish its longer-term efficacy.

A naturalistic longitudinal study of the order of service provision with respect to cocaine use and outcomes in an urban homeless sample

AIMS

Little is known about outcomes of drug abuse related to attainment of stable housing. This study examined outcomes of cocaine use and service provision in an urban homeless sample.

METHODS

Two-year longitudinal study of systematically selected homeless individuals (N = 255) in St. Louis, Missouri from 1999 to 2001. The sample was interviewed three times annually using a structured diagnostic interview. Urine drug testing was conducted at every interview, and service utilisation data were obtained from the structured interviews and the agency-provided service use data.

RESULTS

Cocaine use disorder and cocaine use proved to be distinct concepts because they predicted different outcomes across time. Cocaine use predicted subsequent poor housing outcomes, but stable housing had no apparent effect on subsequent use of cocaine. Service use predicted neither subsequent reduced cocaine use nor attainment of stable housing. Services used were appropriate to type of mental health need, but cocaine use may have reduced successful utilisation of appropriate psychiatric services.

CONCLUSION

These findings reinforce the concept that homelessness represents a complex phenomenon and consequently, service systems need to address multiple problems. Service approaches are needed that simultaneously address the complex needs of homeless individuals.

Associations of alcohol use disorder, alcohol use, housing, and service use in a homeless sample of 255 individuals followed over 2 years

BACKGROUND

Homeless individuals with alcohol use disorders have multiple comorbidities and therefore various service needs. Despite need for services, homeless individuals face numerous barriers to treatment. Little is known about the associations of specific services in relation to homelessness in the context of alcohol problems. The current study analyzed 2-year prospective longitudinal data on a homeless sample, examining relationships between alcohol use disorder, alcohol use, housing status, and service use over time.

METHODS

Two hundred fifty-five of 400 individuals recruited systematically from shelters and street locations completed 3 annual assessments (69% completion). Data on lifetime and current psychiatric disorders, housing status, and past-year service use were obtained and merged with service use data gathered from local agencies. Generalized estimating equation (GEE) models were created to predict dependent outcome variables of stable housing, alcohol use, and service use in both follow-up years.

RESULTS

Lifetime alcohol use disorder was positively associated with substance and medical service use. Alcohol problems did not hinder attainment of stable housing, and placement in housing did not necessarily increase risk for alcohol use. Stable housing was negatively associated with psychiatric and substance service use. In the second year, when alcohol use was finally associated with receiving substance services, it appears that these services provided a gateway to psychiatric services. The psychiatric services in turn appeared to provide a gateway to medical services.

CONCLUSIONS

Alcohol use behaved differently compared with lifetime alcohol use disorder in relation to service use. Lack of association between alcohol use and housing supports Housing First policy. Obtaining housing may have ameliorative effects on mental health, diminishing perceived need for psychiatric services. Services may also be more accessible during homelessness. Obtaining substance treatment may provide a gateway for those who use alcohol after becoming homeless to connect with psychiatric and medical services, informing policy and practice.

Social networks and substance use after transitioning into permanentsupportive housing

BACKGROUND

Substance use disorders are common among persons experiencing homelessness, and research has identified social networks as important correlates of substance use in this population. Permanent supportive housing (PSH), particularly Housing First, which uses a harm reduction model not requiring substance abstinence, is a key solution for ending homelessness. However, conflicting evidence exists regarding the associations between moving into PSH and changes in substance use, and there is limited understanding of how networks may influence such changes.

METHODS

Using observational, longitudinal data from 421 persons before they moved in and over their first year in PSH (collected as part of a HIV-risk study), this paper assesses substance use change (alcohol, marijuana, and illicit drugs) and associations between perceived network characteristics and individual substance use.

