Homelessness and Substance Abuse

Part 1

Over the past millenniums, homelessness has been considered as one of the greatest epidemics globally. Correspondingly, substance abuse is viewed as a significant factor affecting the homeless population, contributing to increased mortality risk. In the U.S., substance addiction among this population became a national issue during the 1870s due to the industrial revolution, which led to rising inequality levels in the Gilded age ( Clifford, Wilson & Harris, 2019 ). The rise of morphine addiction also serves as a significant contributor to homelessness in the nation. It is imperative to note that homelessness is also considered a major cause of substance abuse among the affected population. Since these individuals are forced to use drugs to cope with their current condition, the number of those who abuse drugs has grown considerably. This research study explores homelessness and its correlation to substance abuse, its causes, and effects. 

Substance abuse as a terminology emerged to replace the traditional phrase drug abuse because the latter invoked judgment and social stigma in communities ( Johnson & Chamberlain, 2008 ). Its use led to the alienation and marginalization of drug users, who in turn were shunned from receiving the support they needed. The term substance has been used to indicate a wide range of psychoactive substances that include prescription drugs, illegal drugs, alcohol, cigarettes, and inhalants. The change was done to reduce stigmatization and show users that it was possible to seek assistance if they found themselves in such a situation. 

Clifford, Wilson & Harris (2019) note that there are many potential harms that result from substance abuse. These are not limited to the pharmacological effects of using the substance itself. They impair an individual’s ability to make sound decisions and carry out tasks effectively and to completion. Continued abuse leads to increased chances of risky behaviors, deteriorating health, and in some cases, death. Other effects that result from addiction include family breakups, divorce, engagement in crime, and dissociation from society. 

One of the main risks that people living on the streets are faced with is the challenge of obtaining employment and housing ( Magwood et al., 2020 ). These problems are often recurrent because the state lacks adequate harm reduction programs to reduce substance abuse and create a safe environment for homeless individuals to stabilize and abstain. If the programs are to be successful, housing initiatives need to be provided so that the stress of worrying about food and shelter may be reduced. For instance, transitional housing may be used to address substance abuse issues through the provision of recovery facilities, support, and emergency shelters. After this is done, special consideration needs to be made on the residents because a majority often have addiction problems that warrant further action. These individuals need to be received and offered treatment options to overcome addiction because, without such, their recovery is put in jeopardy. 

Grinman et al. (2010) observe that for homeless substance abusers, it is often very difficult to find shelter or housing. A majority of the state's programs require individuals to complete and pass drug tests as well as drug treatment schedules if they are to be eligible for emergency housing. The most important thing to consider for substance addicts is that it affects the brain and as such, rehabilitation may take a very long time. The situation is worse if a person is homeless because they lack the support necessary to stop the habit. One of the factors that is essential during recovery is the availability of food and shelter, which lack for a person living in the streets. Addiction also causes estrangement from family and friends, making recovery difficult because such a person would lack support ( Van Straaten et al., 2016 ). In addition to this, recovery is also a long-term pursuit, and as such, professional treatment may be required if success is to be achieved. Since these individuals lack health insurance and resources to seek such medical attention, it may be difficult to address the issues, thus making it challenging to access rehabilitation services. 

It has been established that alcohol dependence is the most common substance use disorder among homeless populations. The drug is a relatively inexpensive and widely available substance that is very common among the homeless population. Alcohol contributes to critical health problems such as liver cirrhosis, stroke, cancer, and heart disease, which are overwhelming for individuals with limited access to healthcare. The Substance Abuse and Mental Health Services Administration ( Santa Maria et al., 2018 ) notes that an estimated 41% of homeless people are dependent on alcohol, whereas 29% abuse other drugs. In older generations, alcohol is the most consumed substance, while the youth are reported to engage in other types of drugs. There are those who view drug abuse as a norm that should be accepted among the homeless community. 

Smoking has also been established to be the second most widely abused drug, leading to serious health conditions such as lung and throat cancers. Some of the other abused drugs include heroin and prescribed opioids. These are extremely addictive substances that pose a very high risk of overdose. Grinman et al. (2010) note that more than 20% of the homeless population abuse prescription drugs for certain states. Methamphetamine is also a highly addictive drug that is linked with various mental and physical health problems, including paranoia, extreme weight loss, overdose, and cognitive impairments. Cocaine, famously referred to as crack cocaine, is more prevalent among homeless individuals as compared to its powdered form. Smoking crack is detrimental to a person’s health because it damages the cardiovascular and respiratory systems. Its use leads to serious mental issues and if addicted, leads to unpredictable behaviors and paranoia. 

