The social context of homeless men's substance use

Does the Relationship between Affect and Social Interactions among Adults Experiencing Homelessness Differ during Moments when at a Shelter versus Not?

The prevalence of alcohol use disorders is higher amongst adults experiencing homelessness (AEH) compared with domiciled adults. Greater exposure to heavy drinkers increases personal risk for heavy alcohol use. AEH spend substantial periods of time at shelters and report greater pressure to use alcohol when near shelter locations, as well as greater negative affect when near a shelter. It is unclear if the relationship between affect and 1) interacting with people and 2) being near someone AEH drank alcohol with before differs when AEH are at a shelter versus not. AEH reporting alcohol misuse (n = 72, Mage= 47, 85% Male, 68% Non-White) completed five daily smartphone-based ecological momentary assessments (EMAs) over 28 days. Generalized multilevel modeling revealed that when AEH were interacting with someone they drank with before, they had significantly lower positive affect when at a shelter (b = -0.17, p = 0.05), versus when not (b = 0.00, p = 0.99). AEH are likely to interact with previous drinking partners while at shelters. It may be important to deliver real-time treatment messages targeting affect in these moments, as well as deliver alcohol reduction/abstinence messages.

Because We Love You (BeWeL): A protocol for a randomized controlled trial of two brief interventions focused on social and cultural connectedness to reduce risk for suicide and substance misuse in young Alaska Native people

Background

Suicide among young people in Alaska Native (AN) communities was nearly unheard of through the establishment of statehood in 1959, but in the 1970s, AN suicide rates began to double every five years, with most of the increase due to suicide among 15 to 25-year-olds. From 1960-1995, the suicide rate increased by approximately 500% during this period of rapid, imposed social transition. For example, families were forced to live in settlements and children were sent to boarding schools. These disruptions increased conditions associated with suicide risk (e.g., substance use disorders, cultural disconnection), and challenged the community-level social safety net of youth protective factors that might have moderated effects of these traumas. The present study addresses the significant gap in culturally appropriate evidence-based programming to address suicide prevention among AN young people as part of aftercare. Our key research questions and methodology have been informed by AN stakeholders, and the intervention approach is Indigenous-led.

Methods

Our interventions are targeted toward Alaska Native young people ages 14-24 who present with suicide attempt, ideation, or associated risk behaviors, including alcohol-related injury in the Yukon-Kuskokwim region or the Interior. In a randomized controlled trial, 14-24-year-old AN individuals will receive either BeWeL (n = 185), which comprises a 45-minute virtual cultural talk addressing family and ancestral strengths and increasing protective factors, or BeWeL plus motivational interviewing with social networks, which includes an additional 15 minutes focused on discussion of the individual's social networks (n = 185). We will evaluate intervention effects on primary outcomes of suicide-intent risk, depression, anxiety, frequency of alcohol use, and alcohol consequences. Some of our secondary outcomes include individual and community protective factors, social networks, and awareness of connectedness.

Discussion

This project has the potential to expand the range and effectiveness of suicide prevention services for AN young people and will help meet the need in Alaska to link clinical behavioral health services to AN community-based networks, and to engage local cultural resources in aftercare for individuals at risk for suicide. Findings have potential to provide practical information to advance the field of suicide prevention and enhance protective factors and resiliency among this population.

Trial registration

ClinicalTrials.gov Identifier: NCT05360888.

Motives for alcohol use, risky drinking patterns and harm reduction practices among people who experience homelessness and alcohol dependence in Montreal

BACKGROUND

People experiencing homelessness are disproportionately affected by harms related to alcohol use. Indeed, their alcohol dependence is associated with numerous physical and mental health problems along with strikingly high rates of alcohol-related mortality. Recent research has extensively examined alcohol use patterns among people experiencing homelessness in an effort to develop interventions and treatments for this problem. However, only a few studies have incorporated the perspectives of the individuals under study about their drinking or examined the ways in which they manage the associated harms. To bridge this gap, we conducted a qualitative study exploring the relation between the drinking motives, risky drinking patterns and harm reduction practices of a group of people (n = 34) experiencing homelessness in Montreal, Canada.

METHODS

The qualitative methods we used consisted of semi-structured interviews (n = 12) and focus groups (n = 2, with a total of 22 participants). The content of the collected data was then analyzed.

RESULTS

Participants identified their various motives for alcohol use (coping with painful memories, dealing with harsh living conditions, socializing/seeking a sense of belonging, enjoying themselves/having fun); their risky drinking patterns (binge drinking, mixing alcohol with drugs, non-beverage alcohol drinking, failing to keep sufficient alcohol on hand to prevent acute withdrawal, drinking in public settings); their harm reduction practices (planning how much to drink, keeping a supply of alcohol to prevent acute withdrawal, hiding to drink, concealing alcohol, drinking alone, drinking/hanging out with others, drinking non-beverage alcohol, and taking benzodiazepines, cocaine or other stimulant drugs); and the rationales underpinning their alcohol use and harm reduction practices.

CONCLUSION

Associating the drinking motives of a group of study participants with their risky drinking patterns and harm reduction practices shed light on their rationales for alcohol use, yielding insights that could be used to better tailor policies and interventions to their needs.

Development and preliminary effectiveness of a smartphone-based, just-in-time adaptive intervention for adults with alcohol misuse who are experiencing homelessness

BACKGROUND

Adults experiencing homelessness have much higher rates of alcohol misuse than housed individuals. This study describes the development and preliminary effectiveness of a smartphone-based, just-in-time adaptive intervention (JITAI) to reduce alcohol use among adults experiencing homelessness.

METHODS

We conducted a pilot trial (N = 41; mean age [SD] = 45.2 [11.5]; 19.5% women) of the Smart-T Alcohol JITAI where participants completed brief ecological momentary assessments (EMAs) each day, received personalized treatment messages following each EMA, and accessed on-demand intervention content for 4 weeks. The prediction algorithm and treatment messages were developed based on an independent but similar sample as part of the trial. We examined three drinking outcomes: daily drinking (yes/no), drinks per day, and heavy episodic drinking, controlling for scores on the Alcohol Use Disorders Identification Test (AUDIT) at baseline, age, and sex using quadratic growth curve models.

RESULTS

Over the 4-week period, participants showed a decline in all alcohol use outcomes. Participants also reported high levels of satisfaction with the JITAI.

