Publication guide: Homelessness

Below are some abstracts from publications from the library collection. Please contact us for more information.

Calcaterra, S. L., Beaty, B., Mueller, S. R., Min, S.-J., & Binswanger, I. A. (2014). The association between social stressors and drug use/hazardous drinking among former prison inmates. Journal of Substance Abuse Treatment, 47(1), 41–49

Social stressors are associated with relapse to substance use among people receiving addiction treatment and people with substance use risk behaviors. The relationship between social stressors and drug use/hazardous drinking in former prisoners has not been studied. We interviewed former prisoners at baseline, 1 to 3weeks post prison release, and follow up, between 2 and 9months following the baseline interview. Social stressors were characterized by unemployment, homelessness, unstable housing, problems with family, friends, and/or significant others, being single, or major symptoms of depression. Associations between baseline social stressors and follow-up drug use and hazardous drinking were analyzed using multivariable logistic regression. Problems with family, friends, and/or significant others were associated with reported drug use (AOR 3.01, 95% CI 1.18–7.67) and hazardous drinking (AOR 2.69, 95% CI 1.05–6.87) post release. Further research may determine whether interventions and policies targeting social stressors can reduce relapse among former inmates.

Erickson, R. A., Stockwell, T., Pauly, B. (Bernie), Chow, C., Roemer, A., Zhao, J., … Wettlaufer, A. (2018). How do people with homelessness and alcohol dependence cope when alcohol is unaffordable? A comparison of residents of Canadian managed alcohol programs and locally recruited controls. Drug and Alcohol Review, 37(Supplement 1), S174–S183

We investigated coping strategies used by alcohol‐dependent and unstably housed people when they could not afford alcohol, and how managed alcohol program (MAP) participation influenced these. The aim of this study was to investigate potential negative unintended consequences of alcohol being unaffordable. A total of 175 MAP residents in five Canadian cities and 189 control participants from nearby shelters were interviewed about the frequency they used 10 coping strategies when unable to afford alcohol. Length of stay in a MAP was examined as a predictor of negative coping while controlling for age, sex, ethnicity, housing stability, spending money and drinks per day. Multivariate binary logistic and linear regression models were used. Most commonly reported strategies were re‐budgeting (53%), waiting for money (49%) or going without alcohol (48%). A significant proportion used illicit drugs (41%) and/or drank non‐beverage alcohol (41%). Stealing alcohol or property was less common. Long‐term MAP participants (>2 months) exhibited lower negative coping scores than controls (8.76 vs. 10.63, P< 0.001) and were less likely to use illicit drugs [odds ratio (OR) 0.50, P= 0.02], steal from liquor stores (OR 0.50, P= 0.04), re‐budget (OR 0.36, P< 0.001) or steal property (OR 0.40, P= 0.07). Long‐term MAP participants were also more likely to seek treatment (OR 1.91, P= 0.03) and less likely to go without alcohol (OR 0.47, P= 0.01). People experiencing alcohol dependence and housing instability more often reduced their alcohol consumption than used harmful coping when alcohol was unaffordable. MAP participation was associated with fewer potentially harmful coping strategies.

Ezard, N., Cecilio, M. E., Clifford, B., Baldry, E., Burns, L., Day, C. A., … Dolan, K. (2018). A managed alcohol program in Sydney, Australia: Acceptability, cost‐savings and non‐beverage alcohol use. Drug and Alcohol Review, 37(Supplement 1), S184–S194

