Homelessness, substance misuse, and access to public entitlements in a soup kitchen population

Monitoring alcohol use in heavy drinking soup kitchen attendees

Rates of heavy alcohol use in soup kitchen attendees range from 30% to 38%, but these data are based entirely on self-reported drinking. Little is known about the intensity or frequency of drinking in this population. We assessed alcohol use transdermally every 30 min over a 3-week period among heavy drinkers who attended local soup kitchens. In addition to transdermal alcohol monitoring, participants were randomly assigned to daily breath alcohol monitoring with or without reinforcement for alcohol-negative breath samples (BrAC). Analyses assessed feasibility of transdermal monitoring and examined alcohol use based on BrAC, transdermal, and self-report data, as well as effect sizes for these metrics based on group assignment. Nineteen participants completed the 21-day monitoring period in full; three persons removed the anklet 3-16 days early due to hospitalization, impending hospitalization, or incarceration. Participants reported minimal impacts of the monitors, and severity ratings of side effects were mild. When using BrAC, transdermal, and self-report data, the percentage of non-drinking days was 93%, 58%, and 57%, and the longest duration of consecutive non-drinking days averaged 10.3, 7.2, and 5.7 days, respectively. About half of drinking days involved heavy drinking (5 + drinks). Self-report and transdermal drinking days correlated significantly, p < .001, but neither index was associated with BrAC. Group comparisons indicate small-to-moderate sized effects of reinforcement compared to no reinforcement for increasing the proportion of alcohol-negative breath samples and durations of consecutive non-drinking samples during the study when BrAC was the metric. Transdermal data and self-report data indicated a more complex pattern. Reinforcement participants drank more often but at lower quantities than monitoring (control) participants per both transdermal and self-report data. These data suggest that transdermal monitors are well tolerated and document substantial heavy drinking in this population. Soup kitchens users are in need of alcohol interventions, and soup kitchens may represent a novel opportunistic setting for intervention delivery for an important and growing health disparities population.

Setting up a methadone maintenance clinic in a hostel in London's West End

Aims and Method

A satellite methadone prescribing service was set up in a hostel in London's West End. The aim was to investigate if it were feasible to engage and retain these hard-to-reach, chaotic, polydrug users in treatment. A basic needs assessment was undertaken with staff and clients at the hostel. Treatment outcomes were assessed at 16 weeks using the Maudsley Addiction Profile.

Results

At 16 weeks 87% of the original cohort (26 out of 30) were still in treatment. There were also significant reductions in mean heroin use (from 29.7 to 14.5 out of the past 30 days, P<0.001) and in the frequency of injecting (from 25.9 to 15.9 days, P<0.001).

Clinical Implications

This outreach clinic offers a model for developing services to homeless people with substance misuse problems.

Moving toward a holistic conceptual framework for understanding healthy aging among gay men

In the last four decades, we have witnessed vast and important transitions in the social, economic, political, and health contexts of the lived experiences of gay men in the United States. This dynamic period, as evidenced most prominently by the transition of the gay rights movement to a civil rights movement, has shifted the exploration of gay men's health from one focusing primarily on HIV/AIDS into a mainstream consideration of the overall health and wellbeing of gay men. Against this backdrop, aging gay men in the United States constitute a growing population, for whom further investigations of health states and health-related disparities are warranted. In order to advance our understanding of the health and wellbeing of aging gay men, we outline here a multilevel, ecosocial conceptual framework that integrates salient environmental, social, psychosocial, and sociodeomgraphic factors into sets of macro-, meso-, and micro-level constructs that can be applied to comprehensively study health states and health care utilization in older gay men.

Towards a comprehensive developmental model of cannabis use disorders

AIMS

To develop a comprehensive risk-factor model of cannabis use disorders (CUD) based on Kendler's development model for major depression.

DESIGN

Risk factors were divided into five developmental tiers based on Kendler's model of depression (childhood, early adolescence, late adolescence, adulthood, past year). Hierarchical logistic regression models were used to examine the independent contribution of each risk factor. Separate models were built to predict the lifetime risk of cannabis use and the risk of CUD among those with a history of lifetime risk of cannabis use.

SETTING

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) in the United States.

PARTICIPANTS

Participants consisted of wave 2 of the NESARC (n = 34 653).

MEASUREMENTS

Odds ratios (OR), Adjusted OR (AOR) and confidence intervals (95% CI) were used to determine the risk factors in each tier and with multiple models.