Several mental illnesses affect homeless substance abusers. According to data from the HUD, an estimated 25% of homeless individuals in the U.S. suffer from severe mental illnesses ( Magwood et al., 2020 ). Some of the most common psychological health conditions affecting homeless populations include; schizophrenia, which as a disorder, is characterized by episodes of psychosis, cognitive impairments, motivation issues, and negative moods. Symptoms include paranoia, hallucinations, disorganized thinking and trouble focusing, delusional beliefs. The bipolar disorder leads people to suffer from dramatic changes in mood, activity levels, and energy. The periods shift from feeling happy to feeling very depressed, sad, and hopeless. Major depression is a common condition that may be very dangerous among the homeless, although it occurs across all social classes. The main symptoms include chronic fatigue, hopelessness, suicidal thoughts and behaviors, persistent sadness, and insomnia ( McCarty et al., 2011 ). It is imperative to note that critical mental illness symptoms often make it difficult for an individual to perform normal day-to-day activities such as developing relationships, working, or maintaining homes. People must therefore be aware of the fact that mental illness and substance abuse co-exist. People who suffer from psychological problems brought about by addiction have co-occurring disorders or dual diagnosis.

Consequently, it has been reported that more than 48% of mentally ill homeless persons suffer from co-occurring drug abuse disorder ( Santa Maria et al., 2018 ). The continued abuse of substances has been proved to worsen mental conditions by affecting vital areas of the brain, thus leading to further impediment of the body. On its part, dual diagnosis is very serious and tends to make treatment complicated because other mental illnesses are masked by the symptoms of drug addiction and alcoholism. Health practitioners must screen for both substance abuse and mental illness in their patients so that an appropriate mix of both treatments can be offered, thus encouraging recovery and preventing relapse. 

According to Clifford, Wilson & Harris (2019) , more than half of Americans, whether homeless or housed, do not receive adequate treatment as far as substance addiction is concerned. The National Association of State Alcohol and Drug Abuse Directors (NASADAD) notes that in 2018, an estimated 10 Million drug-dependent people did not receive the treatment they required ( Santa Maria et al., 2018 ). Some of the factors that prevented the individuals from proper health care include lack of health insurance, high medical costs, and unavailability of substance abuse treatment programs. Since most homeless individuals lack health insurance, their health keeps deteriorating up to a point where rehabilitation becomes impossible. Even for those working but in low-income groups, obtaining health insurance is still a challenge, because they have to put food on their families' table. Homeless people are far disadvantaged as compared to these individuals and, as such, cannot afford basic medical care. Even though some programs have been initiated to help homeless addicts get the help they need, other impediments such as lack of transportation, long waiting lists, and lack of documentation still hinder them from accessing health care. In addition to this, there are very few state substance abuse treatment and prevention initiatives that target individuals from the homeless population. 

Housing authorities, health services, and local councils should work together to adopt and implement a tailored approach that will tackle drug misuse among the homeless ( Van Straaten et al., 2016 ). Doing so would reduce the number of deaths that occur as a result of a drug overdose and addiction. They will save one percent of this population if their first priority is to reduce substance abuse and provide a secure room over homeless people’s head. Interventions should be adopted to address drug-related harms in homeless populations through coordinated approaches. 

Homeless individuals using drugs lack social connectedness, and as such, their personal safety stands at a greater risk because they have no one to confide in. Homeless teenagers, for instance, when exposed to good counsel and the love of family and friends, have responded positively to drug treatment programs because they are at a transition stage. Consequently, this shows that if these populations' needs are met and evidence-based approaches adopted through peer mentors, outreach programs, integrated and targeted services, the epidemic may be reduced ( McCarty et al., 2011 ). 

There are many reasons why homeless substance abuse programs have not been successful. Addicts without shelters have different needs as compared to those who are housed, and as such, these programs are not tailored to meet their needs ( Van Straaten et al., 2016 ). In addition to this, a punitive approach has been focused on substance abusers, and as such, it becomes hard for these individuals to access prejudiced care in society. Since substance abuse is considered a cause and effect of homelessness, there is a need to assess the issue from a multidisciplinary approach. The need to provide stable housing is a promising strategy because it reduces the risk of relapse in the future. Substance abuse treatment programs for the homeless cannot be used alone without a supportive housing initiative. Johnson & Fendrich (2013) note that in addition to this, other programs such as physical health care, mental health treatment, peer support, employment opportunities, and entrepreneurship skills training are also critical for such individuals. Going back to a society without the aforementioned needs addressed would not reap positive results. Outreach programs and active engagements coupled with the availability of flexible treatment options would serve as effective means of reintegrating recovered substance abusers back into their communities ( Santa Maria et al., 2018 ). In the long run, they would reduce homelessness on the streets and enable affected individuals to re-establish themselves and attain residential stability. 

