Substance misuse and homelessness

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Substance misuse and homelessness
The Centre for Housing Policy
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Recent work for Scottish Government

• Looked at evidence of effective services around
  the World
• Focused just on services for homeless people
• Not a study of whether any and all services for
  people involved in substance misuse might work
  for homeless people
• Though most services are based on mainstream
  practice

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Substance misuse and homelessness

• One is not automatically a trigger for the other
• But substance misuse and homelessness are
  mutually reinforcing
• Once one is true, the other becomes more likely
• Alcohol and heroin, not wine and cocaine

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What works?

• There is some evidence of success for all models
  of service delivery
• But the evidence suggests that models that
  require abstinence suffer from high attrition
  rates
• Surprise, surprise...
• Models that do not expect abstinence tend to have
  better retention rates
• But then their outputs are more modest, people
  are more stable, using less, not becoming
  homeless, but still using

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USA

• What has been referred to as a paradigm shift
  (change in model) from continuum of care services
  towards housing first models
• Former is a staircase model, slow progression
  through stages towards independent living,
  usually requiring abstinence
• Need to be cautious about terminology, but New
  York Pathways version of Housing First is a
  resettlement service using general needs housing,
  provides support, does not require abstinence

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USA

• Housing First (in New York) is focused on
  severely mentally ill people with substance
  misuse problems who also tend to have been
  homeless
• It produces stability, retains clients and
  prevents recurrence of homelessness
• There is some evidence it reduces substance
  misuse
• But it does not stop it
• Everything is calling itself Housing First
  because that is where Federal money goes, but HUD
  wants a model that will stop substance misuse
• Issues of scale and costs

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Alcohol A gap in evidence

• The emphasis in research shifted towards illegal
  drug use in the 1970s
• Away from alcohol
• Most systematic research looks at services for
  problem drug users or for users of drugs and
  alcohol

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Barriers to substance misuse services

• Esteem issues
• Pointlessness of existence in that situation
• Alienation
• Depression, severe mental illness
• What is a rational response in that situation?
  Why not obliterate yourself?
• Issues of supply
• Reluctance of mainstream services to engage

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Cultural Factors Deviance and Fear

• These populations generate fear
• Criminal, violent, anti-social behaviour
• Dangerous, unstable, chaotic
• Cultural reactions are those to severe mental
  illness and heroin
• As well as to homeless status
• Cultural imperative to punish
• Must not distract us from what appears effective

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Tackling substance misuse

• Essentially though, we are left with same issue
  as always with homelessness
• Substance misuse is one aspect of compound
  disadvantage and high need
• Mutual reinforcement among various needs
• Cannot tackle one, have to tackle all
• Expensive, difficult, mixed success

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Broad Conclusions

• Health Action for Homeless People in London in
  the early to mid 1990s had the right idea
• Essentially, homelessness has to be tackled on
  all levels
• Or health care can never be effective
• House the homeless if you want to treat them
  effectively

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More information

• www.york.ac.uk/chp/
• Pleace, N. and Quilgars, D. (1996) Health and
  Homelessness in London A Review London, The
  Kings Fund.
• Pleace, N. Jones, A. and England, J. (2000)
  Access to Primary Care for People Sleeping Rough
  York CHP/Department of Health
• Quilgars, D. and Pleace, N. (2003) Delivering
  Health Care to Homeless People An Effectiveness
  Review, Edinburgh NHS Health Scotland
• Pleace, N. (2008) Effective Services for
  Substance Misuse and Homelessness in Scotland
  Evidence from an international review Edinburgh
  The Scottish Government

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