Homeless Users Research Articles

Predictors of rehospitalization of military veterans who abuse substances

The study reported in this article is of a systematic random sample of 600 homeless Vietnam veterans, ages 46 to 65, who abuse substances, many of whom are comorbid with psychological afflictions. All of these veterans were in a Midwestern residential program for homeless substance abusers at the time of the interview. Cox's proportional-hazards model was used to estimate the relative rate of rehospitalization (hazard function) across the follow-up interval of two years by the predictors. The ecological predictors include, but are not limited to, demographic characteristics, history of drug and psychiatric treatment, psychological afflictions, abuse before 18 years of age, inner strengths, social support, religiosity, and direct combat experience in Vietnam. The range of ecological factors investigated presents more comprehensive findings for future conceptual models and for more thorough social work intervention. Key words: comorbidity; drug abuse; ecological predictors; homeless veterans; survival analysis ********** Large numbers of homeless military veterans are being treated for substance abuse at Veterans' Affairs medical centers (VAMCs). For example, in 1996, 36 percent of the more than 250,000 discharges of Vietnam veterans nationwide were related to substance abuse (Virgo, Price, Spitznagel, & Ji, 1999). In addition, more than 25 percent of all veterans treated at VAMCs in an inpatient setting in 1996 had a substance abuse diagnosis. Forty percent had a diagnosis of comorbidity, or the coexistence of chemical abuse and other psychological problems. In 1996 one-third of the 10.9 million days of inpatient care provided by VAMCs were for veterans with substance use disorders. Veterans who suffer comorbidity have longer and more frequent hospitalizations than veterans treated in inpatient settings for other reasons (Piette, Baisden, & Moos, 1997). Comorbidity, in fact, appears to be one of the strongest predictors of rehospitalization among veterans (Dixon, McNary, & Lehman, 1997; Marshall, Jorm, Grayson, & O'Toole, 1998; Murray, Anthenelli, & Maxwell, 2000; Rosenheck & Cicchetti, 1998). At the same time, substance abuse historically has been treated in a different system than other psychological or mental health problems. Typically, these systems have had dissimilar, even contradictory, treatment orientations and approaches. Given these dissimilarities, substance abuse frequently is not properly assessed or is overlooked in mental health centers, whereas mental health problems generally are not appropriately diagnosed or treated in drug rehabilitation programs. Often, chemical abusers who suffer other psychological afflictions are shuffled between drug rehabilitation and mental health systems, using scarce resources, without receiving adequate treatment in either system to resolve their problems (Dixon et al., 1997; Nuttbrock, Rahav, Rivera, Ng-Mak, & Link, 1998; Rosenheck, & Cicchetti, 1998). Whereas integrative programs have been designed recently to treat substance abuse and a variety of psychological problems, there are still few of these programs for homeless veterans (Nuttbrock et al., 1998; Rosenheck & Cicchetti, 1998). Moreover, little information exists about what factors predict rehospitalization of homeless veterans who abuse substances (Helzer & Przybeck, 1988; Hoff, Rosenheck, Meterko, & Wilson, 1999; Murray et al., 2000; Olfson, Mechanic, Hansell, Boyer, & Walkup, 1999; Rosenheck & Cicchetti, 1998). Yet, a major assumption underlying the present study is that programs are efficacious to the extent that they target the factors that predict rehospitalization (Andrews & Bonta, 1998). Factors that predict rehospitalization can be categorized into two useful classes for intervention purposes: (1) static factors, which are not alterable by social work intervention, such as age or history of substance abuse, and (2) dynamic factors, which are amenable to social work change, such as self-esteem or depression (Andrews & Bonta). …

Investigation of a secondary syringe exchange program for homeless young adult injection drug users in San Francisco, California, U.S.A.

This study investigated an HIV prevention program for homeless young adult injection drug users (IDUs) that combined a secondary syringe exchange program (SEP) with community-level activities. Homeless young IDUs were recruited from street-based settings in San Francisco, and a structured questionnaire was administered. The secondary SEP operated in a circumscribed geographic area, and for analytic purposes respondents were assigned to the intervention site group if they primarily spent time in this area (n = 67), or the comparison site group if they primarily spent time elsewhere (n = 55). Almost all (96%) intervention site youth had used the secondary SEP in the past 30 days and were significantly more likely to regularly use SEP. In bivariate analysis, comparison site IDUs were more likely to share syringes, reuse syringes, share the cotton used to filter drugs, and use condoms with casual sex partners only inconsistently. In multivariate analysis, comparison site remained positively associated with sharing syringes (adjusted odds ratio [AOR], 3.748; 95% confidence interval [CI], 1.406-9.988), reusing syringes (AOR, 2.769; 95% CI,1.120-6.847), and inconsistent condom use with casual sex partners (AOR, 4.825; 95% CI, 1.392- 16.721). This suggests that the intervention was effective in delivering SEP services to homeless young adult IDUs, and that IDUs who frequented the intervention site had a lower HIV risk than comparison group IDUs.