RESULTS

Substance use remained relatively stable among participants over their first year living in PSH, although illicit substance use reduced somewhat at six months compared to baseline levels (from 18.5%-14.5%) and marijuana use increased slightly at 12 months (from 26.6% at baseline to 32.9%). Substance use among social network members was consistently associated with individual-level substance use, both cross-sectionally and longitudinally. Specific network substance use characteristics, such as proximity, location met, and social support, had differential relationships with particular substance types.

CONCLUSIONS

These findings provide longitudinal evidence that changes within substance-using social networks are associated with subsequent changes in individual use and underscore the importance of interventions aimed at promoting positive social relationships for formerly homeless persons and improving PSH's social environments.

Financing Cocaine Use in a Homeless Population

Background: Cocaine use is highly prevalent among homeless populations, yet little is known about how it is financed. This study examined associations of income sources with cocaine use and financing of drugs in a longitudinal evaluation of a homeless sample. Methods: A homeless sample was recruited systematically in St. Louis in 1999–2001 and longitudinally assessed annually over two years using the Diagnostic Interview Schedule and the Homeless Supplement, with urine drug testing. Results: More than half (55%) of participants with complete follow-up data (N = 255/400) had current year cocaine use. Current users spent nearly $400 (half their income) in the last month on drugs at baseline. Benefits, welfare, and disability were negatively associated and employment and income from family/friends, panhandling, and other illegal activities were positively associated with cocaine use and monetary expenditures for cocaine. Conclusions: Findings suggest that illegal and informal income-generating activities are primary sources for immediate gratification with cocaine use and public entitlements do not appear to be primary funding sources used by homeless populations. Policy linking drug testing to benefits is likely to have little utility, and public expenditures on measures to unlink drug use and income might be more effectively used to fund employment and treatment programs.

Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples

BACKGROUND

It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation, with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing, to understanding the social context of homelessness and social interventions to prevent it. However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves. This study aims to examine the stories of homeless people to gain understanding of the social conditions under which homelessness occurs, in order to propose a theoretical explanation for it.

METHOD

Twenty-six semi-structured interviews were conducted with homeless people in three centres for homeless people in Cheshire North West of England.

RESULTS

The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience capacity to cope with life challenges created by series of adverse incidents in one's life. The data show that final stage in the process of becoming homeless is complete collapse of relationships with those close to them. Most prominent pattern of behaviours participants often describe as main causes of breakdown of their relationships are: 1. engaging in maladaptive behavioural lifestyle including taking drugs and/or excessive alcohol drinking 2. Being in trouble with people in authorities.

CONCLUSION

Homeless people describe the immediate behavioural causes of homelessness, however, the analysis revealed the social and economic conditions within which homelessness occurred. The participants' descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

Dutch homeless people 2.5 years after shelter admission: what are predictors of housing stability and housing satisfaction?

Housing stability is an important focus in research on homeless people. Although definitions of stable housing differ across studies, the perspective of homeless people themselves is generally not included. Therefore, this study explored the inclusion of satisfaction with the participant's current housing status as part of the definition of housing stability and also examined predictors of housing stability with and without the inclusion of homeless person's perspective. Of the initial cohort consisting of 513 homeless participants who were included at baseline in 2011, 324 (63.2%) were also interviewed at 2.5-year follow-up. To determine independent predictors of housing stability, we fitted multivariate logistic regression models using stepwise backward regression. At 2.5-year follow-up, 222 participants (68.5%) were stably housed and 163 participants (51.1%) were stably housed and satisfied with their housing status. Having been arrested (OR = 0.36, 95% CI: 0.20-0.63), a high level of somatisation (physical manifestations of psychological distress) (OR = 0.52, 95% CI: 0.30-0.91) and having unmet care needs (OR = 0.77, 95% CI: 0.60-0.99) were negative predictors of housing stability. Having been arrested (OR = 0.43, 95% CI: 0.25-0.75), high debts (OR = 0.45, 95% CI: 0.24-0.84) and a high level of somatisation (OR = 0.49, 95% CI: 0.28-0.84) were negative predictors of stable housing when satisfaction with the housing status was included. Because inclusion of a subjective component revealed a subgroup of stably housed but not satisfied participants and changed the significant predictors, this seems a relevant addition to the customary definition of housing stability. Participants with characteristics negatively associated with housing stability should receive more extensive and individually tailored support services to facilitate achievement of housing stability.

