It may come as no surprise that substance abuse is common among the
homeless population. A 1997 study conducted in Alameda County, Calif., found
that such abuse was eight times more prevalent among homeless people than
among the general population.
Yet even if substance abuse is widespread among homeless individuals, much
less is known about the relationship between homelessness and substance abuse.
So Thomas O'Toole, M.D., of the Johns Hopkins University School of Medicine,
and colleagues conducted a study to explore this relationship.
One of the interesting pieces of information they uncovered—and one
that surprised them—is that substance abuse may not necessarily increase
after people become homeless; in fact, it may even decrease.
O'Toole and his coworkers surveyed more than 500 homeless adults at 91
sites in Pittsburgh and Philadelphia, and in such diverse settings as
emergency shelters, congregated eating facilities, abandoned cars, and park
benches. After completing the interview, each participant in the survey
received $5 in cash or the equivalent in bus tokens and a listing of area
health and social service providers. To create a more comfortable environment
for respondents to answer questions truthfully, formerly homeless research
assistants conducted the interviews.
The researchers used a version of the National Technical Center Telephone
Substance Dependence Needs Assessment Questionnaire, modified for face-to-face
interviews and with questions specific to homelessness added. The
questionnaire included questions about demographic characteristics, past and
current alcohol and drug use, medical and mental health comorbidities, prior
substance abuse—related treatments, means of acquiring drugs,
interactions with the criminal justice system, and an assessment of current
health and social services needs.
Some 78 percent of the survey respondents, the researchers reported in the
May American Journal of Public Health, met DSM-III-R
criteria for substance abuse, dependence on alcohol or drugs, or a combination
of both. Alcohol, cocaine, and heroin were the most commonly reported
substances of abuse, with alcohol being the most commonly misused substance
both individually and in combination with other substances.
Of the 78 percent of survey respondents with a substance abuse problem, 30
percent reported using more substances after becoming homeless, and 70 percent
reported using the same amount of substances, or even less, after becoming
homeless. This finding surprised the investigators; they had expected that
becoming homeless would generally lead to more drug and alcohol use.
If what the 70 percent of respondents reported was accurate—that they
were not just telling interviewers what they believed the interviewers wanted
to hear—why might they have used the same amount of substances, or even
less, after becoming homeless? Fifty-one percent of the 70 percent who said
that they were using the same amount of substances, or even less, said that
the reason was because they were in recovery, whereas 22 percent of the 70
percent said that the reason was that they were no longer able to afford
substances now that they were homeless.
An increase in substance use after becoming homeless appeared to be in
response to the person's experiencing mental health symptoms such as anxiety
or depression or to living in a homeless environment. Surges in substance use
after becoming homeless were noted more commonly with alcohol than with other
substances. Panhandling, selling plasma to support one's addiction, and not
having health insurance were found to be independently associated with more
substance use after becoming homeless.
These results have some practical implications, the researchers believe.
For instance, "for those who reported an increase in their substance use
after they became homeless, the increase often was in response to
self-reported mental health symptoms," stated the researchers in their
study report. "This apparent self-medication highlights the
co-occurrence of mental health issues with substance abuse among homeless
persons and the need for dual-diagnosis-specific and other integrated care
Also, although a number of homeless persons may be receiving drug and
alcohol treatment, they are still homeless. This situation, the investigators
added, "highlights the importance of linking substance abuse treatment
for homeless persons to housing and other wraparound service needs. This
linking should include medical and mental health care, permanent housing,
education assistance, or work-readiness programs. Strategies for homeless
persons need to include more outreach and on-site treatment co-located in
emergency shelters, soup kitchens, and other congregate sites...."
The study was financed by the National Institute on Drug Abuse and the
Center for Substance Abuse Treatment.
An abstract of the study, "Self-Reported Changes in Drug and
Alcohol Use After Becoming Homeless," is posted online at<www.ajph.org/cgi/content/abstract/94/5/830>.▪
Am J Public Health