National Trends in Condom Use Among At-Risk Heterosexuals in the United States

This study investigated an HIV prevention program for homeless young adult injection drug users (IDUs) that combined a secondary syringe exchange program (SEP) with community-level activities. Homeless young IDUs were recruited from street-based settings in San Francisco, and a structured questionnaire was administered. The secondary SEP operated in a circumscribed geographic area, and for analytic purposes respondents were assigned to the intervention site group if they primarily spent time in this area (n = 67), or the comparison site group if they primarily spent time elsewhere (n = 55). Almost all (96%) intervention site youth had used the secondary SEP in the past 30 days and were significantly more likely to regularly use SEP. In bivariate analysis, comparison site IDUs were more likely to share syringes, reuse syringes, share the cotton used to filter drugs, and use condoms with casual sex partners only inconsistently. In multivariate analysis, comparison site remained positively associated with sharing syringes (adjusted odds ratio [AOR], 3.748; 95% confidence interval [CI], 1.406-9.988), reusing syringes (AOR, 2.769; 95% CI, 1.120-6.847), and inconsistent condom use with casual sex partners (AOR, 4.825; 95% CI, 1.392- 16.721). This suggests that the intervention was effective in delivering SEP services to homeless young adult IDUs, and that IDUs who frequented the intervention site had a lower HIV risk than comparison group IDUs.

Motivation for change and psychological distress in homeless substance abusers.

This study explores the treatment needs of homeless individuals participating in a large urban day shelter program. Alcohol and drug use, psychological distress, and stage of change were assessed in 100 participants presenting for services. The associations among substance use, risk perception, and readiness to change were examined for alcohol and drugs separately. Participants had high levels of psychological distress compared to "non-patient" samples. Eighty percent had used alcohol in the past 6 months, with 65% of those drinking at higher-risk levels; 60% had used drugs, with 82% in the higher-risk levels. While the majority felt that they drank and/or used drugs "too much", most were in precontemplation or contemplation stages of change. Intervention efforts for this population should focus on motivation, facilitation through the stages, and the associations between psychiatric symptoms and substance use.

Juvenile Delinquency and the Social Development Model: The Retrospective Accounts of Homeless Substance Abusers

Teens involved with drugs and engaged in delinquent behavior lessen their life chances. This article examines the relationship between early illicit drug exposure, delinquency, and subsequent adult experience through the life history accounts of 31 men who are homeless drug addicts today. The men's retrospective reports link personal history and social circumstance to describe common pathways associated with and emerging from adolescent delinquency and drug involvement. Their accounts, framed within the social development model, indicate that the life chances of teens at risk might improve if policy-based solutions and interventions target and ameliorate contextual and interpersonal risk factors interfering with the accumulation of social capital.

Young homeless drug users?ways of coping with harassment

This paper explores young homeless drug users' ways of coping with harassment. Discussions of coping and harassment are based on the cognitive appraisal model. Coping accounts were essentially problem-focused and action-oriented. Results indicate the need for more policy developments to prevent homelessness and for specific interventions around homelessness and harassment. Copyright © 2000 John Wiley & Sons, Ltd.

Effectiveness of outreach to homeless substance abusers

Substance abuse is a frequent and complicating feature of homelessness. Barriers to service access have prevented homeless individuals from receiving substance abuse care. Outreach to homeless persons is a mechanism for identifying homeless substance abusers and engaging them in treatment. This study describes a program of substance abuse treatment conducted by a medical care provider for homeless persons in Baltimore, Maryland and compares characteristics of outreach recipients to those of walk-in clients. The study also examines the differences in drug abuse pathology and selected treatment outcomes among homeless and non-homeless clients and the extent to which homeless persons are unidentified in the drug abuse treatment reporting system of the state. Homelessness is about 5.5 times more prevalent in the clientele of drug abuse treatment programs than is reflected in the statewide substance abuse management information system of Maryland. Composite scores on the Addiction Severity Index for homeless individuals are significantly higher (reflecting more serious problems) on every measure in the interview, compared to non-homeless individuals. Except for residential treatment settings, homeless persons demonstrate a shorter length-of-stay in substance abuse treatment than housed clients. Our outreach effort successfully located its targets. Outreach clients reported significantly higher levels of substance abuse than walk-in clients. In addition 42.3% of outreach contacts became service recipients. These findings indicate that outreach can be a successful method of targeting and engaging a segment of homeless substance abusers who are otherwise difficult to engage in treatment.

