Homeless people are disproportionately affected by substance use and other health problems, but there’s a noticeable shortage of research about how to provide them with services.
Why? One reason is that people without permanent housing can be difficult to research. That’s no excuse, write Canadian researchers Salvalaggio et al (2013). The problem is too important:
Despite the huge need for effective interventions in this population, patients with unstable substance use and/or without permanent housing are typically excluded from traditional research studies due to challenges in obtaining informed consent and finding patients for follow up. We would argue that more research and expertise around how to take research findings and translate them into effective interventions for the patients with the highest burden of disease is urgently needed.
Despite a dearth of research, there are a variety of programs designed to address physical and behavioral health issues among homeless people. One of these programs is called Healthcare for the Homeless (HCH).
Last month, I spent an afternoon with registered nurse Lisa Pietrusza at one of Pittsburgh’s HCH sites in the Uptown neighborhood. There, she explained how she and her colleagues address substance use and related health problems among the HCH patient population.
What is HCH?
HCH is a national program that funds federally-qualified health centers (FQHCs) to provide specific healthcare services that target homeless people. HCH has been in existence since the 1980s and HCH sites have been located in every U.S. state since 2001.
In Pittsburgh, HCH doesn’t stay in one place. HCH staff move between several places throughout the week–mainly homeless shelters–to provide access to folks throughout our region. In addition to sites in or near downtown, HCH is in McKeesport, East Liberty, and the North Side. Their Facebook page has up-to-date information on their weekly schedule.
HCH does its best to care for the whole person. Services include dental care, preventative medical care, and psychiatric care. Anyone who has been homeless or transient within the last year is eligible. HCH does not require Medicaid or any type of insurance coverage and there are no appointments: patients can just walk in.
How does Pittsburgh’s HCH address substance use?
While many clinics screen for at-risk substance use once a year, HCH screens once a month.
“People’s lives change faster when they’re on the street,” said Pietrusza.
These frequent screenings are a luxury that few other clinics have. Patients tend to visit HCH more regularly than most people see their primary care doctor. This is in part because of the range of services and locations that HCH offers.
More frequent screenings speak to another aspect of serving homeless patients: the issue of trust.
“We find that over time, people reveal their drug and alcohol use,” said Pietrusza. “It’s a matter of building trust.”
At the initial visit, HCH staff sit down with patients individually and walk through a five-page intake form. This form covers medications, sexual health, substance use, and other aspects of patient health.
At HCH, referring patients to specialty treatment can be a challenge.
Interestingly, the intake form separates questions about intravenous drug use from other questions about substance use. Rather, the HCH pairs questions about intravenous drug use with questions about sexually transmitted infections. This is meant to normalize intravenous drug use, said Pietrusza, and frame it as a health issue.
Another tailored approach to screening at the HCH is to ask hypotheticals. Pietrusza explained that homeless patients often have sporadic incomes and their choices are tied to their cash flow. Sometimes, in addition to asking patients about recent substance use, she also asks about what their substance use would look like if they had money.
A positive screen for at-risk substance use triggers the use of motivational interviewing (MI) to explore the patient’s reasons for substance use and areas of ambivalence. Pietrusza is an enthusiastic supporter of MI. She said MI opens up conversations about issues that really matter to her patients. At the same time, it offers her an opportunity to provide health education with a harm reduction orientation as opposed to lecturing patients or ignoring the issue of substance use altogether.
But at HCH, referring patients to specialty treatment can be a challenge.
“The twelve steps work for some people, but not everyone,” said Pietrusza. Most available treatment tends to be abstinence-based, which can seriously deter her patient population. Although some of her patients do achieve abstinence (or low risk use), Pietrusza said they tend to follow a path that begins with harm reduction.
Another challenge is long wait-times for both mental health and substance use treatment.
“It’s hard to want to screen patients if you know it will take months for someone who wants help to get into treatment.”
Although Pittsburgh’s HCH does not now prescribe buprenorphine for opiate addiction, Pietrusza said it’s a service they would love to provide.
“The trouble with Suboxone is that for our patients, it’s often unaffordable. So many clinics only accept cash and it can cost hundreds of dollars per month,” she said.
Currently, Pittsburgh’s HCH is seeking a full-time drug and alcohol counselor with an emphasis on harm reduction.
“The counselor can’t say, ‘Well, if you don’t want to go to inpatient or meetings, then I can’t help you.’ We’re here so our patients can come back to us and talk about these issues again and again. We find out why they’re using. And some people do get engaged in the treatment system. You’d be surprised: we see a lot of patients who are in recovery.”
Guidance on addressing substance use among homeless people
We’ve got an evidence-based approach for reducing unhealthy substance use: it’s called Screening, Brief Intervention and Referral to Treatment (SBIRT). Unfortunately, there is uneven and inadequate information about SBIRT specifically targeted at people in low socioeconomic brackets or without stable housing.
Support for policies…that emphasize health over abstinence will benefit people without stable housing.
The largest-scale study on the topic is not encouraging. In 2014, Roy-Byrne et al. recruited over 800 participants to a randomized controlled trial of SBIRT in a safety-net clinic setting. Of the participants, 30% were homeless. Only 37% of the participants had the goal of trying to abstain from drugs. Comorbid mental health disorders and physical heath problems were common.
Patients who screened positive for risky drug use (any substance other than alcohol) received a 30-minute MI session and a followup booster delivered by telephone. This intervention had no effect on substance use and other measures of high public health value (e.g. ER visits, HIV risk-taking behaviors).
Does this mean we should be pessimistic? Not necessarily. For what it’s worth, Pietrusza is one of the more optimistic people I’ve ever spoken with. Several trends may bode well for addressing substance use among homeless populations:
1. Harm reduction is gaining acceptance. A few years ago, “harm reduction” was a tainted phrase. Now it’s embraced by the White House Office of National Drug Control Policy, community coalitions, and politicians on both sides of the aisle. Support for policies like naloxone distribution, syringe exchange, and other programs that emphasize health over abstinence will benefit people without stable housing.
2. Housing First works. It’s always a bummer when a research-supported intervention is politically infeasible, but Housing First may well have its day. Providing permanent housing without limitation has been shown to improve substance use outcomes and, more than once, Housing First has outperformed Residential Treatment First in head-to-head comparisons (e.g., in a multi-site 2010 observational study and a smaller 2011 qualitative study). Housing First models have been adopted (to a greater or lesser extent) in New York City, Seattle, Salt Lake City, and several cities in the United Kingdom.
3. And finally: Growing momentum behind SBIRT will offer more information about how it can be tailored to specific sites and populations. In a 2015 survey of SBIRT in federally-qualified health centers, Eric Goplerud and Tracy McPherson wrote, “Health center staff indicated that adaptation and tailoring is happening at the clinic level even when sites have multiple clinics. Clinics are figuring out what works best within their operations and patient flows.” Over time, the use and evaluation of different approaches to SBIRT will help determine better ways of addressing substance use in clinics serving homeless patients.