Managed alcohol programs (MAPs) are a novel harm reduction intervention for people who experience long‐term homelessness and severe long‐term alcohol dependence. MAPs provide regulated amounts of alcohol onsite under supervision. Preliminary international evidence suggests that MAPs are associated with improvements such as reduced non‐beverage alcohol consumption and decreases in some alcohol‐related harms. There are currently no MAPs in Australia. We aimed to assess the feasibility of a MAP in inner‐Sydney. A survey among eligible homeless alcohol‐dependent residents of an inner‐Sydney short‐stay alcohol withdrawal service occurred in 2014 to assess acceptability. Administrative data were analysed to ascertain estimates of cost‐savings for a MAP based in Sydney. Fifty‐one eligible participants were surveyed. More than one‐quarter (28%) reported consumption of non‐beverage alcohol. A residential model received greatest support (76%); the majority (75%) of participants indicated a willingness to pay at least 25% of their income to utilise a MAP. Hospital and crisis accommodation cost‐savings were conservatively estimated at AUD$926 483.40 and AUD$347 574.00, respectively per year for a 15‐person residential MAP. Our findings demonstrate the acceptability of a MAP in Sydney among a target population sample, with the implementation of a residential MAP likely to produce significant cost‐savings. A trial of a Sydney MAP evaluating the impact on health and social outcomes, including a comprehensive economic evaluation, is strongly recommended.

Goldman, H. J., Nosova, E., Kerr, T., Wood, E., & DeBeck, K. (2019). Homelessness and incarceration associated with relapse into stimulant and opioid use among youth who are street‐involved in Vancouver, Canada. Drug and Alcohol Review, 38(4), 428–434

While much research has sought to identify the factors associated with initiation and cessation of various forms of drug use among vulnerable youth, little is known about relapse into drug use in this population. We sought to characterise relapse into stimulant and opioid use among street‐involved youth in Vancouver, Canada. Data were collected between 2005 and 2017 from the At‐Risk Youth Study, a prospective cohort study of street‐involved youth who use illicit drugs in Vancouver. Multivariable extended Cox regression was utilised to identify factors associated with relapse into illegal stimulants and/or opioids among youth who had previously ceased using stimulants and/or opioids for 6 months or longer. Among 246 participants who reported a period of cessation lasting 6 months or longer, 165 (67.1%) relapsed at some point during study follow‐up. Youth who were recently incarcerated (adjusted hazard ratio [AHR]: 1.46), homeless (AHR: 1.43), or had a history of daily stimulant use (AHR: 1.48) were significantly more likely to report relapse, while youth of who identified as white (AHR: 0.74) were significantly less likely to report relapse (all P< 0.05). Relapse into stimulants and/or opioids was common among youth in our setting, and incarceration, homelessness, and daily stimulant use were found to be positively associated with relapse among youth. Findings suggest that increased access to youth housing supports and alternatives to the criminalisation of drug use may help to reduce the rates of relapse into stimulants and/or opioids in this population.

Ibabe, I., Stein, J. A., Nyamathi, A., & Bentler, P. M. (2014). Predictors of substance abuse treatment participation among homeless adults. Journal of Substance Abuse Treatment, 46(3), 374–381

The current study focuses on the relationships among a trauma history, a substance use history, chronic homelessness, and the mediating role of recent emotional distress in predicting drug treatment participation among adult homeless people. We explored the predictors of participation in substance abuse treatment because enrolling and retaining clients in substance abuse treatment programs is always a challenge particularly among homeless people. Participants were 853 homeless adults from Los Angeles, California. Using structural equation models, findings indicated that trauma history, substance use history and chronicity of homelessness were associated, and were significant predictors of greater recent emotional distress. The most notable result was that recent emotional distress predicted less participation in current substance abuse treatment (both formal and self-help) whereas a substance use history alone predicted significantly more participation in treatment. Implications concerning treatment engagement and difficulties in obtaining appropriate dual-diagnosis services for homeless mentally distressed individuals are discussed.

Kennedy, D. P., Osilla, K. C., Hunter, S. B., Golinelli, D., Maksabedian Hernandez, E., & Tucker, J. S. (2018). A pilot test of a motivational interviewing social network intervention to reduce substance use among housing first residents. Journal of Substance Abuse Treatment, 86(1), 36–44