Housing and abstinence self-efficacy in formerly incarcerated individuals

To avoid recidivism, formerly-incarcerated individuals must successfully navigate barriers to re-entry, including finding adequate housing and avoiding substance use. This study examined the role that time in diverse housing situations affect abstinence self-efficacy in formerly-incarcerated individuals. Formerly-incarcerated individuals were surveyed about previous housing situations and abstinence self-efficacy after release from prison or inpatient substance use treatment. Models were estimated with both days spent in different housing situations in the past 180 and past 30 days. More time spent in recovery situations was associated with increased abstinence self-efficacy, while more time spent in precarious situations was associated with decreased abstinence self-efficacy.

Residential Transience, Major Depressive Episodes, and the Risk of Suicidal Thoughts, Plans, and Attempts

The association between past-year residential transience (frequent moving) and suicidal ideation among a nationally representative sample of over 190,000 U.S. adults was evaluated. Suicidal thoughts, plans, and attempts were more prevalent among transient adults. Among adults without major depressive episodes (MDE), transience was associated with 70% to 90% greater odds of suicidal ideation compared to nontransient adults. Among adults with MDE, transience was associated with a 60% to 80% increased odds of suicidal ideation compared to nontransient adults. Residential transience may be an indicator for increased suicide risk even in the absence of depression.

Disparities in Cancer Incidence, Stage, and Mortality at Boston Health Care for the Homeless Program

INTRODUCTION

Homeless people have a high burden of cancer risk factors and suboptimal rates of cancer screening, but the epidemiology of cancer has not been well described in this population. We assessed cancer incidence, stage, and mortality in homeless adults relative to general population standards.

METHODS

We cross-linked a cohort of 28,033 adults seen at Boston Health Care for the Homeless Program in 2003-2008 to Massachusetts cancer registry and vital registry records. We calculated age-standardized cancer incidence and mortality ratios (SIRs and SMRs). We examined tobacco use among incident cases and estimated smoking-attributable fractions. Trend tests were used to compare cancer stage distributions with those in Massachusetts adults. Analyses were conducted in 2012-2015.

RESULTS

During 90,450 person-years of observation, there were 361 incident cancers (SIR=1.13, 95% CI=1.02, 1.25) and 168 cancer deaths (SMR=1.88, 95% CI=1.61, 2.19) among men, and 98 incident cancers (SIR=0.93, 95% CI=0.76, 1.14) and 38 cancer deaths (SMR=1.61, 95% CI=1.14, 2.20) among women. For both sexes, bronchus and lung cancer was the leading type of incident cancer and cancer death, exceeding Massachusetts estimates more than twofold. Oropharyngeal and liver cancer cases and deaths occurred in excess among men, whereas cervical cancer cases and deaths occurred in excess among women. About one third of incident cancers were smoking-attributable. Colorectal, female breast, and oropharyngeal cancers were diagnosed at more-advanced stages than in Massachusetts adults.

CONCLUSIONS

Efforts to reduce cancer disparities in homeless people should include addressing tobacco use and enhancing participation in evidence-based screening.

Substance use among Dutch homeless people, a follow-up study: prevalence, pattern and housing status

BACKGROUND

Previous studies have shown that substance use among homeless people is a prevalent problem that is associated with longer durations of homelessness. Most studies of substance use among the homeless were carried out outside Europe and have limited generalizability to European countries. This study therefore aimed to address the prevalence of substance use among homeless people in the Netherlands, the pattern of their use and the relationship with housing status at follow-up.

METHODS

This study included 344 participants (67.1% of the initial cohort) who were followed from baseline to 18 months after the baseline interview. Multinomial logistic regression analyses examined the relationship between substance use and housing status.

