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The health impact of homelessness and addiction

Dr Jo-Hanna Ivers is Assistant Professor in Addiction. She is based at Trinity College since 2009 and prior to this she worked in the frontline addiction services. Her research examines addiction from a public health perspective.  Jo-Hanna’s research priorities include Addiction, Recovery, Homelessness, Neuropsychological Health, Behavioural Interventions and Integrated Care.

Homelessness is a major public health concern. Excess mortality is associated with extensive social exclusion, with studies in the USA suggest that one in five individuals experiencing homelessness will go on to become chronically homeless. The longer a person is homeless, the more likely it is that they will suffer from a medical condition, and chronically homeless individuals are far more likely to experience higher rates of chronic disease,  mental health issues and addiction.  Accessing treatment is incredibly difficult for homeless people.

In a recent study, myself and my colleagues examined  201 deaths that occurred among homeless people in the Dublin region between 2011 and 2015. Mortality rates were much higher among homeless people compared with the general population.  These rates for homeless men were between 3 and 10 times higher when compared to men of the same age in the general population, while the rates for homeless women ranged from 6 to 10 times higher than women of the same age in the general population. Drug and alcohol-related deaths were the leading cause of death, accounting for more than one-third of deaths in homeless individuals. With mortality rates among homeless persons exceptionally high, services and programmes, particularly housing and those targeting overdose and alcoholism, are urgently needed to prevent premature deaths in this vulnerable population.

Understanding the link between addiction and homelessness

Addiction is both a causal factor and a consequence of homelessness. Prevalence estimates of addiction among homeless people are around 20-35%; with as many as 10-20% having a dual diagnosis of mental health and addiction.

Data on homeless people accessing treatment is scant. The majority of addiction treatment in Ireland occurs within the public health care system. Thus, access to such as detoxification is limited in the public domain, creating a blockage for those who need medically supervised detoxification. There is a lack of data on waiting times for detoxification in Ireland. In the United States, less than one-quarter of individuals in need of addiction treatment receive it. Both systemic and interpersonal barriers to accessing treatment are made worse by the realities of homelessness. While homeless persons often have a higher need for treatment, when compared to the housed population, they face more difficulties in accessing the help they need.

An understanding of the underlying issues of homelessness and addiction helps reduce stigma.  Homeless individuals in need of treatment for addiction, particularly those who have additional and often complex needs, (i.e. mental health or chronic illness) present significant challenges to treatment services. The first challenge in addiction treatment is in the engagement process, and many homeless individuals fall at this hurdle.

The importance of housing when engaging in treatment can often be understated.  The focus on direct, tangible assets or ‘Recovery Capital’, such as housing, access to income, education, and employment, are all linked to improved retention in treatment and better outcomes long-term. However, engaging in employment or education, or having access to benefits, are less likely if a person does not have access to stable housing. Thus, the continuing cycle of addiction and homelessness remains.

 Addiction treatment for homeless people

Research on interventions to positively impact the health of homeless people has received a substantial increase in attention over the last decade. Overall, treatment programmes that address housing as well as addiction; need to be flexible and non-demanding.  They must also target specific population needs, such as gender, age, and addiction severity, and provide longer-term, heavily-supported interventions.

Let’s stop the stigma and provide progressive addiction services that address the needs of this  vulnerable population.

You can follow Jo-Hanna Ivers on Twitter at @jo_ivers. 

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