CONCLUSIONS

Use of the Smart-T Alcohol JITAI was well received and provided encouraging evidence that it may reduce any drinking, drinks per day, and heavy episodic drinking among adults experiencing homelessness.

The Hidden Face of the Moon: Unveiling the Minutiae of a Black Woman’s Experience on the Streets

The homeless population is mostly male. When it comes to the female presence, especially when considering the markers of race, gender and class, the invisibility and delegitimization are even more insidious. The aim of this article is to identify the singularities of a black woman living on the streets and to understand them based on the relationships she establishes with the territory. The method used was the case study of a homeless black woman, constructed through body map storytelling. Thematic analysis of the empirical content was used in the light of decolonial criticism. Luna, the protagonist of the story, reveals in her narratives, the multiple dimensions of the presence of the female body on the street, the process of taking care of oneself and the other, considering the intrinsic relationships with the territory, with the use of drugs and with the male figure. Thus, unveiling society’s views in relation to the place of invisibility of these women and creating strategies to face the colonial, racist and patriarchal logic of valuing knowledge is what Luna makes explicit with her trajectory of struggle, survival, and resilience on the streets.

An Exploration of Narcan as a Harm Reduction Strategy and User's Attitudes toward Law Enforcement Involvement in Overdose Cases

The street homeless, those who spend their nights either in shelters or unofficial camps, whether in tents on a street or in society’s hidden spaces such as beneath an overpass, face multiple challenges beyond finding a safe place to sleep. Of further concern is how official actions can worsen these situations, through day-to-day activities or planned intervention strategies. In this paper we explore how a planned intervention may be negatively perceived—even as a form of “structural violence”—and may prevent Narcan (naloxone) use to stop an overdose related death in the Skid Row of Los Angeles. Data for this study consisted of a combination of Spatial Video Geonarratives (SVGs) and 325 incident reports from the Homeless Health Care Los Angeles Center for Harm Reduction (HHCLA-HRC) between November 2014 and December 2015. Chi-square and simple logistic regression models were used to examine the association between fear-of-arrest and other covariates of interest. Mapping results are presented with different sets of shapefiles created for (1) all Narcan uses, (2) all homeless, (3) all homeless with a worry about being arrested, (4) all Narcan uses where an ambulance attended, (5) and the same as 4 but also with police attendance. In the multivariable model, the estimated adjusted odds of fear-of-arrest is over three times higher among Narcan users ages 30–39 when compared to users under the age of 30. Analyzing the association of calling 9-1-1 on Narcan user demographics, socio-contextual characteristics, and overdose victim demographics, the crude estimated probability of calling 9-1-1 for Narcan users aged 50 and older is nearly three times higher when compared to Narcan users aged 19–29. Conclusion: Results suggest that the fear-of-arrest and calling 9-1-1 during an overdose is still a concern among Narcan users despite protective legislation and access to harm reduction resources.

Restructuring personal networks with a Motivational Interviewing social network intervention to assist the transition out of homelessness: A randomized control pilot study

BACKGROUND

Social relationships play a key role in both substance use and homelessness. Transitioning out of homelessness often requires reduction in substance use as well as changes in social networks. A social network-based behavior change intervention that targets changes personal social networks may assist the transition out of homelessness. Most behavior change interventions that incorporate social networks assume a static network. However, people experiencing homelessness who transition into housing programs that use a harm reduction approach experience many changes in their social networks during this transition. Changes may include disconnecting from street-based network contacts, re-connecting with former network contacts, and exposure to new network members who actively engage in substance use. An intervention that helps people transitioning out of homelessness make positive alterations to their social networks may compliment traditional harm reduction housing program services.

METHODS

We conducted a pilot randomized controlled trial (RCT) of an innovative Social Network Intervention (MI-SNI), which combines network visualization and Motivational Interviewing to assist adults transitioning out of homelessness. The MI-SNI provides feedback to new residents about their social environments and is designed to motivate residents to make positive changes in both their individual behavior and their personal network. In a sample of 41 adult housing program residents with past year risky substance use, we examined whether participants randomized to receive a MI-SNI showed greater changes in their personal networks over 3 months compared to those receiving usual care.

RESULTS

There were significant differences in the networks of the MI-SNI group compared to the group receiving usual care at follow-up, controlling for baseline network characteristics. The MI-SNI group had greater reductions in the proportion of their network members who influenced alcohol or other drug use (AOD) use, such as drinking partners, and more frequently changed their relationships in the direction of lower AOD risk with network members who were retained in their networks across waves.

CONCLUSIONS

This study is the first pilot test of a MI-SNI customized for assisting the transition out of homelessness to test for personal network changes. Results indicate that MI-SNIs can have a positive impact on short-term network changes and thus may serve as a useful adjunct to behavioral change interventions. These findings suggest that a MI-SNI approach may help individuals experiencing homelessness and risky AOD use positively restructure their social networks while transitioning into supportive housing. These promising results suggest the need for a larger RCT test of this innovative intervention approach.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02140359.

Religion and Recovery Among Individuals Experiencing Homelessness

Faith-based organizations provide essential recovery services to individuals experiencing homelessness. Research suggests that religion and spirituality aid recovery from alcohol and drug addiction, although less is known about these factors in homeless populations. This study used qualitative interviews to explore the role of religion in recovery from addiction in a sample of 14 adults with a history of homelessness. Analysis of emergent themes revealed that religion provided participants with a range of personal and social benefits, many which addressed personal, social, and tangible losses and crises associated with substance use and homelessness. Understanding the specific benefits religion may provide during recovery can guide research and help providers improve programs for this vulnerable population.

Integrating traditional practices and social network visualization to prevent substance use: study protocol for a randomized controlled trial among urban Native American emerging adults

BACKGROUND

Nonmedical use of prescription opioids (defined as taking opioid medications for hedonic effects or in a manner other than prescribed) and the use of heroin have emerged in recent years as major public health concerns in the United States. Of particular concern is the prevalence of opioid use among emerging adults (ages 18-25), as this is a developmental period of heightened vulnerability and critical social, neurological, and psychological development. Data from 2015 show that American Indian/Alaska Native (AI/AN) people have the highest rates of diagnosis for opioid use disorders (OUDs). One recent study found that the overdose death rate among urban-dwelling AI/AN individuals was 1.4 times higher compared to those living in rural areas. To date, there are no evidence-based prevention programs addressing opioid use among urban AI/AN emerging adults that integrate culturally-appropriate strategies with evidence-based treatment. Traditions and Connections for Urban Native Americans (TACUNA) builds on our prior work with AI/AN communities across California to develop and evaluate culturally appropriate programming to address opioid, alcohol, and cannabis use among urban AI/AN emerging adults.