RESULTS

The most reported substances which were used among these homeless people were cannabis (43.9%) and alcohol (≥5 units on one occasion) (30.7%). Other substances were used by around 5% or less of the participants. Twenty-seven percent were classified as substance misuser and 20.9% as substance dependent. The odds to be marginally housed (4.14) or institutionalized (2.12) at follow-up compared to being housed of participants who were substance users were significantly higher than those of participants who did not use substances. The odds to be homeless were more than twice as high (2.80) for participants who were substance dependent compared with those who were not.

CONCLUSION

Homeless people who use substances have a more disadvantageous housing situation at follow-up than homeless people who do not use substances. Attention is needed to prevent and reduce long-term homelessness among substance-using homeless people.

Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston

OBJECTIVES

We quantified tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities among homeless adults.

METHODS

We ascertained causes of death among 28 033 adults seen at the Boston Health Care for the Homeless Program in 2003 to 2008. We calculated population-attributable fractions to estimate the proportion of deaths attributable to tobacco, alcohol, or drug use. We compared attributable mortality rates with those for Massachusetts adults using rate ratios and differences.

RESULTS

Of 1302 deaths, 236 were tobacco-attributable, 215 were alcohol-attributable, and 286 were drug-attributable. Fifty-two percent of deaths were attributable to any of these substances. In comparison with Massachusetts adults, tobacco-attributable mortality rates were 3 to 5 times higher, alcohol-attributable mortality rates were 6 to 10 times higher, and drug-attributable mortality rates were 8 to 17 times higher. Disparities in substance-attributable deaths accounted for 57% of the all-cause mortality gap between the homeless cohort and Massachusetts adults.

CONCLUSIONS

In this clinic-based cohort of homeless adults, over half of all deaths were substance-attributable, but this did not fully explain the mortality disparity with the general population. Interventions should address both addiction and non-addiction sources of excess mortality.

The impact of mood symptomatology on pattern of substance use among homeless

BACKGROUND

Homeless individuals are an extremely vulnerable and underserved population characterized by overlapping problems of mental illness and substance use. Given the fact that mood disorders are frequently associated with substance use disorders, we wanted to further highlight the role of excitement in substance abuse. Patterns of substance abuse among homeless suffering from unipolar and bipolar depression were compared. The "self-medication hypothesis" which would predict no-differences in substance preference by unipolar (UP) and bipolar (BP) depressed homeless was tested.

METHODS

Homeless individuals from the Vancouver At Home/Chez Soi study were selected for lifetime UP and lifetime BP depression and patterns of substances abused in the previous 12 months were identified with the Mini-International Neuropsychiatric Interview. Differences in substance use between BP-depressed homeless and UP-depressed homeless were tested using Chi-square and logistic regression techniques.

RESULTS

No significant differences were observed between UP and BP homeless demographics. The bipolar depressed homeless (BDH) group displayed a higher percentage of Central Nervous System (CNS) Stimulants (χ 8.66, p=0.004) and Opiates (χ 6.41, p=0.013) as compared to the unipolar depressed homeless (UDH) group. CSN Stimulant was the only predictor within the BDH Group (χ(2) 8.74 df 1 p<0.003).

LIMITATIONS

Data collected are self-reported and no urinalyses were performed.

CONCLUSIONS

The results support the hypothesis that beyond the self-medication hypothesis, bipolarity is strictly correlated to substance use; this correlation is also verified in a homeless population.

A prospective study of the associations among housing status and costs of services in a homeless population

OBJECTIVE

The complex needs of homeless populations result in use of a wide range of services and high costs for housing programs and psychiatric and general medical care. Allocation of resources often is not congruent with assessed needs. A series of cost-congruence hypotheses was developed to test assumptions that needs are associated with resources provided for appropriate services in homeless populations.

