Research consistently shows that there is a strong link between homelessness and addiction, and substance use is much more prevalent in people experiencing housing insecurity. Shared risk factors like trauma, mental illness, and poverty contribute to both problems and can create a self-reinforcing cycle. [1][2] Addiction treatment, case management services, and linkage to stable housing are essential to help interrupt this cycle and support long-term recovery. [1][3]
- Homelessness and addiction are closely linked, and each can be a cause or a consequence of the other.
- Individuals who are homeless are much more likely to struggle with severe addictions, in combination with other serious physical and mental health problems.
- Integrated approaches that address housing needs in addition to providing treatment for addiction are the most effective in breaking the cycle of homelessness and addiction.
Substance use and addiction in homeless individuals
Individuals who are ‘homeless’ may be living in sheltered or unsheltered environments, but their living situations are either temporary, unstable, or inconsistent. According to extensive research, people who are homeless are much more likely than those with stable housing to abuse drugs or alcohol. Rates of substance use disorders, the formal term for addiction, are also much higher in homeless individuals than in the general population. [2][3]
Some estimate that over 50% of people who are homeless have a substance use disorder, with alcohol, opioids, and cocaine being the most commonly abused substances. [3] Despite the high rates of addiction, homeless individuals are much less likely to seek treatment, engage in, or remain in treatment for substance use disorders. [2]
Many homeless individuals are also struggling with co-occurring mental illnesses, which are linked to heavier, more frequent, and severe abuse of drugs and alcohol. Having a co-occurring mental illness is also a risk factor for unemployment, economic instability, criminal involvement, and homelessness. Combined, these factors can create a cycle of instability where homelessness and substance use reinforce one another. [1][2]
Understanding the link between substance use and homelessness
Homelessness has been described as both a cause and a consequence of substance use. Research suggests that as many as two-thirds of homeless people report that substance use was a primary cause of becoming homeless. [3] This illustrates how the link between substance use and homelessness is usually complex, bidirectional, and self-perpetuating.
Underneath both problems is a shared set of risk factors that includes factors like trauma, poverty, unemployment, untreated mental illness, and a lack of social support. It is common for people who are homeless and addicted to drugs or alcohol to endorse several of these factors as being linked to their circumstances. This highlights the role that chronic stress and instability play in reinforcing the cycle of drug abuse and homelessness. [1]
Common patterns of substance use in homeless individuals
People who are struggling with both homelessness and substance use disorders tend to have more severe forms of addiction. Commonly abused substances include alcohol, heroin and other opioids, and crack cocaine. Because of the severity of their substance use, drug overdose is the number one leading cause of death amongst people who are homeless. [3]
Physical and mental health issues related to homelessness and addiction
People who are homeless are less physically and mentally healthy and at much higher risk for a number of chronic and acute health problems. Research shows that people who are homeless and abusing substances are more likely to have co-occurring physical and mental health conditions, and that these conditions tend to be more severe in nature. Part of the increased risk has to do with a lack of access and utilization of professional treatment, in addition to lifestyle factors that increase the risk for physical and psychological disorders. [1][2]
Dealing with the chronic stress related to finding shelter also causes people to deprioritize treatment for medical or mental health problems until they become life-threatening. This means that by the time they do receive treatment, their symptoms and conditions are likely to have gone untreated for long periods of time, leading to more severe and complex medical and psychiatric problems. This contributes to a number of serious risk factors, including increasing the risk for early mortality by three to four times, compared to the general population. [2][3]
Many of the health problems common in homeless individuals are relatively uncommon in the general population, including infectious diseases and illnesses linked to substandard living conditions. Homeless individuals who abuse drugs are at especially high risk for drug overdoses, which is the leading cause of death in this population. Heavy substance use can also affect their mental health, worsening pre-existing conditions like mood disorders and psychosis. Worsened mental health is often a precursor to self-medication with drugs and alcohol, leading to an escalation of substance abuse. [2][3]
Barriers to addiction treatment
When a person is homeless and has a substance use disorder, they are also more likely to face a number of obstacles to accessing physical and mental health treatment. Many are unemployed and do not have access to health insurance, which would make care more affordable, and cannot afford to pay out-of-pocket. Economic instability is a primary barrier to treatment, but it is not the only one.