METHODS/DESIGN

In a randomized controlled trial, 18-25 year old urban AI/AN emerging adults will receive either TACUNA (n = 185), which comprises three virtual workshops utilizing motivational interviewing, social network visualization, and integrating traditional practices and a wellness circle, or one virtual culturally sensitive opioid education workshop (n = 185). We will evaluate intervention effects on primary outcomes of frequency of opioid, alcohol, and cannabis use, as well as secondary outcomes of social network characteristics and cultural connectedness, over a 12-month period.

DISCUSSION

This project has the potential to expand the range and effectiveness of opioid, alcohol, and cannabis services for urban AI/AN emerging adults by addressing the opioid epidemic and use of other substances at both the community and individual level. In addition, it provides important culturally grounded conceptual and practical information to advance the field of substance use interventions and enhance resiliency among this population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04617938. Registered October 26, 2020 https://clinicaltrials.gov/ct2/show/record/NCT04617938 .

Motivational network intervention to reduce substance use and increase supportive connections among formerly homeless emerging adults transitioning to housing: study protocol for a pilot randomized controlled trial

BACKGROUND

Studies indicate high rates of substance use among youth experiencing homelessness (YEH). Further, the social networks of YEH, although multi-dimensional in composition, are largely comprised of other YEH, substance users, and individuals who do not provide the youth with tangible or emotional support. For YEH who have the opportunity to enter a housing program, helping them to reduce their substance use and strengthen their prosocial supportive connections during this critical transition period may increase their stability and reduce their risk of re-entering homelessness. The goal of this study is to pilot test a brief motivational network intervention (MNI), delivered by case managers, to help former YEH who have recently transitioned to a housing program reduce their substance use and strengthen their prosocial supportive connections.

METHODS/DESIGN

Up to 60 residents of housing programs in the Los Angeles area will be randomized to receive four sessions of usual case manager support or four sessions of case manager support + MNI. Each MNI session consists of three parts: (1) identifying two goals that are most important for the resident over the next year (e.g., get or keep a job, finish or stay in school, reduce substance use); (2) a network interview with the resident to capture network data pertaining to their interactions in the past 2 weeks; and (3) a discussion between the case manager and the resident of the resulting network visualizations, conducted in a Motivational Interviewing (MI) style, and what role the resident's network may play in reaching their most important goals over the next year.

DISCUSSION

This study addresses a critical gap by pilot testing a computer-assisted MNI, delivered using MI techniques, that can help case managers work with recent YEH to reduce substance use and increase permanent supportive connections during the critical transitional period from homelessness to housing. Trial registration ClinicalTrials.gov Identifier: NCT04637815. Registered November 10, 2020.

Social Network Change after Moving into Permanent Supportive Housing: Who Stays and Who Goes?

Social relationships are important among persons experiencing homelessness, but there is little research on changes in social networks among persons moving into permanent supportive housing (PSH). Using data collected as part of a longitudinal study of 405 adults (aged 39+) moving into PSH, this study describes network upheaval during this critical time of transition. Interviews conducted prior to and after three months of living in PSH assessed individual-level characteristics (demographics, homelessness history, health and mental health) and included a social network component that assessed network size and composition (demographics, relationship type, social support); interviewers utilized network member characteristics to assess whether network members were new or sustained between baseline and 3 months post-housing. Multilevel logistic regression models assessed what characteristics of network members were associated with being newly-gained or persisting in networks 3 months after moving into PSH. We found that only one-third of social networks were retained during the transition to PSH, and that veterans, African Americans and other persons of racial/ethnic minorities, and those living in scattered-site housing were more likely to experience network disruption. Relatives, romantic partners, and service providers were most likely to be retained after move-in. Some network change was moderated by tie strength, including the retention of street-met persons. Implications are discussed.

Social network heavy drinking moderates the effects of a brief motivational intervention for alcohol use among injured patients

BACKGROUND

Limited research has focused on identifying the extent to which social networks impact the effectiveness of brief alcohol interventions delivered in trauma care settings.

OBJECTIVES

The research presented here examines the extent to which the percent of heavy drinkers and percent of abstainers in one's social network moderates the effectiveness of a brief motivational intervention with and without a telephone booster on alcohol use among trauma patients.

METHOD

Secondary data analyses were conducted using data from 596 participants (456males) who were recruited from three urban Level I trauma centers. Patients were randomized to one of the three intervention conditions: brief advice (BA; n = 200), brief motivational intervention (BMI; n = 203), and BMI with a telephone booster (BMI + B; n = 193). For the purpose of the present study, measures of alcohol-specific social network characteristics at baseline and alcohol use at 3- and 6-month follow-up were used.

RESULTS

At low percentages (0% to ~7%) of people in one's social network who are heavy drinkers, there was a negative, statistically significant effect of the BMI conditions versus the BA condition on alcohol use. However, percent of abstainers did not moderate the effects of the BMI conditions.

CONCLUSION

The results suggest that the BMI and BMI + B conditions may be most effective among patients with no heavy drinkers in their social networks. BMIs may benefit from including a component that addresses having one or more heavy drinkers in one's social network.

The Assessment of Recovery Capital (ARC) predicts substance abuse treatment completion

Recovery from addiction requires various personal and environmental resources. The purposes of this study were to determine if the Assessment of Recovery Capital (ARC) scores measured at admission could predict substance abuse treatment (SAT) completion and to identify personal and environmental factors associated with ARC scores. Participants (N = 2265) comprised clients entering a Midwestern SAT facility (August 2015 - June 2017). Logistic regression was used to predict SAT completion using ARC scores. Nonparametric group comparisons were used for personal and environmental covariates. ARC scores significantly predicted successful SAT completion (OR = 1.05, 95% CI = 1.04, 1.05, Wald z = 12.9, p < 0.001). Employment had a positive relationship with ARC scores (Kruskal-Wallis χ² = 215.96, df = 8, p < 0.001). ARC scores varied according to primary substance (Kruskal-Wallis χ² = 101.10, df = 6, p < 0.001); alcohol and marijuana showed the highest scores and heroin the lowest. ARC scores decreased as number of problem substances increased (Kruskal-Wallis χ² = 70.57, df = 2, p < 0.001, r_S = -0.163, p < 0.001). Living arrangement was also significant (Kruskal-Wallis χ² = 146.36, df = 8, p < 0.001); clients who were homeless had the lowest ARC scores. A number of personal and environmental covariates were associated with the ARC scores and potentially with the outcome. After adjustment, the ARC remained a strong predictor of SAT completion. The ARC should be used in SAT facilities to guide treatment decisions and to create individualized treatment plans for clients.