METHODS

Individuals (N=255) who were homeless were followed for two years and were categorized by housing status over time (consistently housed, housed late, lost housing, or consistently homeless). Detailed information about the individuals was obtained at baseline, and follow-up data were collected one and two years later. Extensive data about the costs of services provided by type (medical, psychiatric, substance abuse, and homeless maintenance and amelioration) were derived from 23 agencies, and service use information was collected from the agencies and by self-report. Multiple regression models were used to test the hypotheses.

RESULTS

Medical, psychiatric, and homeless maintenance costs varied by housing status. Serious mental illness predicted costs for psychiatric services, as expected, but also costs for substance abuse services and acute behavioral health care and total costs. Alcohol use disorders predicted substance abuse service costs.

CONCLUSIONS

This study followed a homeless cohort prospectively and provided estimates of costs of service use derived from a large number of agencies. This research increases the understanding of patterns of service use in a homeless population and informs the provision of services appropriate to the complex needs of this difficult-to-serve population.

Is smoking cessation associated with worse comorbid substance use outcomes among homeless adults?

BACKGROUND AND AIMS

Smoking prevalence among homeless adults is exceedingly high, and high rates of comorbid substance use are among the barriers to abstinence experienced by this group. The extent to which smoking cessation might engender an escalation in comorbid substance use could be a concern prohibiting treatment provision and engagement. This study examined whether smoking abstinence status was associated with alcohol and substance use at 26 weeks post-randomization among homeless smokers in a smoking cessation trial.

DESIGN

The current study was a secondary analysis of randomized smoking cessation intervention trial data.

SETTING

The parent study was conducted in the Minneapolis/St Paul area of Minnesota, USA.

PARTICIPANTS

Participants were 427 homeless adult smokers interested in quitting smoking.

MEASUREMENTS

Covariates collected at baseline included alcohol, cocaine, marijuana/hashish, heroin and 'any' drug use, age, sex, race/ethnicity, education, tobacco dependence, length of time homeless and treatment group. Biochemically verified smoking abstinence and self-reported alcohol and substance use were collected at 26 weeks post-randomization.

FINDINGS

Smoking abstinence was associated with fewer drinking days (P = 0.03), fewer drinks consumed on drinking days (P = 0.01), and lower odds of heavy drinking (P = 0.05), but not with differences in the number of days of cocaine, marijuana/hashish, heroin or any drug use.

CONCLUSIONS

In homeless smokers, achieving smoking abstinence may be associated with a reduction in alcohol consumption but appears not to be associated with a substantial change in other drug use.

Does stimulant use impair housing outcomes in low-demand supportive housing for chronically homeless adults?

BACKGROUND

Recent research suggests low-demand housing (i.e., not contingent upon abstinence) is effective in helping people exit homelessness, even among recent active substance users. Whether active users of illicit drugs and stimulants have worse housing outcomes than primary alcohol users, however, is unknown.

METHODS

A total of 149 participants in a multisite supportive housing program who reported high levels of active substance use at program entry were classified as either (1) predominantly "Alcohol Use" (>10 of 30 days alcohol, but not >10 days of drug use) or (2) "Illicit Drug Use" (>10 of 30 days any single illicit drug use with or without alcohol use). Sub-analysis of the "Illicit Drug Use" group compared participants reporting high levels of "Stimulant Use" (>10 days cocaine, crack, or methamphetamine use) to those with high levels of "Non-stimulant Use" (>10 days marijuana or other non-stimulant drug use). Group differences in housing outcomes were examined with mixed model multivariate regression.

RESULTS

During 24-month follow-up, days housed increased dramatically for both the "Alcohol Use" and the "Illicit Drug Use" groups without significant differences. Sub-analysis of illicit drug users showed stimulant use was associated with fewer days housed (p = .01) and more days homeless (p = .02) over time.

CONCLUSIONS

Among illicit drug users, stimulant users have somewhat less successful housing outcomes than other active drug and alcohol users, though both groups maintained substantial housing improvements in low-demand housing.

