Homelessness, Addiction, and the Opioid Crisis

Addiction: A Cause and a Consequence of Homelessness

Each year, the Department of Housing and Urban Development (HUD) presents an Annual Homeless Assessment Report (AHAR) to the United States Congress. The purpose of the report is to give federal lawmakers reliable information and data on the current number of homeless people in the U.S., people at risk of homelessness in the U.S., and people that may not qualify as homeless but experience housing instability that impairs their ability to consistently meet their essential survival needs. Congresspeople and Senators use this data for form policy objectives, funding strategies, and draft bills – that they hope to make law – that all have one primary purpose: eliminate homelessness in the United States.

While eliminating homelessness entirely is the ultimate objective, lawmakers and public advocacy groups understand that this will not happen overnight. Therefore, in addition to the goal of eliminating homelessness, lawmakers and advocates for the homeless support programs that offer health care, childcare, food, temporary shelter, and other services that ease the hardships that homeless people experience every day and night they experience homelessness.

This article will address a specific problem among the homeless population in the U.S.: the prevalence of addiction, a.k.a. alcohol and/or substance use disorder (AUD/SUD). We’ll discuss addiction among the homeless in general, and then narrow our focus to opioid addiction among homeless people. At the end of this article, we’ll present a series of steps outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA) to address behavioral health needs of homeless people, including those diagnosed with an alcohol or substance use disorder (AUD/SUD).

Before we address addiction among the homeless, though, we’ll define homelessness, discuss the different types of homelessness, and present the latest statistics on the prevalence of homelessness in the U.S.

Homelessness in the U.S.: Facts and Figures

When government agencies began keeping track of the number of homeless people in the country, they quickly realized that the figure is not static. The nature of homelessness means the number changes daily, as some people experience hardship and end up on the streets, others find stable housing, and still others find themselves temporarily without a permanent and personal fixed address.

Therefore, the primary approach to quantifying homelessness is what’s called a point in time count, which refers to the number of people experiencing homelessness on a single night. For the AHAR, officials collect data during the last ten days of January each year, then collate that data into an estimate of the number of experiencing homelessness on any given single night of the year.

The last full AHAR report includes point-in-time data for 2020 since the COVID-19 pandemic impacted an accurate, full count for 2021.

First, let’s define homelessness. HUD identifies four categories of homelessness. Homeless people are:

• Individuals and/or families who lack a fixed, regular, and adequate nighttime residence:
  • This includes people who resided in an emergency shelter, or a place not meant for human habitation
• Individuals and/or families at imminent risk of losing their nighttime residence
• Unaccompanied youth/children and families with children/youth who are defined as homeless under other federal statutes who do not otherwise qualify as homeless under this definition
• Individuals and families fleeing domestic violence, dating violence, sexual assault, stalking, or other dangerous, life-threatening conditions

Now let’s look at the point-in-time data for 2020.

A Single Night in January: Homeless Estimates

• 580,466 people experienced homelessness
• 61% spent the night in sheltered locations
• 39% spent the night in locations other than shelters
• 70% were adults
• 36% of homeless adults were unsheltered
• 34% of homeless adults where sheltered
• 30% of homeless people were part of a family with at least one person under the age of 18
• 3,598 were unaccompanied minors, under age 18 with no adult family members or guardians present

Those are the big-picture facts on homelessness in the U.S. Now let’s take a look the prevalence of addiction among people experiencing homelessness.

Addiction and Homelessness: Facts and Figures

The National Coalition for the Homeless fact sheet on substance use disorder and homelessness stresses that although a common stereotype of a homeless person is that they’re addicted to alcohol, drugs, or both. It’s true that homeless people experience rates of alcohol and substance use disorder are higher among homeless people than the general population, the idea that “all homeless people are alcoholics or addicts” is an archaic notion that has no basis in evidence.

