A naturalistic longitudinal study of the order of service provision with respect to cocaine use and outcomes in an urban homeless sample

Associations of housing stress with later substance use outcomes: A systematic review

A synthesis of existing evidence regarding the association of housing stress with later substance use outcomes can help support and inform housing interventions as a potential strategy to address problematic substance use. We conducted a comprehensive search of PubMed, Web of Science, PsycInfo, CINAHL, Social Work Abstracts, and Sociological Abstracts and systematically screened for articles examining housing stress and later substance use outcomes among U.S. adults. Across 38 relevant articles published from 1991 to 2020, results demonstrated an association of homelessness with an increased likelihood of substance use, substance use disorders (SUD), and overdose death. Results regarding the association of homelessness with receipt and completion of SUD treatment were mixed, and one study indicated no association of homelessness with motivation to change substance use behaviors. Several studies did not find an association of unstable housing with substance use or receipt of SUD treatment, while others found an association of unstable housing with intensified SUD symptoms and a decreased likelihood of completing SUD treatment. Overall, while there is evidence of an association of homelessness with later substance use, SUD, and overdose death, results for other forms of housing stress and some substance use outcomes are less consistent. There are several methodological considerations specific to selected measures of housing stress and substance use, study populations, and analytic approaches that have implications for results and directions for future research. Despite these considerations, results collectively suggest that innovative interventions to address housing stress, namely homelessness, may help mitigate some substance use outcomes.

Longitudinal Cost of Services in a Homeless Sample with Cocaine Use Disorder

Homeless people with cocaine use disorder have multiple comorbidities and costly service needs. This study examined service costs associated with cocaine use and substance service use in substance, psychiatric, and medical service sectors. 127 homeless participants with cocaine use disorder were interviewed annually. Self-report and agency-report service use and cost data were combined. Pairwise comparisons were made with cocaine abstinence and substance service use in relation to mean and yearly proportional service costs in 3 service sectors. Among substance service users, achievement of abstinence was not associated with decreased substance service costs. Cocaine abstinence was associated with proportional reduction of substance service costs over time. Substance service use was associated with proportional reduction of psychiatric service costs over time among the abstinent subgroup. Conversely, substance service use was associated with continuing higher medical service expenditures in the abstinent subgroup and higher psychiatric service expenditures in those not abstinent. Homeless individuals who achieved cocaine abstinence after using substance services had decreased substance service expenditures. Individuals with continued substance service use had greater medical and psychiatric service costs. Policy based on maximizing benefits while minimizing costs appears insufficiently complex to incorporate the multiple needs and associated with costs of treating homeless populations.

Associations of alcohol use disorder, alcohol use, housing, and service use in a homeless sample of 255 individuals followed over 2 years

BACKGROUND

Homeless individuals with alcohol use disorders have multiple comorbidities and therefore various service needs. Despite need for services, homeless individuals face numerous barriers to treatment. Little is known about the associations of specific services in relation to homelessness in the context of alcohol problems. The current study analyzed 2-year prospective longitudinal data on a homeless sample, examining relationships between alcohol use disorder, alcohol use, housing status, and service use over time.

METHODS

Two hundred fifty-five of 400 individuals recruited systematically from shelters and street locations completed 3 annual assessments (69% completion). Data on lifetime and current psychiatric disorders, housing status, and past-year service use were obtained and merged with service use data gathered from local agencies. Generalized estimating equation (GEE) models were created to predict dependent outcome variables of stable housing, alcohol use, and service use in both follow-up years.

RESULTS

Lifetime alcohol use disorder was positively associated with substance and medical service use. Alcohol problems did not hinder attainment of stable housing, and placement in housing did not necessarily increase risk for alcohol use. Stable housing was negatively associated with psychiatric and substance service use. In the second year, when alcohol use was finally associated with receiving substance services, it appears that these services provided a gateway to psychiatric services. The psychiatric services in turn appeared to provide a gateway to medical services.

CONCLUSIONS

Alcohol use behaved differently compared with lifetime alcohol use disorder in relation to service use. Lack of association between alcohol use and housing supports Housing First policy. Obtaining housing may have ameliorative effects on mental health, diminishing perceived need for psychiatric services. Services may also be more accessible during homelessness. Obtaining substance treatment may provide a gateway for those who use alcohol after becoming homeless to connect with psychiatric and medical services, informing policy and practice.