Overdose, housing, and homelessness

I read an article this morning that led me to this article on overdose, housing, and homelessness.

A common assumption is that there is a unidirectional causal pathway between drug use and homelessness; that is, people become homeless because of their drug use. This misconception places the blame on the individuals and away from the root structural contributors to homelessness as well as perpetuates stigma and points to the wrong solutions. In reality, the association between homelessness and drug use is bidirectional, and homelessness itself plays a role in drug use and overdose risk. People experiencing homelessness may use drugs for adaptive reasons, such as to stay awake or to sleep as needed or simply to adjust and cope with the trauma of homelessness. The criminalization of both homelessness and drug use compels potentially dangerous behaviors, such as using drugs hastily in public locations or alone in hidden spots.

Doran KM, Fockele CE, Maguire M. Overdose and Homelessness—Why We Need to Talk About Housing. JAMA Netw Open. 2022;5(1):e2142685. doi:10.1001/jamanetworkopen.2021.42685

There’s little doubt that homelessness influences drug use and overdose risk. However, to acknowledge that there is a directional relationship between drug problems (particularly severe drug problems characterized by impaired control) and homelessness shouldn’t imply blame or stigma. We can acknowledge that relationship and also acknowledge that community recovery capital, like recovery safe housing, (or the lack thereof) can influence the risk, onset, course, and treatment response of drug problems.

In recent years there’s been growing interest in social and environmental factors as causal factors in drug problems. This brings to mind this quote from Bill White on the historical essence of addiction counseling.

If AOD problems could be solved by physically unraveling the person-drug relationship, only physicians and nurses trained in the mechanics of detoxification would be needed to address these problems. If AOD problems were simply a symptom of untreated psychiatric illness, more psychiatrists, not addiction counselors would be needed. If these problems were only a reflection of grief, trauma, family disturbance, economic distress, or cultural oppression, we would need psychologists, social workers, vocational counselors, and social activists rather than addiction counselors. Historically, other professions conveyed to the addict that other problems were the source of addiction and their resolution was the pathway to recovery. Addiction counseling was built on the failure of this premise. The addiction counselor offered a distinctly different view: “All that you have been and will be flows from the problem of addiction and how you respond or fail to respond to it.”

Addiction counseling as a profession rests on the proposition that AOD problems reach a point of self-contained independence from their initiating roots and that direct knowledge of addiction, its specialized treatment and the processes of long-term recovery provide the most viable instrument for healing and wholeness. If these core understandings are ever lost, the essence of addiction counseling will have died even if the title and its institutional trappings survive. We must be cautious in our emulation of other helping professions. We must not forget that the failure of these professions to adequately understand and treat addiction constituted the germinating soil of addiction counseling as a specialized profession.

White, W. (2004). The historical essence of addiction counseling. Counselor, 5(3), 43-48.

It’s important to note that Bill was discussing addiction, the most severe drug problems, which constitute a portion of drug problems and what applies to addiction may not apply to other kinds of drug problems.

Later this morning I came across this article on overdose deaths in supportive housing in San Francisco.

Almost every time Edwin Armando Alvarez overdosed on fentanyl, he said he awoke grateful to be alive. But on March 9, alone in his residential hotel room in San Francisco’s Tenderloin, he didn’t wake up. He died at 53, lying on his apartment floor among cockroaches, moldy food and heaps of trash.

A week before he died, he called his daughter, Genoveva Alvarez-Arroyo, expressing a desire to escape the life he found himself in. He started using fentanyl while living on San Francisco’s streets, and the city had placed him in housing just blocks from where drug dealers hawked the deadly opioid. 

Sjostedt, D. (2023, October 17). 3 People Fatally Overdose Every Week in SF Homeless Housing. Retrieved October 17, 2023, from The San Francisco Standard website: https://sfstandard.com/2023/10/17/san-francisco-homeless-housing-drug-overdose-deaths

Edwin’s story highlights the need not just for housing, but for recovery safe housing.

The San Francisco Standard report indicates that 15% of all of the city’s OD deaths happened in the city’s supportive housing program. 1

Alvarez was one of at least 85 people who fatally overdosed in San Francisco’s housing for formerly homeless people this year by July 31, according to data from the Chief Medical Examiner’s Office analyzed by The Standard.

…A record number of 563 people citywide lost their lives to overdoses by August this year, according to preliminary data from the medical examiner’s office. 

Sjostedt, D. (2023, October 17). 3 People Fatally Overdose Every Week in SF Homeless Housing. Retrieved October 17, 2023, from The San Francisco Standard website: https://sfstandard.com/2023/10/17/san-francisco-homeless-housing-drug-overdose-deaths

The overdose crisis is prompting some helpers to rethink their models and assumptions about housing and drug problems.

As part of a policy called “housing first,” the city has long worked to remove barriers people face in acquiring housing. That means removing requirements such as drug treatment and sobriety mandates. The city has served as a national model for the policy, according to proponents, providing subsidized homes for over 10,000 people at a time.

Now, some social service providers at the forefront of the homelessness crisis say fentanyl is forcing them to contemplate ways to evolve the policy….

…Callandrillo said 80% of tenants in one of Episcipocal Community Services’ buildings acknowledged having a drug addiction, while roughly 65% said their drug use was a serious impediment in their lives.

Shaw, of the Tenderloin Housing Clinic, said he wants the city to require tenants of supportive housing to participate in case management and other services.

“Housing first wasn’t created with the threat of fentanyl,” Shaw said. “The circumstances have changed.”

Sjostedt, D. (2023, October 17). 3 People Fatally Overdose Every Week in SF Homeless Housing. Retrieved October 17, 2023, from The San Francisco Standard website: https://sfstandard.com/2023/10/17/san-francisco-homeless-housing-drug-overdose-deaths

Housing First feels like a bold and aggressive intervention to improve the lives of vulnerable people. In some ways it is. In other ways, it’s a very “hands off” approach to helping. A hands off approach is probably the ideal response to people whose primary problem is a housing problem. For people with addiction (and their neighbors), an illness whose hallmark is impaired control, a specialized “hands on” approach is called for. This doesn’t mean coercion, but it may mean some contingencies and a system that has a safety net for people who choose not to accept those contingencies.

  1. 15% is an interesting figure because the article that got this post rolling reported that people experiencing homelessness accounted for around 16% of opioid overdose deaths in 2021.
    [Booth, RG, Shariff, SZ, Carter, B, Hwang, SW, Orkin, AM, Forchuk, C, et al. Opioid-related overdose deaths among people experiencing homelessness, 2017 to 2021: A population-based analysis using coroner and health administrative data from Ontario, Canada. Addiction. 2023. https://doi.org/10.1111/add.16357] ↩︎
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