Mental health change in the transition to permanent supportive housing: The role of housing and social networks

AIMS

Permanent Supportive Housing (PSH) may improve homeless adults' mental health via housing stabilization and/or improved relational factors, however, the role of housing and social networks on PSH residents' mental health change is minimally understood.

METHODS

Interviews were conducted with a baseline sample of adults experiencing homelessness ( N = 421), across their initial year in PSH (3-months, 6-months, and 12-months). Generalized linear mixed models assessed changes in positive past-month psychiatric disability screenings (Modified-Colorado Symptom Index [MCSI]) and probable posttraumatic stress disorder (PC-PTSD) in controlled models, and between and within-subject effects of time-varying social network correlates on mental health changes.

RESULTS

Compared with baseline, positive MCSI screens continuously decreased over time (56%, 54%, and 50%) while PC-PTSD screens declined initially (40%) with marginal decreases at remaining follow-ups (39% and 38%). These differences remained significant in controlled models. Gaining a romantic partner was associated with a longitudinal increase in a positive MCSI screening. Between subjects, emotional health counselors and conflicting network members were associated with an increased likelihood in positive screenings, while doctors and case managers were protective.

CONCLUSION

Housing may facilitate positive changes in PSH residents' mental health, yet positive screenings remain high. Social network interventions that increase residents' positive interpersonal exchanges and prosocial relationships are warranted.

Characterizing Alcohol Use Behaviors among Homeless Men and Women

Objectives: In this study, we characterized alcohol use behaviors by sex among sheltered homeless adults and explored associations with health and readiness to change drinking behaviors. Methods: Participants (N = 581; 63.7% men; Mage = 43.6, 29.4% white) self-reported alcohol use and readiness to change drinking behaviors. Sex differences were analyzed via Wilcoxon ranksum, chi-square tests, logistic regression, and ANCOVAs. Results: Overall, 38.5% of the sample met criteria for current at-risk drinking, 39.7% self-reported a history of alcohol problems, and 22.9% reported having a formal alcohol use disorder (AUD) diagnosis. Among current alcohol users, 83.8% reported at-risk drinking. Men had more drinks per drinking day, more drinks per week, and more drinking days per week when compared to women. No sex differences were found for at-risk drinking, self-reported alcohol problems, probable alcohol abuse/dependence, AUD diagnosis, readiness to change drinking, or recent alcohol/substance abuse counseling. Conclusions: High rates of at-risk drinking were found among alcohol users. Homeless men and women did not exhibit differences in several manifestations of problematic alcohol use. Alcohol use interventions might be equally appealing to both sexes given equivalent readiness to change drinking; however, rates of recent treatment receipt were low.

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.

Social support and housing transitions among homeless adults with serious mental illness and substance use disorders

OBJECTIVE

Research suggests that social supports are associated with housing retention among adults who have experienced homelessness. Yet, we know very little about the social support context in consumers find and retain housing. We examined the ways and identified the junctures in which consumers' skills and deficits in accessing and mobilizing social supports influenced their longitudinal housing status.

METHOD

We performed semi-structured qualitative interviews with VA Greater Los Angeles consumers (n = 19) with serious mental illness, substance use disorders, and a history of homelessness; interviews explored associations between longitudinal housing status (categorized as: stable, independent housing; sheltered housing, continually engaged in structured housing programs; and unstable housing) and social supports. We compared data from consumers in these 3 mutually exclusive categories.

RESULTS

All participants described social support as important for finding and maintaining housing. However, participants used formal (provider/case managers) and informal (family/friends) supports in different ways. Participants in stable housing relied on formal and informal supports to obtain/maintain housing. Participants in sheltered housing primarily used formal supports, for example, case management staff. Unstably housed participants used formal and informal supports, but some of these relationships were superficial or of negative valence. Interpersonal problems were prevalent across longitudinal housing status categories.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Social context, including patterns of formal and informal support, was associated with participants' longitudinal housing status. Within interventions to end homelessness, these findings suggest the value of future research to identify, tailor, and implement practices that can help consumers improve their social resources. (PsycINFO Database Record

Moving Beyond Housing: Service Implications for Veterans Entering Permanent Supportive Housing

As a result of efforts to end homelessness among U.S. veterans, more former service members are entering permanent supportive housing (PSH). While PSH has been successfully used to house homeless veterans, more research is needed about services beyond housing placement and retention. This study uses the Gelberg-Andersen behavioral model for vulnerable populations to determine associations between predisposing, enabling, and need characteristics and recent service use (i.e., services to satisfy basic needs, occupational development, financial, healthcare, mental health) among unaccompanied homeless veterans (N=126) entering PSH in Los Angeles. Among the significant findings, as indicated using univariable logistic regression models, were veterans who had incarceration histories were more likely to utilize basic needs services, compared to those without incarceration histories. Veterans who received an honorable discharge were more likely to utilize occupational development services, compared to veterans with other discharge statuses. Veterans who had a case manager were more likely to utilize mental health services than those without a case manager, while those who received social security were less likely to utilize mental health services compared to veterans who did not receive social security. Veterans who met criteria for a psychological disability and veterans who met criteria for probable PTSD were more likely to use basic needs services and mental health services than veterans who fell below these thresholds. Clinical implications for social workers including "equal access to services," "enhancing economic stability," "providing safe and affordable housing with trauma-informed services," and "training service social workers to deliver well-informed linkages and services" are discussed.