Housing First: exploring participants' early support needs

BACKGROUND

Housing First has become a popular treatment model for homeless adults with mental illness, yet little is known about program participants' early experiences or trajectories. This study used a mixed methods design to examine participant changes in selected domains 6 months after enrollment in a Canadian field trial of Housing First.

METHODS

The study sample included 301 participants receiving the Housing First intervention at the Toronto site of the At Home/Chez Soi project. This study used a pre-post design to compare quantitative 6-month outcome data to baseline values in key domains and multivariate regression to identify baseline demographic, clinical or service use variables associated with observed changes in these domains. In addition, qualitative data exploring participant and service provider perspectives and experiences was collected via stakeholder interviews and focus groups, and analyzed using thematic analysis.

RESULTS

The majority (60 to 72%) of participants followed the expected trajectory of improvement, with the remaining experiencing difficulties in community integration, mental health symptom severity, substance use, community functioning and quality of life 6 months after program enrollment. Diagnosis of psychotic disorder was associated with a reduction in quality of life from baseline to 6-months, while substance use disorders were associated with reduced mental illness symptoms and substance use related problems and an improvement in quality of life. Participants housed in independent housing at 6-months had greater improvements in community integration and quality of life, and greater reduction in mental illness symptoms, compared to those not independently housed. The quality of the working alliance was positively associated with improvements in physical and psychological community integration and quality of life. Qualitative data provided a unique window into the loneliness and isolation experienced by Housing First participants, as well as problems related to substance use and a need for life skills training and support.

CONCLUSIONS

Additional strategies can help support Housing First participants in the early stages of program participation and address potential causes of early difficulties, including lack of life skills and social isolation. This study highlights the importance of early and ongoing evaluation, monitoring and program adaptations to address consumer support needs.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42520374.

Shelter proximity and affect among homeless smokers making a quit attempt

OBJECTIVES

To explore the associations between shelter proximity and real-time affect during a specific smoking quit attempt among 22 homeless adults.

METHODS

Affect was measured via 485 smartphone-based Ecological Momentary Assessments randomly administered during the weeks immediately before and after the quit day, and proximity to the shelter was measured via GPS. Adjusted linear mixed model regressions examined associations between shelter proximity and affect.

RESULTS

Closer proximity to the shelter was associated with greater negative affect only during the post-quit attempt week (p = .008). All participants relapsed to smoking by one week post-quit attempt.

CONCLUSIONS

Among homeless smokers trying to quit, the shelter may be associated with unexpected negative affect/stress. Potential intervention applications are suggested.

Housing instability and alcohol problems during the 2007-2009 US recession: the moderating role of perceived family support

The 2007-2009 US economic recession was marked by unprecedented rates of housing instability and relatively little is known about how this instability impacted alcohol problems. While previous studies have linked homelessness to increased rates of alcohol use and abuse, housing instability during a recession impacts a much larger segment of the population and usually does not result in homelessness. Using a nationally representative sample of US adults, this study examines the association between housing instability during the recession and alcohol outcomes. Additionally, we assess whether this association is moderated by perceived family support. In multivariate negative binomial regressions, both trouble paying the rent/mortgage (vs. stable housing) and lost (vs. stable) housing were associated with experiencing more negative drinking consequences and alcohol dependence symptoms. However, these associations were moderated by perceived family support. In contrast to those with low perceived family support, participants with high perceived family support reported relatively few alcohol problems, irrespective of housing instability. Furthermore, while job loss was strongly associated with alcohol problems in univariate models, no significant associations between job loss and alcohol outcomes were observed in multivariate models that included indicators of housing instability. Findings point to the importance of the informal safety net and suggest that alcohol screening and abuse prevention efforts should be intensified during periods of recession, particularly among those who experience housing instability.

Housing first improves residential stability in homeless adults with concurrent substance dependence and mental disorders

OBJECTIVES

We examined the relationship between substance dependence and residential stability in homeless adults with current mental disorders 12 months after randomization to Housing First programs or treatment as usual (no housing or support through the study).

