Addressing Substance Abuse and Homelessness
Despite the common myth that substance abuse and homelessness go and hand in hand, the truth is, most addicts aren’t homeless, and most homeless aren’t addicts. However, there are definitely some shared factors. And truthfully, the homeless do suffer from addiction at a higher rate than the general population.
But there are societal factors which fuel substance abuse and homelessness, and they have nothing to do with sloth.
By some estimates, there are nearly 690,000 people in the U.S. who qualify as homeless on any given night. Furthermore, 1 in 5 homeless persons (as of 2012) also struggled with chronic substance use. That’s over 131,000 people.
According to the recent study in JAMA Internal Medicine, drug overdoses, most of which involved opioids, are now responsible for the most deaths (it used to be HIV) in the Boston area.
Among 28,000 homeless adults studied between 2003-2008, drug overdoses account for nearly 17% of deaths, 81% being attributed to opioids.
Cancer and heart disease were next on the list of killers. But among those from age 25-44, drug overdoses accounted for an incredible 2/3 of all deaths.
The reduction in deaths due to HIV over the years were completely offset by an increase in drug overdose deaths, as well as other mental health issues such as suicide.
These findings in some ways mirror the general population, where prescription drugs, specifically opioids, are also the main cause of overdose deaths.
But the link between substance abuse and the homeless isn’t limited to just drug overdoses. For example, alcoholism accounts for almost 8% of the homeless mortality rate ( that’s in addition to drug overdose deaths.) Also, nicotine addiction, which is common among homeless adults (73%!) contributes to many cancers such as lung and trachea.
Cause and Effect
One of the main reasons why substance abuse and homelessness are so strongly correlated is because one can directly cause the other. That is, a severe addiction can result in homelessness, and homelessness tends to drive those on the streets to use substances to escape or self-medicate.
In 2003, the Substance Abuse and Mental Health Services Administration estimated that 38% of the homeless were alcohol dependent, and 26% abused drugs.
Older persons more commonly abuse alcohol, whereas younger persons are more inclined to drugs.
A 2008 survey by the United States Conference of Mayors polled 25 cities for their top 3 causes of homelessness. Sixty-eight percent of cities reported that substance abuse was the #1 cause of homelessness.
According to a 2007 study, two-thirds of homeless people state that drugs and/or alcohol were a a significant factor for their becoming homeless. The consequences of addiction, such as the loss of employment and income, family estrangement, and drug-offense convictions can all result in life on the streets.
However, substance abuse is often a result of becoming homeless – or as noted above, a coping mechanism of sorts. Substance abuse can help them obtain some escape, albeit temporarily, for their situation.
But unfortunately, substance abuse makes these problems worse, as dependence keeps the homeless from bettering their situation. And addiction, as anyone who has suffered from it knows, can be extremely hard to kick. When you are on the streets with no hope and no support – well, just think how much harder it would be.
And if persons on the street do manage to get clean, they are still living among others who frequently use, and thus, relapse is a constant possibility. Abstinence-based programs, in contrast to harm-reduction approaches, don’t work well for people in these situations. But unfortunately, harm reduction strategies are not widely practiced.
And finally, mental illness can cause also homelessness, and there is a huge overlap between mental illness and substance abuse. That is, those diagnosed with mental disorders are often much more likely to abuse substances than those with a healthy mental status. And of course, substance abuse can make mental illness worse.
Quick side note: Can you imagine being homeless, suffering from depression, and not committing suicide? Really, the strength of some of these people is astounding.
Having these co-occurring diagnoses make it more difficult for the homeless to get treatment.
Programs which help the mentally ill and homeless often do not accept those with addiction disorders.
Conversely, those which treat substance abuse among the homeless do not accept persons with mental illness.
Policies and Changes Needed
According to 2008 data released by the United States Conference of Mayors 28% of the cities surveyed listed substance abuse services as one of the top three items needed to help the homeless. Indeed, even among the general population, most people suffering from substance abuse do not receive the treatment they require.
Many treatment centers require health insurance. For the homeless, having insurance is rare. Additionally, there are just too few places which offer treatment – even those with the means to get it, face long waiting lists and other obstacles.
Because substance abuse and homelessness can effect one another, both problems should be addressed simultaneously. For example, stable housing is needed after treatment to prevent relapse.
And in addition to housing, the homeless need mental health care, physical health care, and help to re-establish daily living activities. These services are just for basic needs – we haven’t even mentioned help with education or employment skills.
Simply put, it takes a lot more than housing and substance abuse treatment to effectively serve the homeless – but it’s a start. For the chronically homeless, permanent supportive housing succeeds because it combines housing with the support and services so desperately needed by these persons.
According to the National Mental Health Association (now known as Mental Health America) successful supported housing programs include community outreach, as well as flexible treatment options and services to help persons reenter the community. Integrating substance abuse treatment into these programs is perhaps the most effective solution.
Other Prevention Efforts
We also need to increase efforts to prevent prescription drug abuse and diversion among the homeless. In addition to substance abuse, the homeless also tend to have high rates of chronic pain. This is yet another factor which needs to be addressed.
A final tactic would be to increase the availability of effective drug treatments such as buprenorphine, and the anti-overdose drug, naloxone.
Traditionally, we have approached the subject of substance abuse and homelessness as “who cares?” But I assure you, someone cares. There’s the addict, on the street, who has desperately tried to quit – several times – but cannot allocate help. Also, the friends and families who love those who are suffering, but feel powerless to make a difference.
~ G. Nathalee Serrels, M.A., Psychology