Here’s the most recent data on addiction and related problems among people experiencing homelessness, as reported by the National Coalition for the Homeless:

• 38% of people experiencing homelessness meet criteria for alcohol use disorder
• 26% of people experiencing homelessness meet criteria for substance use disorder
• 43% of mayors at the United States Conference of Mayors indicate that lack of substance use disorder treatment was a leading cause of homelessness

Here are additional statistics reported in the peer-reviewed journal article “Association between Homelessness and Opioid Overdose and Opioid-related Hospital Admissions/Emergency Department Visits”:

• People experiencing homelessness have an 80% increased likelihood of opioid overdose compared to low-income individuals with housing
• People experiencing homelessness have a 900% increased likelihood of an opioid related emergency room visit (yes, you read that correctly)
• Non-Hispanic white females experiencing homelessness had the highest risk of opioid overdose among people experiencing homelessness
• Non-Hispanic white males experiencing homelessness had the highest risk of an opioid related emergency room visit

Now let’s look at opioid-related deaths among people experiencing homelessness between 2013-2018, a critical period of the opioid crisis. A five-year study conducted in Boston showed the following:

• 91% of overdose deaths among people experiencing homelessness were opioid-related
• The synthetic opioid overdose rate per 100,000 person-years increased from 21.6 to 327 – an increase of over 1400%
• The rate of polysubstance overdose including opioids per 100,000 person years increased from 44 to 237 – an increase of over 400%

Now let’s look at deaths among people experiencing homelessness in San Francisco during the first year of the COVID-19 pandemic, from March 17^th, 2020 to March 16^th, 2021:

• 331 people experiencing homelessness died in that year
• 82% of those deaths were attributed to drug overdose
• 77% of overdose deaths involved methamphetamine
• 68% of overdose deaths involved the synthetic opioid fentanyl

Those statistics tell us that people experiencing homelessness are at increased risk of addiction – which, as we indicate in our introduction, can be both a cause and a result of homelessness – and among those experiencing addiction, people experiencing homelessness are at increased risk of fatal overdose. While the specific details on the prevalence of opioid use disorder among people experiencing homelessness are not available, the data from Boston are impossible to misinterpret: opioid use is a prime driver in fatal overdose death, which increased dramatically during the middle phase of the opioid epidemic, 2013-2018.

Now let’s look at how we can help people experiencing homelessness who also have OUD.

SAMHSA Offers Practical Guidance for Providers

In August 2021, in collaboration with the Homeless & Housing Resource Center, SAMHSA published a toolkit called “Whole-Person Care for People Experiencing Homelessness and Opioid Use Disorder.” The toolkit outlines a list of best practices and evidence-based approaches for support people with OUD who are also homeless.

As the title of the publication implies, the best practices revolve around the concept of whole person care. That’s an approach to addiction treatment we espouse, and the elements of whole person care identified by SAMHSA for people experiencing homelessness and OUD align with both our core beliefs about treatment and our practical approach to treatment when we engage in outreach activities in homeless shelters.

Here’s what SAMHSA says:

Core Elements of Whole Person Care

1. Person-Centered. This requires putting the needs and goals of the individual who seeks support ahead of institutional goals. Individuals identify their desired outcomes, rather than providers.
2. Trauma-informed and Healing-Centered. Providers need to understand there may be trauma in a homeless person’s past, and realize the experience of homelessness is itself traumatic. Therefore, providers working with this population must have experience with the effects of trauma, and understand how to address those effects during treatment.
3. Recovery-Oriented. SAMHSA stresses that there are many paths to recovery, and it’s the job of the provided to “walk alongside people on their individual journeys” and help them find the type of recovery support service that works best for them.
4. Racially Equitable. In the words of the SAMHSA guidelines, “Racial discrimination persists in excluding BIPOC from accessing safe and affordable housing, health care, and behavioral health treatment.” In order to support people experiencing homelessness and OUD, providers must ensure they offer support in a manner that includes everyone and excludes no one.
5. Non-stigmatizing. People experiencing homelessness and OUD have direct knowledge of stigma on at least two levels, because both homelessness and addiction are stigmatized in our culture. Providers must “challenge stigma with awareness and employ affirming, nonjudgmental, non-stigmatizing language, beliefs, and practices.”
6. Housing-Focused. A person living without consistent housing lives in survival mode every day. This is a stressful, chaotic, and frustrating. It’s difficult for a person to focus on recovery when they don’t know where they’re going to sleep that night. That’s why connecting people to addiction support services and housing support service simultaneously is essential: together, they can help a person rebuild their life, and move past both homelessness and addiction.

When we read this list, we understood everything on it completely. In fact, based on our outreach work in homeless shelters and our work with people living with housing and food insecurity, we could have written this list ourselves. Our list would have included most, if not all, of the points above. With that said, what we really believe is that the first item on the list is the most important, and all the other elements stem from taking a person-first approach to treatment and support. When we welcome a person with open arms, see them for who they are, and listen to their immediate needs and goals for recovery, we know that increases their chances of accepting treatment, and taking that important first step that can change their lives.