FINDINGS

After mutually adjusting for the effect of other risk factors, lifetime history of drug use disorder (AOR = 4.78, 95% CI = 1.53-14.91), past year alcohol use disorders (AOR = 6.55, 95% CI = 2.54-16.89) and independent (AOR = 1.57, 95% CI = 1.15-2.14) and dependent (AOR = 1.25, 95% CI = 1.01-1.55) stressful life events predicted lifetime cannabis use. Impulsivity (AOR = 2.18, 95% CI = 1.34-3.53), past year alcohol use disorders (AOR = 4.09, 95% CI = 2.29-7.31), greater number of Axis I disorders (AOR = 1.56, 95% CI = 1.01-2.40) and social deviance (AOR = 1.19, 95% CI = 1.08-1.32) independently increased the risk of the development of CUD, whereas religious service attendance (AOR = 0.50, 95% CI = 0.30-0.85) decreased this risk. In both models, the effect of earlier development tiers was mediated by more proximal ones. There were few gender differences in both models.

CONCLUSIONS

A modification of Kendler's risk factor model for major depression which stratifies risk factors into five groups (childhood, early adolescence, late adolescence, adulthood, past year) provides a useful foundation for a comprehensive developmental model of cannabis use and cannabis use disorders.

Helping homeless individuals with co-occurring disorders: the four components

Homeless individuals with co-occurring disorders (CODs) of severe mental illness and substance use disorder are one of the most vulnerable populations. This article provides practitioners with a framework and strategies for helping this client population. Four components emerged from a literature review: (1) ensuring an effective transition for individuals with CODs from an institution (such as a hospital, foster care, prison, or residential program) into the community, a particularly important component for clients who were previously homeless, impoverished, or at risk of homelessness; (2) increasing the resources of homeless individuals with CODs by helping them apply for government entitlements or supported employment (3) linking homeless individuals to supportive housing, including housing first options as opposed to only treatment first options, and being flexible in meeting their housing needs; and (4) engaging homeless individuals in COD treatment, incorporating modified assertive community treatment, motivational interviewing, cognitive-behavioral therapy, contingency management, and COD specialized self-help groups.

High rates of homelessness among a cohort of street-involved youth

Using multivariate logistic regression, we examined the prevalence and correlates of homelessness among youth enrolled in a community-recruited prospective cohort known as the At-Risk Youth Study (ARYS), between September 2005 and October 2006. Of 478 individuals included in this analysis, 132 (27.6%) were female and 120 (25.1%) self-identified as Aboriginal. The median age was 22 (IQR: 20-24). In total, 284 (56.9%) participants reported baseline homelessness, with most living either at no fixed address, on the street, or in a hostel or shelter. Factors associated with homelessness included public injecting, frequent crack use, experienced violence, having less than a high-school education, and not having been in any addiction treatment. Homeless individuals were at-risk for various adverse health outcomes. These findings indicate the need for additional interventions, including residential addiction treatment, to address homelessness and drug use among youth.

Structural and Personal Factors Related to Access to Housing and Housing Stability among Urban Drug Users in Hartford, Connecticut

Several policies criminalizing drug use significantly impact drug users' access to housing. This article explores the impact of housing policies on active drug users' access to housing and structural and personal factors related to their homelessness and housing stability. Qualitative interviews were conducted with 65 active cocaine or heroin users at baseline, three and six months. Participants were purposively sampled to reflect a variety of housed and homeless statuses. Interviews were analyzed to explore the processes associated with changes in housing status. Factors that led to homelessness included arrest, eviction, absence of housing subsidies, and lack of social support. Participants reported being evicted, and losing housing subsidies, welfare entitlements, and important social relationships following arrest. Criminal histories also limited their ability to find employment and permanent housing. Factors that led to housing stability included having family support, housing subsidies, and social supportive services. Active drug users can maintain independent housing when provided appropriate structural supports including rental subsidies and social services. But arrest disrupts drug users' housing stability. Programs to appropriately house those released from jail could help decrease homelessness among this population.

Implications of Medicaid coverage in a program for Latino substance users

BACKGROUND

This cross-sectional study explored baseline differences between Medicaid covered and uninsured clients (n=368) in the Project La Voz, a community outreach program targeting Latino substance users.

