2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Opioids and Homelessness in America

We will present five strategies behavioral health providers can use to help combat the opioid crisis among our national homeless population. Two catastrophic public health issues have become American epidemics: opioids and homelessness. The two are clearly interrelated—opioid use/misuse contributes to homelessness and homelessness exacerbates opioid use/misuse. Both take a tremendous personal toll on individuals, families, and communities. Consider Charlisa and Joe (not their real names):

Charlisa’s chronic pain stems from a history of intimate partner violence, and chronic health conditions; now it is coupled with 20 years of addiction to opioids and homelessness. She lost everything, including parental rights. Nights are the worst. She stays in shelters, with boyfriends or acquaintances if they will have her or in shelters or. She’s always afraid. The pain rarely stops and never for long.

Joe has been in and out of institutions most of his life. He has been using heroin for 15 years, doing whatever he must to keep the shakes away. He lives in an encampment. Recently the city held a sweep because of a hepatitis outbreak. He lost his sleeping bag and all his belongings, even his few pictures.

Most people experiencing chronic homelessness have multiple vulnerabilities that can lead to and an opioid addiction. Vulnerabilities include significant trauma, serious mental illness, poly-substance use, chronic pain, health conditions, grief, and loss. Substance use disorders and homelessness both result in intensive stigma and discrimination, health problems, criminal justice involvement, and reduced life expectancy. In fact, in a Boston study, adults aged 25–44 experiencing homeless were nine times more likely to die from a drug overdose than their housed counterparts (Baggett et al., JAMA Intern Med, 2013).

The United States Interagency Council on Homelessness identified five strategies for addressing the intersection of the opioid crisis and homelessness (2017). Recommendations for behavioral health (BH) providers to help those who are homeless follow each strategy.

  1. Assess the prevalence of OUDs and opioid misuse among individuals experiencing homelessness. BH Providers: Assess homelessness and housing instability among your patients/clients. Talk with individuals experiencing homelessness about the types of services they need. Consider advocating for data on homelessness from opioid safety coalition dashboards or mortality review board tools.
  2. Develop and implement overdose prevention and response strategies. BH Providers: Provide training, support, and resources to first responders, homeless programs, and outreach workers on a range of overdose prevention and response strategies. Make other harm reduction strategies such as fentanyl testing strips available. Naloxone distribution efforts have been established across the country and are effective at combatting overdose. One example of targeted outreach to homeless populations occurs in San Francisco (SF). With approximately 30 percent of overdose deaths occurring in single room occupancy hotels, the SF Department of Public Health is educating residents and plans to make Naloxone rescue boxes readily available (NBC Bay Area, San Francisco to Launch Program to Combat Opioid Overdose Deaths at SRO Hotels, 2019).
  3. Strengthen partnerships between housing and health care providers to provide tailored assistance. BH Providers: Collaborate with housing and health care providers to customize assistance to meet the stated and unstated needs of your individuals experiencing homelessness and OUD. One innovative program is the Washington State pilot Peer Pathfinders Program modeled after the Projects for Assistance in Transition from Homelessness (PATH) program and funded by the This program conducts outreach and engagement specifically targeting individuals with OUDs experiencing homelessness linking them with medication-assisted treatment (MAT) services, and navigating systems to help access community resources that facilitate recovery (https://www.compasshealth.org/services/pathfinder-peer-project).
  4. Improve access to Medication Assisted Treatment (MAT). BH Providers: Access to medications is critical to treatment and recovery from OUD. Research shows that medications, even without other interventions, improves outcomes for individuals with OUD (Connock et al., Health Technology Assessment, 2007; National Institute on Drug Abuse, Medications to Treat Opioid Use Disorder, 2018). Encourage Federally Qualified Health Centers (FQHCs) and x-waivered prescribers in your community to serve individuals who are homeless and have complex needs. Work with Health Care for the Homeless Clinics, advocates, and other stakeholders to reduce barriers to accessing OUD medications. For example, low-threshold access to medications, mobile and street medicine programs, or providing inductions at shelters all make it easier for individuals to obtain medications.

A prime example is the California ED Bridge Program, which engages individuals with MAT in emergency rooms (ERs) (https://www.bridgetotreatment.org/cabridgeprogram). One ER also distributes a simple business card within the community, and individuals can present the card at the hospital for immediate access to MAT.

Many individuals experiencing homelessness and OUD are involved with the criminal justice system. Rhode Island Department of Corrections has developed a comprehensive intervention. (http://www.doc.ri.gov/rehabilitative/health/behavioral_substance.php). Individuals are screened, assessed, and begin MAT (methadone, buprenorphine, naltrexone) of their choice while incarcerated. Once released, they are immediately connected to a community provider that assists with housing, medications, and peer services.

Health providers provide medications but often rely on behavioral health providers for the skill-building behavioral therapies, psycho-social and recovery supports, case management, and peer supports needed by people experiencing OUD and homelessness. Expert panelists that informed a recent report from the U.S. Department of Health and Human Services’ Assistant Secretary for Planning and Evaluation had consensus that sustained recovery for individuals with complex problems requires other supports in addition to housing and MAT (Pfefferle et al., Choice Matters: Housing Models that May Promote Recovery for Individuals and Families Facing Opioid Use Disorder, 2019).

  1. Remove barriers to housing. BH Providers: Familiarize yourselves with the shelters, housing counseling, Continuums of Care (CoCs), Coordinated Entry systems, Rapid Rehousing, and homeless service programs in your community. Work with homeless outreach programs and case managers to ensure that housing is addressed and offered to patients who need it.

HUD and its related CoCs have adopted a Housing First approach with significant expansions of available permanent supportive housing for people who experience chronic homelessness. The positive outcomes have been significant; there are more trauma-informed outreach programs available, and barriers to housing have been reduced through low-threshold requirements. Once people are housed, they can better address their health issues (National Academies of Sciences, Engineering, and Medicine, Permanent Supportive Housing: Evaluating the Evidence for Improving Health Outcomes Among People Experiencing Chronic Homelessness, 2018).

HousingNow in Philadelphia is a dedicated Housing First program for individuals who experience OUD and homelessness. It provides access to permanent housing, case management, and an array of harm reduction and behavioral health services. An FQHC and a pharmacy serve as partners, making MAT as easy to access as possible (https://pathwaystohousingpa.org/HousingNow).

Across the nation, an array of recovery housing is available (https://narronline.org). These are alcohol- and illicit-drug free shared housing programs with peer support. Many states, including Missouri and Massachusetts, provide vouchers or short-term subsidies to help people access recovery housing, which may be either short-term or permanent housing.

In conclusion, it is key to acknowledge the bi-directional relationship between the opioid and homeless crises. Behavioral health providers can help by working with health and housing providers to remove barriers to hope, health, and home for people and communities. This opens the door to replacing a hopeless cycle with one of promise.

To learn more about how to help people experiencing homelessness who also have OUD, and state and federal programs for homelessness, please contact Deb Werner at dwerner@ahpnet.com.

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