Response to culturally competent drug treatment among homeless persons with different living arrangements

This study investigated the association between program cultural competence and homeless individuals' drug use after treatment in Los Angeles County, California. Los Angeles County has the largest and most diverse population of homeless individuals in the nation. We randomly selected for analysis 52 drug-treatment programs and 2158 participants who identified as homeless in the Los Angeles County Participant Reporting System in 2011. We included their living arrangements (indoors and stable, indoors and unstable, and outdoors) and individual and program characteristics (particularly whether their programs used six culturally competent practices) in multilevel regression analyses. The outcome was days of primary drug use at discharge.Results showed that higher levels of staff personal involvement in minority communities (IRR=0.437; 95% CI=0.222, 0.861) and outreach to minority communities (IRR = 0.406; 95% CI=0.213, 0.771) were associated with fewer days of drug use at discharge. Homeless individuals living outdoors used their primary drug more often than any other group. Yet, compared to individuals with other living arrangements, when outdoor homeless individuals were treated by programs with the highest community resources and linkages (IRR=0.364; 95% CI=0.157, 0.844), they reported the fewest days of drug use. We discuss implications for program evaluation and community engagement policies and practices.

Mortality among the homeless: Causes and meteorological relationships

Background

The homeless constitute a subpopulation particularly exposed to atmospheric conditions, which, in the temperate climate zone, can result in both cold and heat stress leading to the increased mortality hazard. Environmental conditions have become a significant independent risk factor for mortality from specific causes, including circulatory or respiratory diseases. It is known that this group is particularly prone to some addictions, has a shorter life span, its members often die of different causes than those of the general population and may be especially vulnerable to the influence of weather conditions.

Materials and methods

The retrospective analysis is based on data concerning 615 homeless people, out of which 176 died in the analyzed period (2010–2016). Data for the study was collected in the city of Olsztyn, located in north-east Poland, temperate climatic zone of transitional type. To characterize weather conditions, meteorological data including daily minimum and maximum temperatures and the Universal Thermal Climate Index (UTCI) were used.

Results

The average life span of a homeless person was shorter by about 17.5 years than that recorded for the general population. The average age at death of a homeless male was 56.27 years old (SD 10.38), and 52.00 years old (SD 9.85) of a homeless female. The most frequent causes of death were circulatory system diseases (33.80%). A large number of deaths were attributable to smoking (47.18%), whereas a small number was caused by infectious diseases, while a relatively large proportion of deaths were due to tuberculosis (2.15%). Most deaths occurred in the conditions of cold stress (of different intensity). Deaths caused by hypothermia were thirteen-fold more frequently recorded among the homeless than for the general population. A relative risk of death for a homeless person even in moderate cold stress conditions is higher (RR = 1.84) than in thermoneutral conditions.

Conclusions

Our results indicate excessive mortality among the homeless as well as the weak and rather typical influence of atmospheric conditions on mortality rates in this subpopulation, except for a greater risk of cold related deaths than in the general population. UTCI may serve as a useful tool to predict death risk in this group of people.

A pilot test of a motivational interviewing social network intervention to reduce substance use among housing first residents

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.

Health outcomes associated with crack-cocaine use: Systematic review and meta-analyses

BACKGROUND

Crack-cocaine use is prevalent largely in socio-economically marginalized populations in the Americas. Its use has been associated with diverse health outcomes, yet no recent or systematic reviews of these exist.

METHODS

A systematic review of health outcomes associated with crack-cocaine use was performed, using MEDLINE, Scopus, Web of Science, CINAHL, PsycINFO, and LILACS up to October 2016. Search terms included crack-cocaine and health outcome-related keywords, targeting peer-reviewed studies on quantified health outcomes associated with crack-cocaine use. Random effects meta-analyses produced pooled odds ratios. Levels of evidence for major results were assessed using the GRADE approach. A review protocol was registered with PROSPERO (CRD42016035486).

RESULTS

Of 4700 articles returned, 302 met eligibility criteria, reporting on health outcomes for 14 of 22 ICD-10 chapters. Conclusive evidence and meta-analyses showed positive associations between crack-cocaine use and blood/sexually transmitted diseases (HIV and hepatitis C virus, others); moderate evidence and meta-analyses supported associations with neonatal health, and violence. There were mixed associations for mental and other health outcomes, yet insufficient evidence to perform meta-analyses for many categories (e.g., mortality). Most underlying research was of limited or poor quality, with crack-cocaine commonly assessed as a secondary covariate.

CONCLUSIONS

Crack-cocaine use was associated with a range of health outcomes, although it was unclear if there was direct causal impact, interactions between risk factors, or external drivers of both crack-cocaine use and outcomes. Rigorous epidemiological studies are needed to systematically assess health outcomes of crack-cocaine use and underlying pathways, also to inform evidence-based interventions.

Differences in Health and Social Support between Homeless Men and Women Entering Permanent Supportive Housing

BACKGROUND

Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH.

METHODS

This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area.

RESULTS

Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict.

CONCLUSIONS

There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.

Understanding of the life experience of homeless women

Abstract OBJECTIVE To understand the life experience of homeless women. METHOD A social phenomenological study was conducted with 10 women assisted by a shelter. The analysis of the interviews was based on the theoretical framework of social phenomenology of Alfred Schütz and thematic literature. RESULTS The participants face adversities in the street context, with emphasis on the risk of physical and sexual abuse, and seek shelters as a possibility for minimizing difficulties experienced. They hope to leave the streets; however, they see themselves trapped in this social reality, due to the addiction to alcohol and other drugs. CONCLUSION The understanding of the life experience of homeless women shows daily confrontations and reveals the conflict between the desire for leaving and remaining on the streets, given the complexity of the reality that keeps them in this condition.

Feasibility of a computer-assisted social network motivational interviewing intervention for substance use and HIV risk behaviors for housing first residents

Background

Social networks play positive and negative roles in the lives of homeless people influencing their alcohol and/or other drug (AOD) and HIV risk behaviors.

Methods

We developed a four-session computer-assisted social network motivational interviewing intervention for homeless adults transitioning into housing. We examined the acceptability of the intervention among staff and residents at an organization that provides permanent supportive housing through iterative rounds of beta testing. Staff were 3 men and 3 women who were residential support staff (i.e., case managers and administrators). Residents were 8 men (7 African American, 1 Hispanic) and 3 women (2 African American, 1 Hispanic) who had histories of AOD and HIV risk behaviors. We conducted a focus group with staff who gave input on how to improve the delivery of the intervention to enhance understanding and receptivity among new residents. We conducted semi-structured qualitative interviews and collected self-report satisfaction data from residents.

Results

Three themes emerged over the course of the resident interviews. Residents reported that the intervention was helpful in discussing their social network, that seeing the visualizations was more impactful than just talking about their network, and that the intervention prompted thoughts about changing their AOD use and HIV risk networks.