This article presents findings of a pilot test of a Motivational Interviewing social network intervention (MI-SNI) to enhance motivation to reduce high risk alcohol and other drug (AOD) use among formerly homeless individuals transitioning to housing. Delivered in-person by a facilitator trained in MI, this four-session computer-assisted intervention provides personalized social network visualization feedback to help participants understand the people in their network who trigger their alcohol and other drug (AOD) use and those who support abstinence. If ready, participants are encouraged to make changes to their social network to help reduce their own high-risk behavior. Participants were 41 individuals (33 male, 7 female, 1 other; 23 African-American, 5 non-Latino White, 6 Latino, 7 other, mean age 48) who were transitioning from homelessness to permanent supportive housing. They were randomly assigned to either the MI-SNI condition or usual care. Readiness to change AOD use, AOD abstinence self-efficacy, and AOD use were assessed at baseline and shortly after the final intervention session for the MI-SNI arm and around 3-months after baseline for the control arm. Acceptability of the intervention was also evaluated. MI-SNI participants reported increased readiness to change AOD use compared to control participants. We also conducted a subsample analysis for participants at one housing program and found a significant intervention effect on readiness to change AOD use, AOD abstinence self-efficacy, and alcohol use compared to control participants. Participants rated the intervention as highly acceptable. We conclude that a brief computer-assisted Motivational Interviewing social network intervention has potential to efficaciously impact readiness to change AOD use, AOD abstinence self-efficacy, and AOD use among formerly homeless individuals transitioning to permanent supportive housing, and warrants future study in larger clinical trials.

Somers, J. M., Moniruzzaman, A., & Palepu, A. (2015). Changes in daily substance use among people experiencing homelessness and mental illness: 24‐month outcomes following randomization to Housing First or usual care. Addiction, 110(10), 1605–1614

Aims: Housing First (HF) is an established intervention for people experiencing homelessness and mental illness. We compared daily substance use (DSU) between HF and treatment as usual (TAU). Design: Two concurrent randomized controlled trials with 24‐month follow‐up. Setting: Market rental apartments with support provided by Assertive Community Treatment (ACT) or Intensive Case Management (ICM); a single building with on‐site supports (CONG); TAU in Vancouver, Canada. Participants: Inclusion criteria were current homelessness and mental illness. Participants were assessed as having either ‘high needs’ (HN; n = 297) or ‘moderate needs’ (MN; n = 200). MN participants were randomized to ICM (n = 100) or MN‐TAU (n = 100). HN participants were randomized to ACT (n = 90), CONG (n = 107) or HN‐TAU (n = 100). Interventions and comparators: All HF interventions included independent housing with support services, with an emphasis on promoting client choice and harm reduction in relation to substance use. TAU included existing services and support available to homeless adults with mental illness. Measurements: DSU over 24 and 12 months was derived from the Maudsley Addiction Profile. Also measured were demographics, homelessness history, psychiatric diagnoses, symptom severity, comorbid illnesses and duration of stable housing. Findings: Compared with HN‐TAU, neither CONG [adjusted odds (AOR) ratio = 0.73, 95% confidence interval (CI) = 0.39–1.37] nor ACT (AOR = 1.22, 95% CI = 0.61–2.45) differed on DSU at 24 months, and MN‐TAU did not differ from ICM (AOR = 0.78, 95% CI = 0.37–1.63). There were no differences at 12 months, when analyses were restricted to participants who indicated substance use at baseline, or when considering the duration of stable housing. Conclusions: Housing First, an intervention to support recovery for homeless people who have co‐occurring mental illness and substance use disorders, did not reduce daily substance use compared with treatment as usual after 12 or 24 months.

Tucker, J. S., Wenzel, S. L., Golinelli, D., Zhou, A., & Green, H. D. (2011). Predictors of substance abuse treatment need and receipt among homeless women. Journal of Substance Abuse Treatment, 40(3), 287–294

Many homeless women do not receive needed treatment for substance abuse. This study identified social network and other predisposing factors associated with perceived need for and receipt of substance abuse treatment among 273 homeless women who screened positive for past-year substance abuse. Perceived treatment need was more likely among women with drug-using sex partners, a denser network, and an arrest history but less likely for those with a minor child and a longer history of homelessness. Receiving treatment was more likely among women who received informational support from their sex partners and who had an arrest history but less likely among those who had a more street-based social network, had a minor child, considered themselves homeless, and recently needed mental health treatment. Treatment services researchers should attend more closely to social contextual factors, as well as the more traditional individual factors, to understand access and barriers to treatment.