There are various means of addressing substance abuse among the homeless. These include prevention, which has turned out to be difficult to achieve for this population. Treatment is also considered a very challenging process. Programs that focus on harm reduction can also help alleviate the situation, even though this may not be a permanent solution. It is also important to note that some harmful substances are politicized and, as such, made legal, thus increasing the potential harm of using them. 

Part 2

According to Clifford, Wilson & Harris (2019) , more than half a million people in the nation were homeless in 2019, translating to 17% of the population. Homelessness goes hand in hand with addiction. These individuals' population has reached an epidemic level, with many cases reported in parts of New York, California, Colombia, and Oregon. Researchers and policy advocates believe that this phenomenon has been brought about because residents in the area spend a higher proportion of their income on mortgage and rent payments than those from other regions. Statistics also indicate that 70% of this population are men, with Native Americans and African Americans contributing to a substantial portion of this population ( Magwood et al., 2020 ). 

According to McCarty et al. (2011) , substance abuse has often been cited as one of the leading causes of homelessness. It has been reported that when under the influence of a substance, these populations indulge themselves in disruptive behaviors that ruin relationships at home and the workplace. Addictive actions may be detrimental for individuals who are already struggling to pay bills because, in the long run, they run into bankruptcy and, as such, lose their ability to pay for their mortgages and housing. Research conducted by Clifford, Wilson & Harris (2019) indicates that three-quarters of the homeless population reported drugs and alcohol abuse as the major reason for their current state. 

The use of alcohol and drugs is strongly linked to mortality and morbidity and is of high prevalence among homeless populations ( Beijer et al., 2011 ). Research shows that mortality rates among these individuals are nine times higher as compared to housed populations. The leading case of mortality among the homeless is drug overdose. It has been established that more than 80% of these individuals are dependent on drugs and, as such, cannot do without their use for a day ( Magwood et al., 2020 ). According to Gomez, Thompson & Barczyk (2010) , more than 50% of homeless youth are dependent on either drug or alcohol use, whereas marijuana accounted for 28%. 

From an economic perspective, the National Coalition for the Homeless (NCH) notes that some of the economic factors that cause homelessness in the country include the inability to access medical care and pay medical bills ( Magwood et al., 2020 ). Sometimes, medical costs may be overwhelming and, as such, contribute to poverty or bankruptcy. In some cases, people become homeless because of a serious health emergency or disability. The second economic reason is the loss of an employment contract. A majority of individuals live in poverty and have lost their houses due to unemployment. Lack of public support programs also contributes to this growing epidemic. These initiatives are becoming less available, and as such, there has been a decreased value provided to the families in need, thus leading to increased poverty and homelessness. A person’s inability to afford housing may also be contributed by low income below the national minimum wage. The rising costs of living in the current world where housing assistance programs are few have pushed low-income families to the streets. Other reasons include domestic violence and mental illnesses.

The main ethical issues that may arise during the project include informed consent, voluntary participation, and confidentiality and anonymity ( Comstock, 2012 ). Homeless individuals are vulnerable and susceptible to risk and harm and, as such, should be treated with utmost care. It is very important for a researcher to ensure that any form of participation in the study s voluntary and not coerced. In addition to this, there is also a need for a researcher to inform all the participants of the objectives of the study and its goals and what it is intended to achieve ( Comstock, 2012 ). The participants should be aware of the fact that if they decide to exit from the study halfway, they will still have access to the facilities they are entitled to. An unethical researcher may lie to the participants on some rewards such as free meals or a job if they participate in the study. Such behavior s not acceptable according to the research standards. In addition to this, confidentiality must be maintained at all times. All participant information must remain anonymous because, in most cases, they are not comfortable taking part in such a study ( Comstock, 2012 ). In this case, they should be assured of anonymity during the entire process. Breaching any of the above is considered an ethical violation. 

Research Problem

What are some of the causes and effects of substance abuse among homeless individuals? 

Substance abuse is a more common phenomenon among homeless communities as compared to the general population. It is imperative to understand that, whereas in some cases, substance abuse is the cause of homelessness, a majority use it as a means of coping with their current condition ( Clifford, Wilson & Harris, 2019 ). Most of those living on the streets use drugs as a temporary escape from their problems because lacking a place to call home is stressful. The situation is usually very tough, especially if a person does not know where their next meal will come from. They are forced to turn to drugs to cope with stress, which in the long run leads to addiction that worsens the situation further. According to the National Coalition for the Homeless, getting clean is a big problem for homeless addicts, and as such, it becomes impossible to get support. 

This study aims to establish the prevalence of substance use and the factors influencing drug use among a representative sample of homeless persons. The overall objective is to establish its cause and effect on the individuals, their physical and mental health conditions. The information will be collected on demographic characteristics as well as the patterns of drug use. An addiction severity index will be used to gauge the participant’s drug dependence level.

Research Hypothesis  

The hypothesis of the study is: homelessness increases the likelihood of substance abuse. The results will be achieved based on the study of patterns and factors associated with increased use. 