Conclusions

This study is the first of its kind that has developed, with input from Housing First staff and residents, a motivational interviewing intervention that targets both the structure and composition of one’s social network. These results suggest that providing visual network feedback with a guided motivational interviewing discussion is a promising approach to supporting network change.

ClinicalTrials.gov Identifier NCT02140359

Coping Styles and Alcohol Dependence among Homeless People

BACKGROUND AND OBJECTIVES

The ways in which homeless individuals cope with stress may differ from those relied upon by the members of the general population and these differences may either be the result or the cause of their living conditions. The aim of the study was to determine the preferred coping style among the homeless and its relationship with alcohol dependence.

METHODS

The study included 78 homeless individuals and involved the collection of demographic, sociological, psychological and medical data from each participant. Coping styles relied upon when dealing with stressful situations were assessed using a Polish adaptation of the Coping Inventory for Stressful Situations. Alcohol dependence was assessed using the Michigan Alcoholism Screening Test (MAST) and a quantitative analysis of alcohol consumption.

RESULTS

Men accounted for 91.93% of the study population. Nearly 75% of the subjects met the alcohol dependence criterion. Significant relationships were observed between the individual's age, preferred coping style and alcohol consumption level. As an individual's age increased, the use of emotion-oriented coping styles decreased, while an increase in alcohol consumption was associated with a more frequent use of emotion- and avoidance-oriented strategies.

CONCLUSIONS

The findings of this study, similarly to those of many other studies of homeless individuals but investigating other areas (e.g. epidemiology of tuberculosis and traumatic injuries), are an exaggerated representation of associations observed in the general population. The results describe a group of people living on the margins of the society, often suffering from extremely advanced alcoholism, with clear evident psychodegradation. The presence of specific ways of coping with stress related to excessive alcohol consumption in this group of individuals may interfere with active participation in support programmes provided for the homeless and may further exacerbate their problems.

Evaluating the Paper-to-Screen Translation of Participant-Aided Sociograms with High-Risk Participants

While much social network data exists online, key network metrics for high-risk populations must still be captured through self-report. This practice has suffered from numerous limitations in workflow and response burden. However, advances in technology, network drawing libraries and databases are making interactive network drawing increasingly feasible. We describe the translation of an analog-based technique for capturing personal networks into a digital framework termed netCanvas that addresses many existing shortcomings such as: 1) complex data entry; 2) extensive interviewer intervention and field setup; 3) difficulties in data reuse; and 4) a lack of dynamic visualizations. We test this implementation within a health behavior study of a high-risk and difficult-to-reach population. We provide a within-subjects comparison between paper and touchscreens. We assert that touchscreen-based social network capture is now a viable alternative for highly sensitive data and social network data entry tasks.

A computer-assisted motivational social network intervention to reduce alcohol, drug and HIV risk behaviors among Housing First residents

BACKGROUND

Individuals transitioning from homelessness to housing face challenges to reducing alcohol, drug and HIV risk behaviors. To aid in this transition, this study developed and will test a computer-assisted intervention that delivers personalized social network feedback by an intervention facilitator trained in motivational interviewing (MI). The intervention goal is to enhance motivation to reduce high risk alcohol and other drug (AOD) use and reduce HIV risk behaviors.

METHODS/DESIGN

In this Stage 1b pilot trial, 60 individuals that are transitioning from homelessness to housing will be randomly assigned to the intervention or control condition. The intervention condition consists of four biweekly social network sessions conducted using MI. AOD use and HIV risk behaviors will be monitored prior to and immediately following the intervention and compared to control participants' behaviors to explore whether the intervention was associated with any systematic changes in AOD use or HIV risk behaviors.

DISCUSSION

Social network health interventions are an innovative approach for reducing future AOD use and HIV risk problems, but little is known about their feasibility, acceptability, and efficacy. The current study develops and pilot-tests a computer-assisted intervention that incorporates social network visualizations and MI techniques to reduce high risk AOD use and HIV behaviors among the formerly homeless. CLINICALTRIALS.

GOV IDENTIFIER

NCT02140359.

Personal support networks, social capital, and risk of relapse among individuals treated for substance use issues

BACKGROUND

The success of treatment for substance use issues varies with personal and social factors, including the composition and structure of the individual's personal support network. This paper describes the personal support networks and social capital of a sample of Italian adults after long-term residential therapeutic treatment for substance use issues, and analyses network correlates of post-treatment substance use (relapse).

METHODS

Using a social network analysis approach, data were obtained from structured interviews (90-120 min long) with 80 former clients of a large non-governmental therapeutic treatment agency in Italy providing voluntary residential treatments and rehabilitation services for substance use issues. Participants had concluded the program at least six months prior. Data were collected on socio-demographic variables, addiction history, current drug use status (drug-free or relapsed), and the composition and structure of personal support networks. Factors related to risk of relapse were assessed using bivariate and multivariate logistic regression models.

RESULTS

A main goal of this study was to identify differences between the support network profiles of drug free and relapsed participants. Drug free participants had larger, less dense, more heterogeneous and reciprocal support networks, and more brokerage social capital than relapsed participants. Additionally, a lower risk of relapse was associated with higher socio-economic status, being married/cohabiting, and having network members with higher socio-economic status, who have greater occupational heterogeneity, and reciprocate support.

CONCLUSIONS

Post-treatment relapse was found to be negatively associated with the socioeconomic status and occupational heterogeneity of ego's support network, reciprocity in the ties between ego and network members, and a support network in which the members are relatively loosely connected with one another (i.e., ego possesses "brokerage social capital"). These findings suggest the incorporation into therapeutic programming of interventions that address those aspects of clients' personal support networks.

Health, perceived quality of life and health services use among homeless illicit drug users

INTRODUCTION

Drug misuse has been identified as a significant problem in homeless populations. This study examines aspects of physical and mental health, perceived quality of life and health service use among homeless illicit drug users and compares these to non-drug users.

METHODS

Participants were recruited through health clinics across Dublin. A questionnaire assessed participants' drug use, health and well-being, health behaviours and use of health services. Descriptive statistics are presented for the entire cohort and drug users separately. Logistic regression analysis was used to examine the relationship between drug use and (i) multimorbidity, (ii) anxiety and/or depression, (iii) perceived quality of life and (iv) use of health services.