Urbanoski, K., Veldhuizen, S., Krausz, M., Schutz, C., Somers, J. M., Kirst, M., … Goering, P. (2018). Effects of comorbid substance use disorders on outcomes in a Housing First intervention for homeless people with mental illness. Addiction, 113(1), 137–145

Abstract: Background and Aims: Evidence supports the effectiveness of Housing First (HF) programmes for people who are experiencing homelessness and mental illness; however, questions remain about its use in people with comorbid substance use disorders (SUD). The aim of this project was to test whether SUD modifies the effectiveness of an HF intervention. Design: Secondary analysis of data from a randomized controlled trial of HF versus treatment‐as‐usual (TAU) with 24‐month follow‐up, comparing those with and without SUD at trial entry. Setting: Vancouver, Toronto, Winnipeg, Moncton and Montreal, Canada. Participants: A total of 2154 participants recruited from 2009 to 2013 and randomized to HF versus TAU (67% male, mean age 40.8 ± 11.2, 25% ethno‐cultural minority). All were homeless and had a mental disorder at baseline; 35% reported symptoms consistent with SUD. Intervention: Housing paired with Intensive Case Management or Assertive Community Treatment. Measurements: Primary outcomes were days housed and community functioning. Secondary outcomes were general and health‐related quality of life and mental health symptoms. Predictors were SUD status crossed with intervention group (HF versus TAU). Findings: People with SUD in both the HF and TAU groups spent less time in stable housing, but the effect of HF did not vary by SUD status [odds ratio (OR) = 1.17, 95% confidence interval (CI) = −0.77, 1.76]. Similarly, there was no difference between those with and without SUD in the effect of HF (over TAU) on community functioning (b = 0.75, 95% CI = −0.36, 1.87), quality of life (b = −1.27, 95% CI = −4.17, 1.63), health‐related quality of life (b = −0.01, 95% CI = −0.03, 0.02) or mental health symptoms (b = 0.43, 95% CI = −0.99, 1.86). Conclusions: Housing First programs in Canada are equally effective in people with and without comorbid substance use disorder (SUD). Overall, the intervention appears to be able to engage people with SUD and is reasonably successful at housing them, without housing being contingent upon abstinence or treatment.

Whittaker, E., Swift, W., Roxburgh, A., Dietze, P., Cogger, S., Bruno, R., … Burns, L. (2015). Multiply disadvantaged: Health and service utilisation factors faced by homeless injecting drug consumers in Australia. Drug and Alcohol Review, 34(4), 379–387

Homelessness status is strongly correlated with higher rates of substance use. Few studies, however, examine the complex relationship between housing status and substance use in people who inject drugs (PWID). This study extends previous research by comparing the physical and mental health status and service utilisation rates between stably housed and homeless PWID. A cross‐sectional sample of 923 PWIDwere recruited for the 2012 Illicit Drug Reporting System. Multivariate models were generated addressing associations between homelessness and the domains of demographics; substance use; and health status, service utilisation and criminal justice system contact, with significant correlates entered into a final multivariate model. Two‐thirds of the PWIDsample were male. The median age was 39 years and 16% identified as Indigenous. Almost one‐quarter (23%) reported that they were homeless. Homeless PWIDwere significantly more likely to be unemployed [adjusted odds ratio (AOR) 2.83, 95% confidence interval (CI) 1.26, 6.34], inject in public (AOR2.01, 95% CI1.38, 3.18), have poorer mental health (AOR0.98, 95% CI0.97, 1.00), report schizophrenia (AOR2.31, 95% CI1.16, 4.60) and have a prison history (AOR1.53, 95% CI1.05, 2.21) than stably housed PWID. Findings highlight the challenge of mental health problems for homeless PWID. Our results demonstrate that further research that evaluates outcomes of housing programs accommodating PWID, particularly those with comorbid mental health disorders, is warranted. Results also emphasise the need to better utilise integrated models of outreach care that co‐manage housing and mental health needs.

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