HIV Risk Behaviors Among Homeless Injection Drug Users of Different Ethnicities

The objectives of this study were to assess the prevalence of HIV risk behaviors among homeless injection drug users (IDUs) and to determine whether these risk behaviors vary by ethnicity. A face-to-face interview was administered to 769 homeless IDUs in Portland, Oregon, from 1993 to 1996. Homeless IDUs had a high prevalence of needle sharing and sexual intercourse with casual partners, and a low prevalence of condom use. African Americans had the lowest rate of needle sharing, and Hispanics the highest. Compared to Whites, African Americans and Hispanics were both more likely to have had sex with casual partners in the last 30 days. African Americans were most likely to have used a condom with casual partners. Results indicate the need for more effective and culturally tailored interventions. Special efforts are needed to reduce needle sharing and increase condom use among Hispanic homeless IDUs, who exhibited the highest rates of risk behaviors.

From Streets to Homes

This paper describes essential elements of the Consumer Preference Supported Housing (CPSH) Model of homelessness prevention in use at Pathways to Housing, Inc. in New York City. This intervention prevents homelessness by engaging and housing homeless substance abusers with psychiatric disabilities whom other programs have rejected as “treatment resistant” or “not housing ready.” The CPSH model is built on the belief that housing is a basic right for all people. As opposed to the housing continuum model, housing is based on consumer choice and is not connected to compliance or treatment. Housing is provided immediately, and there are separate criteria for housing and treatment needs. Support services are aimed at integration of mental health and substance abuse services. In a randomized controlled study, individuals who are currently homeless and have psychiatric disabilities and/or substance abuse problems are randomly assigned to either the CSPH intervention or an intervention using the linear continuum model. Participants will be followed for a period of one year and the study will provide feedback regarding the effectiveness of the CSPH model.

The Effectiveness of Social Interventions for Homeless Substance Abusers. Guest Editor G. J. Stahl. Edited by D. Stinnel. ($49.95 hb, $19.95 pb.) Haworth Press: New York. 1997.

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Drug use among the young homeless: coping through self-medication

Research has shown that illicit drug use is now a common feature of homelessness. A main aim of the study was to examine the role that drugs played in the lives of young homeless people. Two hundred young homeless drug users (aged 14–25 years) were interviewed. Respondents reported a variety of health problems. Respiratory infections, aching limbs and weight loss were the most common, but of greater concern was mental health and 82% reported psychological symptoms: depression, sometimes severe and often chronic, anxiety and aggression. A very high proportion (43%) had attempted suicide, mostly through drug overdose. Three-quarters of the sample said they used drugs to self-medicate their symptoms. Drug use is one form of stress management that is widely adopted by many people, whether homeless or not, but the particular nature of the stressors endemic in the homeless lifestyle leads to a much increased vulnerability to such selfmedication when other coping strategies fail.

Prevalence of HIV Infection and HIV Risk Behaviors Associated with Living Place: On-the-Street Homeless Drug Users as a Special Target Population for Public Health Intervention

The study described here examined the prevalence of HIV infection as a function of place of residence and high-risk behaviors in six subpopulations of out-of-treatment drug injectors and crack cocaine users who participated in the National Institute on Drug Abuse (NIDA) Cooperative Agreement project. The subpopulations were blacks, Hispanics, and non-Hispanic whites sampled separately by gender. The research asked three questions: (a) Is the HIV infection rate higher among the on-the-street homeless than among those in other places of residence? (b) Do high-risk drug-related behaviors differ by housing status? and (c) What are the joint effects of high-risk drug-related behaviors and housing status on the probability of HIV infection? Overall, on-the-street homeless had a significantly higher HIV + rate (19.0%) than the study population as a whole (11.2%). Rates differed by gender and race, with exceptionally high HIV + rates for on-the-street homeless Hispanic males (29%) and females (32%) and for on-the-street homeless black females (38%). Having used drug works previously used by a HIV-infected person was a strong predictor of HIV+ status, as was frequency of drug injections and crack use. Having multiple sex partners was also a significant risk behavior. Findings argue against considering on-the-street homelessness as equivalent to shelter dwelling or aggregated homelessness for purposes of the AIDS epidemic. On-the-street homeless drug users were at strong risk for acquisition and transmission of HIV infection and therefore in need of targeted—racially relevant, ethnically relevant, and gender-relevant—public health interventions to help prevent the spread of AIDS.

Drugs and Youth Homelessness: Reducing the risk

The increase in youth homelessness in the UK and also internationally, although a cause for public concern, is proving resistant to efforts to contain it. Perhaps an association with drug misuse is one of the most serious social consequences of this trend, threatening the health of many young people with long-lasting effects. The family history and the current privations of the lives of 200 young, homeless drug users in Greater Manchester were studied in depth. The primary aim was to reveal the nature and range of coping responses to the hazards they faced. A major way of coping was through self-medication with drugs. The young and newly homeless, if not using drugs already, were likely to be absorbed into a drug-oriented community. lf they were, like many young people, using drugs recreationally, then their involvement was likely to increase. Older, long-term users were using more drugs and using them more frequently. Possible interventions are discussed that recognize the heterogeneity of the homeless population and the complexity of their needs, taking into account personal history and current levels of support.