RESULTS

Of 105 participants recruited, 35 (33%) were current drug users. Current and previous drug users were significantly more likely to have multimorbidity than those who had never taken drugs (OR 4.86, 95% CI 1.00-23.66). There was no significant difference between drug users and non-drug users in the prevalence of anxiety and/or depression. Drug users were five times more likely than non-drug users to have a low perceived quality of life (OR 5.2, 95% CI 1.7-16.0). Health service utilization was high, although some services were used less by drug users (e.g., dentist and psychiatric outpatient services) while others were used more often (e.g., phoneline services and day care centres).

CONCLUSION

This study highlights the high levels of drug use in this population and the negative impact of drug use on health and perceived quality of life of a homeless population in Dublin.

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.

Previous Homelessness as a Risk Factor for Recovery from Serious Mental Illnesses

This paper argues that the experience of homelessness is inherently traumatic and thus has the potential to affect the manifestation of mental illness. The experiences related to being homeless might act as specific and unique sources of vulnerability. This study included 424 people diagnosed with serious mental illnesses living in supported housing programs in South Carolina. Three hierarchical regression analyses measuring the impact of homelessness on three types of outcomes revealed the following: (1) ever experiencing homelessness as well as the amount of time spent homeless were related to higher levels of psychiatric distress, (2) ever experiencing homelessness was related to higher levels of reported alcohol use, and (3) total amount of time spent homeless was related to lower perceived recovery from mental illness. These findings suggest that experiencing homelessness might contribute to psychosocial vulnerability to negative mental health outcomes. Future investigations examining this concept of risk and vulnerability as a result of homelessness are in order.

Place of Residence Moderates the Relationship Between Emotional Closeness and Syringe Sharing Among Injection Drug Using Clients of Sex Workers in the US-Mexico Border Region

Injection drug-using men from the US and Mexico who purchase sex in Tijuana, Mexico are at risk for transmitting HIV to their contacts in both countries via syringe sharing. We used social network methods to understand whether place of residence (US vs. Mexico) moderated the effect of emotional closeness on syringe sharing. We interviewed 199 drug-using men who reported paying/trading for sex in Tijuana, Mexico using an epidemiological and social network survey and collected samples for HIV/STI testing. Seventy-two men reported using injection drugs with 272 network contacts. Emotional closeness was strongly associated with syringe sharing in relationship where the partner lives in the US, while the relationship between emotional closeness and syringe sharing was considerably less strong in dyads where the partner lives in Mexico. Efforts to reduce HIV risk behaviors in emotionally close relationships are needed, and could benefit from tailoring to the environmental context of the relationship.

Factors affecting exits from homelessness among persons with serious mental illness and substance use disorders

OBJECTIVE

We sought to understand the housing trajectories of homeless consumers with serious mental illness (SMI) and co-occurring substance use disorders (SUD) and to identify factors that best predicted achievement of independent housing.

METHOD

Using administrative data, we identified homeless persons with SMI and SUD admitted to a residential rehabilitation program from December 2008 to November 2011. Our primary outcome measure was independent housing status. On a random sample (N = 36), we assessed a range of potential predictors of housing outcomes, including symptoms, cognition, and social/community supports. We used the Residential Time-Line Follow-Back (TLFB) Inventory to gather housing histories since exiting rehabilitation and to identify housing outcomes. We used Recursive Partitioning (RP) to identify variables that best differentiated participants by these outcomes.

RESULTS

We identified 3 housing trajectories: stable housing (n = 14), unstable housing (n = 15), and continuously engaged in housing services (n = 7). In RP analysis, 2 variables (Symbol Digit Modalities Test [SDMT], a neurocognitive speed of processing measure, and Behavior and Symptom Identification Scale [BASIS-24] Relationships subscale, which quantifies symptoms affecting relationships) were sufficient to capture information provided by 26 predictors to classify participants by housing outcome. Participants predicted to continuously engage in services had impaired processing speeds (SDMT score < 32.5). Among consumers with SDMT score ≥ 32.5, those predicted to achieve stable housing had fewer interpersonal symptoms (BASIS-24 Relationships subscale score < 0.81) than those predicted to have unstable housing. This model explains 57% of this sample's variability and 14% of this population's variability in housing outcomes.

CONCLUSIONS

Because cognition and symptoms influencing relationships predicted housing outcomes for homeless adults with SMI and SUD, cognitive and social skills training may be useful for this population.

Social networks as the context for understanding employment services utilization among homeless youth

Little is known about the factors associated with use of employment services among homeless youth. Social network characteristics have been known to be influential in motivating people's decision to seek services. Traditional theoretical frameworks applied to studies of service use emphasize individual factors over social contexts and interactions. Using key social network, social capital, and social influence theories, this paper developed an integrated theoretical framework that capture the social network processes that act as barriers or facilitators of use of employment services by homeless youth, and understand empirically, the salience of each of these constructs in influencing the use of employment services among homeless youth. We used the "Event based-approach" strategy to recruit a sample of 136 homeless youth at one drop-in agency serving homeless youth in Los Angeles, California in 2008. The participants were queried regarding their individual and network characteristics. Data were entered into NetDraw 2.090 and the spring embedder routine was used to generate the network visualizations. Logistic regression was used to assess the influence of the network characteristics on use of employment services. The study findings suggest that social capital is more significant in understanding why homeless youth use employment services, relative to network structure and network influence. In particular, bonding and bridging social capital were found to have differential effects on use of employment services among this population. The results from this study provide specific directions for interventions aimed to increase use of employment services among homeless youth.

Income level and drug related harm among people who use injection drugs in a Canadian setting

BACKGROUND

Higher income is generally associated with better health outcomes; however, among people who inject drugs (IDU) income generation frequently involves activities, such as sex work and drug dealing, which pose significant health risks. Therefore, we sought to examine the relationship between level of income and specific drug use patterns and related health risks.

METHODS

This study involved IDU participating in a prospective cohort study in Vancouver, Canada. Monthly income was categorized based on non-fixed quartiles at each follow-up with the lowest level serving as the reference category in generalized linear mixed-effects regression.