METHODS

The Vancouver At Home study in Canada included 2 randomized controlled trials of Housing First interventions. Eligible participants met the criteria for homelessness or precarious housing, as well as a current mental disorder. Residential stability was defined as the number of days in stable residences 12 months after randomization. We used negative binomial regression modeling to examine the independent association between residential stability and substance dependence.

RESULTS

We recruited 497 participants, and 58% (n = 288) met the criteria for substance dependence. We found no significant association between substance dependence and residential stability (adjusted incidence rate ratio = 0.97; 95% confidence interval = 0.69, 1.35) after adjusting for housing intervention, employment, sociodemographics, chronic health conditions, mental disorder severity, psychiatric symptoms, and lifetime duration of homelessness.

CONCLUSIONS

People with mental disorders might achieve similar levels of housing stability from Housing First regardless of whether they experience concurrent substance dependence.

Substance use and access to health care and addiction treatment among homeless and vulnerably housed persons in three Canadian cities

Introduction

We examined the prevalence of substance use disorders among homeless and vulnerably housed persons in three Canadian cities and its association with unmet health care needs and access to addiction treatment using baseline data from the Health and Housing in Transition Study.

Methods

In 2009, 1191 homeless and vulnerably housed persons were recruited in Vancouver, Toronto, and Ottawa, Canada. Interviewer administered questionnaires collected data on socio-demographics, housing history, chronic health conditions, mental health diagnoses, problematic drug use (DAST-10≥6), problematic alcohol use (AUDIT≥20), unmet physical and mental health care needs, addiction treatment in the past 12 months. Three multiple logistic regression models were fit to examine the independent association of substance use with unmet physical health care need, unmet mental health care need, and addiction treatment.

Results

Substance use was highly prevalent, with over half (53%) screening positive for the DAST-10 and 38% screening positive for the AUDIT. Problematic drug use was 29%, problematic alcohol use was lower at 16% and 7% had both problematic drug and alcohol use. In multiple regression models for unmet need, we found that problematic drug use was independently associated with unmet physical (adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI] 1.43–2.64) and unmet mental (AOR 3.06; 95% CI 2.17–4.30) health care needs. Problematic alcohol use was not associated with unmet health care needs. Among those with problematic substance use, problematic drug use was associated with a greater likelihood of accessing addiction treatment compared to those with problematic alcohol use alone (AOR 2.32; 95% CI 1.18–4.54).

Conclusions

Problematic drug use among homeless and vulnerably housed individuals was associated with having unmet health care needs and accessing addiction treatment. Strategies to provide comprehensive health services including addiction treatment should be developed and integrated within community supported models of care.

Sobriety as an admission criterion for transitional housing: a multi-site comparison of programs with a sobriety requirement to programs with no sobriety requirement

BACKGROUND

This study examined whether homeless clients enrolled in transitional housing programs that required sobriety (SR) as an admission criterion have outcomes comparable to clients enrolled in programs that did not require sobriety (NSR) as an admission criterion.

METHODS

A total of 1062 military veterans in 40 transitional housing programs funded by the United States Department of Veterans Affairs were grouped based on whether they were in SR or NSR programs and followed over a one-year period after program discharge. Participants in SR and NSR programs were compared on their ratings of the social climate of the program, and housing and psychosocial outcomes.

RESULTS

Participants in SR programs reported more days housed and better psychosocial outcomes than participants in NSR programs, although the differences were small and there were no differences in ratings of their social climate. Both participants in SR and NSR programs showed improvements on most outcomes after discharge from transitional housing. There were no significant differences in outcomes between participants actively abusing substances at program entry compared to those who were not.

CONCLUSIONS

Requiring sobriety as an admission criterion in transitional housing made only a small difference in housing outcomes post-discharge. Further study is needed to determine whether requiring sobriety at admission in transitional housing is necessary for successful client outcomes.