Research Population

Participants of the study were recruited from the streets and those living in shelters at various locations within selected cities. To be eligible, individuals will have to be over the age of 15 years and homeless. The definition of homeless here is those who reside in a shelter, on the street or live independently because they had to run away from home or be pushed out. Informed consent will be obtained from the participants before the study to ensure they are fully aware of the research's purpose. The study will be explained, informed consent obtained, and assured that refusal to participate in the study would not affect the outcome of health service provided to them. A total of 70 male and 40 female homeless persons will be interviewed for this study. Youths living under these conditions will also be interviewed because they constitute a significant number of this population. The expected number to be included in the study is 30. 

Exclusions will be made for individuals who are abusive, incoherent, acutely intoxicated, or psychotic. The data will be conducted through full-time interviews. 50% of the individuals to be selected must meet the criteria for alcohol and illicit drug disorder and a mental disorder. The interviews will be conducted for 20 to 40 minutes, where the data presented will be recorded and coded based on the Likert scale. Different interview sites will be selected depending on the concentration of the desired population. For those that permission will not be granted, other areas will be used to locate homeless individuals. If a family with dependent children has two or more adults, one will be randomly selected to participate in the study. Recruitment will also take place at various meal programs. Since the aim is to recruit individuals who do not have shelter, those who will be found in the designated areas and yet have homes will be eliminated. (There are some individuals who, due to lack of meals or violence at the family level, visit these places for assistance for a day or two. In this study, they will not be considered homeless). The study will be conducted as a part of a longitudinal study with participants divided across four cities according to the population's demographics. Demographic characteristics to be considered include age, gender, ethnicity, and educational level. Education will be categorized from lowest to highest depending on the level completed. 

Survey Instrument 

Demography information
City:  Street:
	Strongly agree	Agree	No opinion	Disagree	Strongly disagree
Homelessness has been caused by substance abuse
I have abused subscription drugs
I have lost friends and family because of drug abuse
I abuse more than one drug at a time
I can get through the week without using drugs
I have lost a job because of drug abuse
I can stop using drugs anytime I want to
I have engaged in illegal activities to obtain drugs
I experience illusions and depression when under the influence
I am an addict
I use drugs to deal with stress and depression
I have a mental health condition brought about by drug abuse

References

Beijer, U., Andreasson, S., Ågren, G., & Fugelstad, A. (2011). Mortality and causes of death among homeless women and men in Stockholm.  Scandinavian journal of public health ,  39 (2), 121-127.

Clifford, B., Wilson, A., & Harris, P. (2019). Homelessness, health, and the policy process: a literature review.  Health Policy ,  123 (11), 1125-1132. 

Comstock, G. (2012).  Research ethics: A philosophical guide to the responsible conduct of research . Cambridge: Cambridge University Press.

Fountain, J., Howes, S., Marsden, J., Taylor, C., & Strang, J. (2003). Drug and alcohol use and the link with homelessness: results from a survey of homeless people in London.  Addiction Research & Theory ,  11 (4), 245-256.

Gomez, R., Thompson, S. J., & Barczyk, A. N. (2010). Factors associated with substance use among homeless young adults.  Substance Abuse ,  31 (1), 24-34.

Grinman, M. N., Chiu, S., Redelmeier, D. A., Levinson, W., Kiss, A., Tolomiczenko, G., ... & Hwang, S. W. (2010). Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status.  BMC Public Health ,  10 (1), 1-7.

Johnson, G., & Chamberlain, C. (2008). Homelessness and substance abuse: Which comes first? Australian Social Work ,  61 (4), 342-356.

Johnson, T. P., & Fendrich, M. (2013). Homelessness and drug use: evidence from a community sample— American Journal of Preventive Medicine ,  32 (6), S211-S218.

Magwood, O., Salvalaggio, G., Beder, M., Kendall, C., Kpade, V., Daghmach, W., ... & Pottie, K. (2020). The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder.  PloS one ,  15 (1), e0227298.

McCarty, D., Argeriou, M., Huebner, R. B., & Lubran, B. (2011). Alcoholism, drug abuse, and the homeless.  American Psychologist ,  46 (11), 1139.

Santa Maria, D., Padhye, N., Yang, Y., Gallardo, K., Santos, G. M., Jung, J., & Businelle, M. (2018). Drug use patterns and predictors among homeless youth: results of an ecological momentary assessment.  The American journal of drug and alcohol abuse ,  44 (5), 551-560.

Van Straaten, B., Rodenburg, G., Van der Laan, J., Boersma, S. N., Wolf, J. R., & Van de Mheen, D. (2016). Substance use among Dutch homeless people, a follow-up study: prevalence, pattern and housing status.  The European Journal of Public Health ,  26 (1), 111-116.