Social Work in Mental Health

Contents Social Work in Mental Health: Trends and Issues* Recovery and Empowerment for People with Psychiatric Disabilities * Community Care and the Origins of Psychiatric Social Work * Strategies for Helping Young Adults with Severe Mental Disorders * Social Networks and Psychological Disability Among Housed and Homeless Users of Self-Help Agencies * Discharge Planning and Community Housing in Ontario * Working Collaboratively with Families * The Universality of Self-Help Program of American Origin: Narcotics Anonymous in Israel * The Ethics of Informed Consent: A Critical Variable in the Self-Determination of Health and Mental Health Clients * Revamping Mental Health Care in Israel: From the Netanyahu Commission to National Health Insurance Law * Index

Social Networks and Psychological Disability Among Housed and Homeless Users of Self-Help Agencies

SUMMARY We look at the effects of psychological disability on social networks and support of homeless and non-homeless individuals. We analyze a survey of 310 long-term users of client-run mental health agencies. Psychological disability is negatively associated with network characteristics for housed individuals, but not for the homeless. There is a positive relationship between psychological distress and network size for the homeless who receive SSI while homeless individuals who do not receive SSI show a negative, non-significant association. We suggest the financial resources of SSI enable network members to become expressively involved with homeless individuals with relatively more psychological disturbance.

Evaluating an alcohol and drug treatment program for the homeless: An econometric approach

The New Orleans Homeless Substance Abusers Project (NOHSAP) was designed as a randomized field experiment to test the effectiveness of a residential alcohol and drug treatment program on the sobriety, employment, housing, and social integration of homeless substance abusers. However, program staff sabotaged randomization into treatment and control groups, and research attrition was also non-random. Non-random assignment to treatment and non-random research attrition threaten internal and external validity by biasing OLS estimates of the effects of treatment and necessitate use of econometric selection bias correction modeling techniques. Results of these corrected models are then used in subsequent estimates of treatment effects on a variety of outcome measures. After correction, positive treatment effects prove relatively modest. However, subsequent analysis suggests that NOHSAP exerted a critical indirect effect on outcomes by facilitating subject's participation in outside substance abuse groups. We conclude with some observations on the policy implications of the substantive results.

Health and healthcare for homeless people

Go Home and Rest?, a new report by Shelter, provides a unique insight into the health problems faced by single homeless people and reveals the health profiles of homeless users of the A&E department of the University College Hospital, London. This study is supported by a growing body of research which demonstrates the harmful effects of homelessness on health, and the obstacles in the way of those who seek care.

Losing the housing game. The leveling effects of substance abuse.

Analysis of the housing dynamics and individual characteristics of a sample of 670 participants in the New Orleans Homeless Substance Abusers Program reveals substantial diversity with respect to income, education, and occupational attainment. Nevertheless, drug consumption and dependence serve as socioeconomic levelers, dissolving otherwise potentially critical differences in human-capital and economic capacities. The need to focus concurrently on both structural and individual causes of homelessness is emphasized.

Sufficient conditions for effective treatment of substance abusing homeless persons

Treatment efficacy for homeless substance abusers (primarily crack cocaine) was studied in a randomized control design with subjects ( n = 176) assigned to usual care (UC) or an enhanced day treatment program plus abstinent contingent work therapy and housing (EC). Subjects met DSM-III-R criteria for Substance Use Disorder and McKinny Act criteria for homelessness. UC involved weekly individual and group counseling. EC involved a day treatment program consisting of daily attendance, transportation, lunch, manualized psychoeducational groups, and individual counseling. A total of 131 (74.4%) subjects (62 UC and 69 EC) were treated and followed. UC subjects attended 28.5% and EC attended 48.4% of expected treatment during the first 2 months. After 2 months, EC subjects experienced up to 4 months of abstinent contingent work therapy (44.9% of EC subjects) and housing (37.7% of EC subjects), with day treatment available two afternoons per week. Longitudinal Wei-Lachin analyses of medians (reported alcohol use, days homeless and employed) and proportions (cocaine toxicologies) were conducted across 2-, 6-, and 12-month follow-up points. EC had 36% fewer positive cocaine toxicologies at 2-months and 18% fewer at 6-months than UC with regression toward baseline at 12-months. EC had 8 days fewer days of reported alcohol use in the past 30 days, 52 fewer days homeless in the past 60 days, and 10 more days employed in the past 30 days from baseline to the 12-months. UC showed no changes except a temporary increase in employment at 6-months. This is one of the first demonstrations that homeless cocaine abusers can be retained and effectively treated.

Social interventions for homeless substance abusers.

Social interventions for homeless substance abusers.