METHODS

Independent variables included client demographics, health status and health service use; the dependent variable was Medicaid coverage vs. uninsured. Bi-variate analyses and three binomial logistic regression models were conducted.

RESULTS

The first logistic regression model examining client characteristics indicated that La Voz enrollees with Medicaid coverage were more likely to be women, reside in stable housing, and report poor health status. Employment and educational status were not significantly associated with having Medicaid. A second model, examining the association between health care utilization in the past 30 days and Medicaid coverage, indicated that LaVoz enrollees with Medicaid were significantly more likely to have entered substance use treatment. In the third model, client characteristics and health care use were examined in one model; all variables remained significant except for gender. IMPLICATIONS FOR PROGRAM PLANNING: Massachusetts recent health care reform efforts include substance abuse treatment benefits through Medicaid. Specific strategies are needed to ensure that Latinos substance abusers, particularly those who are homeless, gain Medicaid coverage and then have access to needed services.

Unofficial policy: access to housing, housing information and social services among homeless drug users in Hartford, Connecticut

BACKGROUND

Much research has shown that the homeless have higher rates of substance abuse problems than housed populations and that substance abuse increases individuals' vulnerability to homelessness. However, the effects of housing policies on drug users' access to housing have been understudied to date. This paper will look at the "unofficial" housing policies that affect drug users' access to housing.

METHODS

Qualitative interviews were conducted with 65 active users of heroin and cocaine at baseline, 3 and 6 months. Participants were purposively sampled to reflect a variety of housing statuses including homeless on the streets, in shelters, "doubled-up" with family or friends, or permanently housed in subsidized, unsubsidized or supportive housing. Key informant interviews and two focus group interviews were conducted with 15 housing caseworkers. Data were analyzed to explore the processes by which drug users receive information about different housing subsidies and welfare benefits, and their experiences in applying for these.

RESULTS

A number of unofficial policy mechanisms limit drug users' access to housing, information and services, including limited outreach to non-shelter using homeless regarding housing programs, service provider priorities, and service provider discretion in processing applications and providing services.

CONCLUSION

Unofficial policy, i.e. the mechanisms used by caseworkers to ration scarce housing resources, is as important as official housing policies in limiting drug users' access to housing. Drug users' descriptions of their experiences working with caseworkers to obtain permanent, affordable housing, provide insights as to how access to supportive and subsidized housing can be improved for this population.

Predicting treatment retention with a brief "Opinions About Methadone" scale

It is important to identify social conditions, program factors, and client characteristics that predict retention because time in substance abuse treatment is associated with improved health, mood, and social functioning. Treatment dropouts also are at high risk for serious harms, including relapse. Most opioid-dependent persons require long-term stabilization in methadone maintenance treatment (MMT) to normalize brain function and control withdrawal symptoms. The purpose of this study was to determine whether a client characteristic, namely, attitude toward methadone, was related to retention. Analysis of 14 opinion statements about methadone identified a reliable five-item scale with factorial validity. This scale (Opinions About Methadone; OAM-5) also predicted retention in MMT. Of 338 clients followed for one year after MMT enrollment, 48% dropped out of treatment; those who were more likely to remain had more favorable opinions. A supplementary qualitative study with MMT counselors demonstrated face validity for the OAM-5; counselors found the items easy to interpret and relevant to client attitudes towards MMT. The findings suggest that it would be worthwhile for MMT staff to assess client attitudes at intake, using the OAM-5. This would help them to identify and intervene promptly with those in greatest need of support for remaining in treatment.

Housing status and HIV risk behaviors: implications for prevention and policy

This paper examines housing as a contextual factor affecting drug and sexual risk behaviors among HIV positive people using pooled interview data from 2149 clients presenting for services at 16 medical and social service agencies participating in a multi-site evaluation study. The odds of recent drug use, needle use or sex exchange at the baseline interview was 2-4 times as high among the homeless and unstably housed compared to persons with stable housing. Follow-up data collected 6-9 months after baseline showed that change in housing status was associated with change in risk behaviors. Persons whose housing status improved between baseline and follow-up significantly reduced their risks of drug use, needle use, needle sharing and unprotected sex by half in comparison to individuals whose housing status did not change. In addition, for clients whose housing status worsened between baseline and follow-up, their odds of recently exchanging sex was over five times higher than for clients whose housing status did not change. The provision of housing is a promising structural intervention to reduce the spread of HIV.