Lack of access to transportation and frequent moves or transitions also make homeless people less likely to seek treatment, consistently attend scheduled appointments, and remain in treatment long-term. Social stigma can also be a deterrent, causing some homeless people to feel ashamed or embarrassed about their circumstances and avoid treatment.
Because of high rates of addiction and drug and alcohol use in homeless populations, it can be difficult for people to remain clean and sober without a change in their environment and circumstances. For these reasons, it is important to address social determinants of health. Research suggests that the best approaches involve both addiction treatment in combination with case management or supported housing to help people find stable housing. [1][4]
Treatment options for people who are homeless
There are a number of treatments and resources for people who are homeless and struggling with substance use disorders. Integrated approaches that address the addiction as well as the housing needs are the most effective and provide the best chance for long-term recovery. An integrated approach can include combining the following services to provide wrap-around support for someone working towards recovery. [1][2][4]
Residential treatment and sober living
Residential treatments can be offered in a number of different settings, including structured rehabilitation programs, sober living, and transitional housing solutions like therapeutic communities. The exact structure and requirements of these programs vary, but they usually involve routine drug screening and participation in addiction treatment. Residential treatments are promising because they provide a solution for both homelessness and addiction, and are often able to provide long-term support. [2]
Medication-assisted treatment
Opioid use disorder is common in people who are experiencing homelessness, and, untreated, this condition carries a high risk for fatal overdose. Medication-assisted treatments (MAT) involve the use of medications like buprenorphine or methadone to help reduce cravings, withdrawal, and prevent relapse. This medication is usually offered in outpatient clinics, which require routine drug testing and regular engagement in behavioral therapy to continue receiving medication. In recent years, the rise of mobile clinics providing MAT services has increased, which may be specifically helpful to individuals who are homeless. [4]
Housing First approaches
Housing First approaches involve addressing the problem of homelessness without mandating treatment or abstinence from drugs and alcohol. In housing first approaches, the primary goal is to help individuals secure stable, permanent housing, with the notion that increasing stability will naturally decrease rates of addiction. While housing first approaches do reduce housing instability, they have not been proven to lower rates of drug and alcohol use or addiction. [1][2] Therefore, it is important to pair them with other services and forms of treatment to be comprehensive in nature.
Case management services
Case management services involve helping individuals access needed services, treatments, and resources within the community. Case management can be offered as a stand-alone service or in conjunction with other addiction treatments like intensive outpatient rehab. Examples of case management services include help finding and applying for affordable housing, employment training, financial assistance, or medical and psychiatric treatment. While it is not a formal treatment for addiction, case management is an essential service that can improve outcomes by addressing multiple risks, needs, and vulnerabilities. [1][2][4]
Peer support services
Peer support services are a community-based service that links people to a peer mentor who has overcome their own challenges with mental health or addiction. Peer support can provide social support as well as some case management services to help people struggling with homelessness and addiction become more stable. For example, a peer support professional may help transport someone to 12-step meetings, job interviews, or medical appointments. Peer support services can help at-risk populations stay connected to services and treatments that improve their physical, mental, and social well-being. [2][4]
Harm reduction approaches
Individuals who are not ready or willing to stop using drugs or alcohol may benefit from harm reduction approaches, which aim to help lower the risks associated with substance use. Examples of harm reduction programs include needle exchanges and supervised consumption sites that monitor for signs of overdose and intervene when needed. Take-home doses of naloxone can also be administered as a harm reduction approach aimed at reducing rates of fatal opioid overdose. [2]
Continuity of care and long-term recovery
There are many complex factors linking homelessness and addiction. Integrated approaches that address both issues simultaneously are the most likely to succeed in helping people break the cycle and achieve lasting recovery and stability. Flexible treatment models, community-based services, and those that involve peer support or case management services tend to be more effective with this population. [1][4]
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