Going Above and Beyond CARA: An Opportunity to Address Opioid and Heroin Abuse

written by Noƫlle Porter
March 10, 2016

The U.S Senate has passed bipartisan legislation - The Comprehensive Addiction and Recovery Act, or CARA Act - that tackles the nation's growing painkiller and heroin abuse problem.  The bill authorizes more than $300 million over five years in grants for health and justice programs at the state and local levels.

Prescription opioid and heroin abuse is a national crisis, and the Administration and Congress are taking steps – both on the national and state level – to fight this battle. But it’s not enough. Fatal overdoses from prescription drugs and heroin continue to escalate, particularly among those most vulnerable: those experiencing homelessness. We know that substance use disorders are known risk factors for homelessness (1), and that substance abuse and overdose disproportionately impact homeless people (2).

Just take a look at these statistics:

• In 2014, an estimated 2.5 million people suffered from opioid-use disorders (OUD), and opioid-related overdoses were responsible for more than 28,000 deaths, more than any accidental cause of death in the United States. (3)   

• Substance abuse is often identified as one of the top causes of homelessness or an individual’s primary reason for homelessness.(4,5) 

• Research found that veterans who seek treatment for OUD are 10 times more likely to have experience homelessness than the general veteran population.(6)

• Likewise, homeless adults, 25-44, are 9 times more likely to die from an opioid overdose than their counterparts who are stably housed.(7)

While the epidemic is notable for affecting people of any race, gender, socioeconomic status, or other identifier, its effects are felt in unique and notably harmful ways by people who are experiencing homelessness. The solution for this population needs to be more comprehensive than standard treatment protocol, and here’s why:

• Homeless people with OUD experience significant barriers to treatment. Obstacles include disaffiliation or social isolation, lack of mobility or transportation, a fragmented delivery system, and complex treatment needs including co-occurring conditions. Additionally, the social service needs of homeless individuals, including access to employment and housing, increase the morbidity and mortality of substance use disorders.

• Research has shown that integrated treatment which incorporates housing and employment components provides better health outcomes than usual care for people who are homeless.  

The Alliance Recommends

• To maximize treatment efficacy, incorporate housing and social supports, including permanent supportive housing units and rapid rehousing interventions, into treatment for persons with housing instability or those who are experiencing homelessness. This requires collaboration between healthcare providers and housing and homeless services providers.

• Treatment providers should increase their understanding of the additional clinical and social services necessary to engage and keep homeless people with OUD in treatment. Evidence-based training on strategies and supports for coordinated programs should be provided to substance use and primary care practitioners.

• Homeless services systems and providers are encouraged to complete overdose response planning.(8)

It is imperative that the administration, our healthcare system, and homeless services systems and providers come together to respond to the critical rates of addiction and death within homeless populations as a component of the national response to the opioid epidemic. Neither the initiative to address this epidemic, nor the efforts to end homelessness can be entirely successful without considering and prioritizing the urgent needs of people who have OUD and are experiencing homelessness.

Don't miss our next blog post, in which we will talk about the importance of expanding the availability, understanding, and use of naloxone and medication-assisted treatment, specifically buprenorphine.

1  Susser E, Moore R, Link B. Risk Factors for Homelessness. Epidemiol Rev. 1993;15(2):546-56.
2  http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf
3  http://www.samhsa.gov/disorders/substance-use#opioid-use-disorder
4  The United States Conference of Mayors. Hunger and Homelessness Survey. Washington, DC. 2008.
5  Spinner G, Leaf P. Homelessness and drug abuse in New Haven. Hosp Community Psychiatry. 1992 Feb;43(2):166-168.
6  Bachhuber M, Roberts C, Metraux S, and Montgomery A. (2015). Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration. Journal of Opioid Management, 11(6), 459-462.
7  Baggett T, Hwang S, O’Connell J, et al. Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-Year Period. JAMA Intern Med. 2013;173(3):189-195. doi:10.1001/jamainternmed.2013.1604.
8  Hwang S, Tolomiczenko G, Kouyoumdjian F, Garner R. Interventions to improve the health of the homeless: a systematic review. Am J Prev Med. 2005 Nov;29(4):311-9.