RESULTS

Among our sample of 1032 IDU, the median average monthly income over the study follow-up was $1050 [interquartile range=785-2000]. In multivariate analysis, the highest income category was significantly associated with sex work (adjusted odds ratio [AOR]=7.65), drug dealing (AOR=5.06), daily heroin injection (AOR=2.97), daily cocaine injection (AOR=1.65), daily crack smoking (AOR=2.48), binge drug use (AOR=1.57) and unstable housing (AOR=1.67). The high income category was negatively associated with being female (AOR=0.61) and accessing addiction treatment (AOR=0.64), (all p<0.05). In addition, higher income was strongly associated with higher monthly expenditure on drugs (>$400) (OR=97.8).

CONCLUSION

Among IDU in Vancouver, average monthly income levels were low and higher total monthly income was linked to high-risk income generation strategies as well as a range of drug use patterns characteristic of higher intensity addiction and HIV risk. These findings underscore the need for interventions that provide economic empowerment and address high intensity addiction, especially for female IDU.

Correlates of prescription drug misuse among heterosexually active homeless men

OBJECTIVE

Prescription drug misuse (PDM) is an emerging epidemic in the United States. This study examines the prevalence and correlates of PDM among homeless men. Homeless men experience higher risk for substance misuse and associated health problems and are particularly vulnerable to PDM and its negative health consequences.

METHODS

Participants were a representative probability sample of 305 heterosexually active homeless men interviewed from meal programs in the Skid Row region of Los Angeles. Interviews assessed demographics, substance use, mental health, and social networks. Logistic regression examined correlates of PDM.

RESULTS

Twenty-six percent of the study population reported PDM in the past year. PDM was more likely among homeless men suffering from posttraumatic stress disorder (PTSD) (odds ratio [OR] = 2.41, 95% confidence interval [CI]: 1.03-5.61) and among those with more substance-using social network members (OR = 1.07, 95% CI: 1.01-1.14). Decreased PDM was associated with good health (OR = 0.34, 95% CI: 0.16-0.75).

CONCLUSIONS

The prevalence of PDM is higher among the homeless men in this study than in the general population. Correlates of PDM included PTSD and poor health, suggesting that homeless men may use PDM to self-medicate. PDM was also associated with increased substance-using social network alters. Physical and mental health and social context are important aspects to consider in prevention efforts to reduce PDM among homeless men.

"I felt like a superhero": the experience of responding to drug overdose among individuals trained in overdose prevention

BACKGROUND

Overdose prevention programs (OPPs) train people who inject drugs and other community members to prevent, recognise and respond to opioid overdose. However, little is known about the experience of taking up the role of an "overdose responder" for the participants.

METHODS

We present findings from qualitative interviews with 30 participants from two OPPs in Los Angeles, CA, USA from 2010 to 2011 who had responded to at least one overdose since being trained in overdose prevention and response.

RESULTS

Being trained by an OPP and responding to overdoses had both positive and negative effects for trained "responders". Positive effects include an increased sense of control and confidence, feelings of heroism and pride, and a recognition and appreciation of one's expertise. Negative effects include a sense of burden, regret, fear, and anger, which sometimes led to cutting social ties, but might also be mitigated by the increased empowerment associated with the positive effects.

CONCLUSION

Findings suggest that becoming an overdose responder can involve taking up a new social role that has positive effects, but also confers some stress that may require additional support. OPPs should provide flexible opportunities for social support to individuals making the transition to this new and critical social role. Equipping individuals with the skills, technology, and support they need to respond to drug overdose has the potential to confer both individual and community-wide benefits.

Unprotected sex among heterosexually active homeless men: results from a multi-level dyadic analysis

HIV is a serious public health problem for homeless populations. Homeless men who have sex with women have received less attention in the HIV risk literature than other homeless populations. This research uses multi-level modeling to investigate the context of unprotected sex among heterosexually active homeless men in the Skid Row area of Los Angeles. Based on interviews with 305 randomly selected men who discussed 665 of their recent female sexual relationships, this project investigates the correlates of unprotected sex during the past 6 months at the partnership, individual, and social network levels. Several different measures of relationship closeness and lack of communication about HIV/condoms were associated with unprotected sex. Controlling for relationship factors, men's negative attitudes towards condoms, mental health, and higher number of male sex partners also were associated with having unprotected sex with female partners. We discuss the implications of these findings for health interventions.

Behavioral health and social normative influence: correlates of concurrent sexual partnering among heterosexually-active homeless men

Sexual concurrency poses significant HIV/STI transmission risk. The correlates of concurrency have not been examined among homeless men. A representative sample of 305 heterosexually active homeless men utilizing meal programs in the Skid Row area of Los Angeles reported on their mental health, substance use, and social network characteristics. Nearly 40% of men reported concurrency with one of their four most recent sex partners. Results indicated that HIV seropositivity (OR = 4.39, CI: 1.10, 17.46; P = 0.04), PTSD (OR = 2.29, CI: 1.05, 5.01; P = 0.04), hard drug use (OR = 2.45, CI: 1.07, 5.58; P = 0.03), and the perception that network alters engage in risky sex (OR = 3.72, CI: 1.49, 9.30; P = 0.01) were associated with increased odds of concurrency. Programs aimed at reducing HIV/STI transmission in this vulnerable population must take into account the roles that behavioral health and social networks may play in sexual concurrency.

HIV risk behavior and access to services: what predicts HIV testing among heterosexually active homeless men?

HIV is a serious epidemic among homeless persons, where rates of infection are estimated to be three times higher than in the general population. HIV testing is an effective tool for reducing HIV transmission and for combating poor HIV/AIDS health outcomes that disproportionately affect homeless persons, however, little is known about the HIV testing behavior of homeless men. This study examined the association between individual (HIV risk) and structural (service access) factors and past year HIV testing. Participants were a representative sample of 305 heterosexually active homeless men interviewed from meal programs in the Skid Row region of Los Angeles. Logistic regression examined the association between past year HIV testing and demographic characteristics, HIV risk behavior, and access to other services in the Skid Row area in the past 30 days. Despite high rates of past year HIV testing, study participants also reported high rates of HIV risk behavior, suggesting there is still significant unmet need for HIV prevention among homeless men. Having recently used medical/dental services in the Skid Row area (OR: 1.91; CI: 1.09, 3.35), and being a military veteran (OR: 2.10; CI: 1.01-4.37) were significantly associated with HIV testing service utilization. HIV testing was not associated with HIV risk behavior, but rather with access to services and veteran status, the latter of which prior research has linked to increased service access. We suggest that programs encouraging general medical service access may be important for disseminating HIV testing services to this high-risk, vulnerable population.